Johnston Medical Center ER Vignette Survey – January 29-30, 2018

On January 29-30, 2018, I performed a brief survey of the medical staff, nursing staff, and other ancillary staff during the night shift in the ED.  Each staff member was given the survey document below, and asked to consider the vignette below for a minute or so and then to write what they thought the most likely problem(s) could be.    With the exception of answering a question about ability to ambulate, (the patient could ambulate) No additional information was provided about the patient.

A total of 31 personnel were surveyed.

Surveys were provided to staff, who were asked not to discuss their responses with other  personnel. On returning the surveys,  the participants, in addition to their answers, indicated only their credential  (MD, PA, RN, etc.)   The purpose of the survey was not disclosed to participants.

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Patient is a 24-year-old female who presents to an urgent care facility for evaluation of right lower extremity pain.  8 days previously the patient had been struck on the right medial calf by a pallet full of heavy photographic equipment.   Patient has pain and swelling to the leg with worsening since onset.

Past history:  No significant medical issues

Medications: NuvaRing contraception

Vital signs: Assume normal

Exam:  Extensive bruising and tenderness to the right medial calf and pain to the ankle

Survey Question:  What is your prime concern(s) in this patient?         

Survey Responses from thirty (30) licensed / certified personnel surveyed, were as follows, listed by each discipline: 

MD (ER) – DVTs

MD (ER) – DVT

MD (IM) – DVT

MD (ER) – DVT, Compartment syndrome

PA-C  (ER) – DVT

PA-C (ER) – DVT, Compartment syndrome

PA-C (IM) – DVT

PA-C (ER) – DVT

PA Student – DVT, Compartment syndrome

FNP (IM) - DVT, Compartment Syndrome, Hematoma, Vascular compromise

RN – DVT

RN – DVT, fracture

RN – DVT

RN – Compartment syndrome

RN – DVT

RN – DVT

RN – DVT

RN – DVT

RN – DVT

RN – DVT

RN – DVT

RN – DVT, Foreign body (if open wound)

RN – DVT

RN – DVT

RN – DVT, fracture

RN – DVT

LPN – DVT, fracture

RCP – DVT, Compartment syndrome,  Necrotizing fasciitis

RCP – DVT, fracture

EMT-Intermediate – DVT

EMT-Paramedic – DVT

Results:

96.8%    (30/31)                  Recognized risk for DVT               

19.4%    (6/31)                    Recognized risk for Compartment syndrome 

12.9%    (4/31)                    Recognized risk of Fracture

9.7 %     (3/31)                    Recognized risk for other conditions (Hematoma, Infection, Vascular) 

DVT Risk Identified by provider groups:

100%      Medicine Group:             MD, PA-C, PA-S, Personnel

 94%       Nursing Group:               FNP, RN, LPN Personnel

100%      Ancillary Personnel:       RCP, EMT Personnel

Specialty CAQs

I received notification last month that I have been awarded my CAQ in Emergency Medicine from the NCCPA. The "certificate of added qualification (CAQ)" program was established by the NCCPA as a means of recognizing those certified PAs who have met certain minimum standards of achievement is a a number of specialty areas.

The CAQ program was started, and originally billed as, a specialty certification program. This eventually morphed into the CAQ as an addition to the basic PA-C credential, rather than as a stand-alone certification. I suppose the thought being that stand-alone certifications would erode the relevance of the basic PA-C credential. It was also postulated that, if specialty certifications were issued, that these credentials might be required by employers. Thus this leads to the CAQ as it exists today. I always felt, and had written to the NCCPA in the past advocating, that the NCCPA establish a series of "extended-core" examinations that could be taken with the PANCE or PANRE to provide "special recognition in" various specialties. This would have been similar to the PANCE exams taken up until 1997, when candidates were required to write both a general exam and at least one "extended core" exam for initial certification. The "extended core" exams at that time, were limited to only primary care and surgery, but the model was established and proven.

In the current CAQ process, the first step is documentation of a minimum of 150 hours of Category I CME specific to emergency medicine within the preceding six years. Fifty of these hours must be earned in the preceding two years and must include an ACLS course. The next step is certifying your work experience. For the emergency medicine CAQ, the minimum experience is 3000 hours or 18 months of full-time experience working in emergency medicine or about half the length of an emergency medicine physician residency program. The next step is certification of your patient management and procedural skills by a specialist physician with consideration to a number of specific areas. The NCCPA also recommends that applicants complete and emergency medicine review course as well as additional courses in pediatric and trauma life support (i.e. APLS/PALS and ATLS).

The final step is taking the CAQ examination. The exam contains 120 emergency medicine-specific questions based on a content blueprint develop by the NCCPA following their 2009-2010 PA practice analysis. After completing all of these requirements and passing the examination, the NCCPA awards you the CAQ in emergency medicine, which is valid for 6 years as long as the PA-C is maintained and certain specialty-specific CME requirements are maintained. Overall, I thought the exam was fairly representative of EM practice despite it's relative brevity. The CAQ program outline for emergency medicine is outline at the NCCPA link below:

http://www.nccpa.net/Emergencymedicine.aspx

The PA-C is a generalist or primary care credential at it's core. Despite this, I have been practicing for over a decade and a half with that credential and an ever-increasing base of experience. My CME since earning my PA-C in 1996 has reflectively been geared toward topics in emergency medicine, and my post PA-graduate master's degree was granted in 2000 with a concentration in emergency medicine. So now that, after over 15 years of emergency medicine practice, I have a "certificate of added qualification" in my specialty. I ponder on what that means.

After all that specialty PAs have contributed to medicine and fought for to achieve this recognition has returned to them a well-packaged "feather in their respective caps." It's nice to be recognized and to put another qualification on your CV/resume'. After all, the recognition was long overdue, and likely prompted most by the fact that some specialty PA organizations were set to bypass both the AAPA and NCCPA to get this done on their own. This less fragmented approach seems more desirable and keeps the CAQ program under the NCCPA, which has for decades now provided the profession with it's both its de-facto licensing examination and "Board certification." In short, the credential has credibility.

Will the decision to have a CAQ, as opposed to a stand-alone certification deter employers from increasingly favoring or even requiring such a credential for employment candidates? Probably not. Now that the cat is out of the bag, so to speak, the more PA's that achieve this credential will hold a definite advantage in the specialty job applicant pool. Both employers and employees will want to showcase credentials to prospective customers/patients. I anticipate that it will not be too long before there will be groups advertising the fact that their staff is comprised of all "board-certified" physicians and physician assistants. Is this a valid representation?

Since the NCCPA is the "Board certifying" body for the PA profession, the certificate of added qualification does indeed provide a specialty certification to PAs. Whether the certification is "added" or stand-alone seems irrelevant. A PA-C holding a CAQ is essentially held out to be "certified," by holding a certificate from an nationally recognized professional certification body, as holding qualifications in both general/primary care medicine and his/her respective specialty.