PA Consultation in the ED

Health & Safety Code, § 1317.1

SB 233 Emergency Services and Care

CAPA sponsored SB 233 in response to an audit which threatened the jobs of PAs working in the Emergency Department. This bill clarified that PAs in California can provide evaluation, treatment and specialty consultation in the Emergency Department setting.

SB 233 Ensures PAs Can Perform Consultations in the ER (Reprinted from the November/December 2011 Edition of the CAPA News)

Legislative goals are discussed every year in the fall. When the CAPA Board approved the legislative agenda, 2011 was looking like a quiet year. That is until we heard from a CAPA member working in orthopedic surgery who had just been told that he could no longer perform consultations in the emergency department at his hospital. We inquired further and found that Mission Hospital was written up for allowing PAs to consult in the ER. After investigation, we found the citation, which quoted Section 1317 of the Health and Safety Code pertaining to emergency services, stated that only a physician can perform a consultation in the emergency department. Furthermore, this code stated that only a physician can TREAT a patient in the emergency department.

Obviously, PAs provide care, both as providers in the ER and as providers in specialty services which perform consultations in the ER. Although most PAs in the state practice in a primary care specialty, the next largest practice areas are in the emergency department and orthopedic surgery. So, CAPA felt compelled to act. This was clearly a concern at this one hospital site, but what if other hospitals followed suit out of fear of a citation? At least one inspector took this code literally to mean that a PA could not legally perform these services.

Now that SB 233 has passed, what is different? Hopefully, not much! We expect that starting January 1, 2012, Mission Hospital can again allow their PAs to provide consultative services in the emergency department. We expect that we have eliminated the possibility that other hospitals will limit the practices of PAs. In the following excerpts, PAs are included in “other appropriate licensed persons.” But, always remember that your Delegation of Services Agreement should explicitly state which functions your supervising physician has delegated to you. This should include the setting, as well as, specific tasks such as “consultation” or “stabilization and transfer” as they apply to your particular job. Remember that a supervising physician or hospital can choose NOT to delegate tasks to you even if the new law allows you to perform these tasks. They can impose additional restrictions or require more stringent supervision than the law requires based in part on your experience, expertise and the length of your partnership as part of a provider team.

If you work as a PA who consults in the emergency department (i.e. in orthopedics or general surgery), you should be aware that the following applies to you:

“Consultation” means the rendering of an opinion or advice, prescribing treatment, or the rendering of a decision regarding hospitalization or transfer by telephone or other means of communication. When determined to be medically necessary, jointly by the treating physician and surgeon, or by other appropriate licensed persons acting within their scope of licensure, under the supervision of a physician and surgeon, and the consulting physician and surgeon, “consultation” includes review of the patient’s medical record, examination, and treatment of the patient in person by a consulting physician and surgeon, or by other appropriate licensed persons acting within their scope of licensure under the supervision of a consulting physician and surgeon, who is qualified to give an opinion or render the necessary treatment in order to stabilize the patient.

If you are a PA who is working in the emergency department, you should be aware that the following applies to you and may change the way that you are currently practicing. It involves requesting a consultation:

A request for consultation shall be made by the treating physician and surgeon, or by other appropriate licensed persons acting within their scope of licensure under the supervision of a treating physician and surgeon, provided the request is made with the contemporaneous approval of the treating physician and surgeon. The treating physician and surgeon may request to communicate directly with the consulting physician and surgeon, and when determined to be medically necessary, jointly by the treating physician and surgeon and the consulting physician and surgeon, the consulting physician and surgeon shall examine and treat the patient in person. The consulting physician and surgeon is ultimately responsible for providing the necessary consultation to the patient, regardless of who makes the in-person appearance.

To save you from Googling®, “contemporaneous” means “existing, beginning, or occurring in the same period of time.” In our many stakeholder discussions, there were those emergency medicine physicians who believed it was essential that the PA consult with their supervising physician PRIOR TO requesting a consultation of a specialty physician. We argued that, while optimal in some settings, putting this into state law could put PAs and physicians at risk since prior approval is not always possible nor in the best interest of our patients. Ultimately we settled on “contemporaneous” and decided that it is best practice for the supervising physician to be aware that a PA is requesting a consultation for an emergency room patient, but notifying the supervising physician prior to requesting the consultation is not mandatory.

All PAs who work in the ER should be aware that they will be covered for stabilizing a patient for transport as well:

A patient is “stabilized” or “stabilization” has occurred when, in the opinion of the treating physician and surgeon, or other appropriate licensed persons acting within their scope of licensure under the supervision of a treating physician and surgeon, the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from, or occur during, the release or transfer of the patient as provided for in Section 1317.2, Section 1317.2a, or other pertinent statute.