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September, 2016


PAs for Tomorrow is a national PA advocacy organization tasked with improving the utilization of PAs in all settings and specialties.

We are writing to you regarding the Los Angeles Fire Department’s utilization of only Nurse Practitioners on the special response unit, to the exclusion of Physician Assistants (PAs).   Per published articles, the LAFD hires only Nurse Practitioners (NPs) to fulfill the role of advanced practice provider in the emergency medical services field setting.  PAs successfully function in similar roles in agencies around the nation, and with previous pre-hospital experience, are uniquely suited to these positions. 

Your stated services provided by the Nurse Practitioner Response Unit include “Physical exam, on-scene blood testing (iStat), Asthma treatments, laceration repair, wound care, medication administration and prescription.”  These are all services PAs are highly trained to provide, and indeed provide to patients every day in a variety of settings. 

There are over 13,000 PAs specializing in Emergency Medicine in the United States, providing care in all settings, ranging from directing urgent care centers to solo coverage of rural emergency departments, in addition to providing care at level 1 trauma centers.   PA training is highly regulated, with mandatory emergency medicine rotations, and students completing over 2500 hours of clinical education within the program, including a mandatory emergency medicine rotation.  There are also currently 29 Emergency Medicine fellowships available to PAs.  The emergence of the emergency medicine certificate of added qualification (CAQ) provides an additional certification demonstrating advanced knowledge and proficiency for Emergency Medicine PAs.  Nurse practitioners by comparison have a high variability in their educational programs, with no mandatory ER rotation for family nurse practitioners and as little as 600 total hours of clinical education.  There is no question why PAs are the preferred emergency medicine advanced practice provider of choice as stated by past presidents of the American College of Emergency Physicians.

Many similar community outreach FD/ EMS programs utilize PAs to provide care for their patients.  The Mesa fire and medical department, one of the pioneers of such programs, has used PAs since the initiation of the advanced practice provider unit in 2008, staffing the unit with a PA and paramedic.  PAs have been demonstrated to play a critical role within their EMS system.  Of the calls that they responded to, 55% of the patients were effectively triaged and treated on scene by the responding PA, reducing the strain placed on local ERs. 

NPs and PAs in California have very similar supervision requirements.  A single physician may only supervise four advanced practice providers (PAs or NPs).  NPs may only provide care under specifically agreed upon protocols.  PAs in California do not have a mandate to operate under protocol, however if it is decided to use protocol based care, only 5% of the charts must be reviewed within 30 days of the patient encounter. 

1/3rd of PAs worked in emergency medical services prior to PA school.  As such, they truly understand the intricacies involved with responding to 911 calls and providing care to patients in their homes.  Having inevitably responded to “super users” during their prior experience in EMS, these PA providers grasp the multivariable causes of their use of the 911 system, which will allow the PAs to better work with the patients to decrease their rate of 911 utilization, a stated goal of your program.

As leaders of the PA community, we believe that PAs belong in the role of advanced practice providers in the pre-hospital setting.  PAs are invaluable members of the emergency medicine team, and uniquely suited to the pre-hospital role.  There is documented evidence from previous agencies proving the benefit to the utilization of PAs in community response units.  We strongly urge you to reconsider your position of utilizing only NPs on your community response units within the Los Angeles Fire Department. 

Thank you for your consideration in this matter.

Eric Holden, PA-C, DHSc, EMT-P
Emergency Medicine PA
Doctor of Health Science & Global Health
President, PAs For Tomorrow


Approved by the Board of PAFT

Thanks to Tamar Zwick, PA-S, EMT-P for significant research and aid in the preparation of this document.

References

NP Regulations
http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20S/PDF%20ScopeOfPracticeLawsNursePractitionersIB.pdf  
http://www.rn.ca.gov/pdfs/regulations/npr-b-23.pdf

PA Regulations
http://www.pac.ca.gov/forms_pubs/sup_of_pa.pd

LAFD NPRU information by medical director
http://www.gatheringofeagles.us/2016/2016presentations/Friday/EcksteinNP.pdf


PAs for Tomorrow is a  professional organization for all PAs of all specialties.  It represents the future interests of all PAs, providing a vocal core group of PAs committed to seeing the PA profession reach its deserved place among America's health care providers and advocating for their role as providers of high-quality, cost-effective, comprehensive and patient-centered health care. 

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