Question: An orthopedic surgeon has a standing order on file stating that his physician assistant ("PA") should be called whenever a patient presents to our ED who is in need of a cast or splint. These procedures are within the PA's scope of practice, but we feel really uncomfortable about this situation since the on call physician is not consulted about the specific condition of the patient before the PA is called. We don't think this practice is in compliance with EMTALA. Is it?

Answer:

Under EMTALA, an on-call physician cannot issue a standing order by which his or her PA is called to come in and assist with a patient, in lieu of contacting the on-call physician. In the Preamble to the Regulations issued in 2003, CMS stated that "any decision as to whether to respond in person or direct the physician assistant to respond should be made by the responsible on-call physician, based on the individual's medical needs…" (emphasis added). CMS provides similar guidance in its Interpretive Guidelines.

This implies that the on call physician must make the determination of whether it is appropriate for a PA to respond on a case-by-case basis, not through a generic standing order. Therefore, while CMS has recognized that it may be appropriate for a PA to respond to a call from an emergency department in certain situations, the on-call physician must be contacted to make that decision.