"
%
"
"
$"
!"
" " # $"
" #&
'
)
$
$
$
.
%
'
%,
%
-
*
+
)
!
%
'
'
/
(
/ 1
+
"
*
2+
"%
+
"
"
#
"
"
*
#
+
+
"
"
%" "
5
*
4 +!
%"
+
"
"
%
4
*
+
%
"
3
"
4 +!%
"
#
"
4
%
'4 % " 6
%"
7
'4*
+8
!
#
#
0
/ 1
+ "
)
2+ "
""
"
#
4
"
"
+
"
" "
"
:
"
"
*
!
"
+%
"
#
" ,9
) #
+
+ 4
"
#
"
#
9
/ 1
+
"
"
<
2+
+
+
'
"
"
=
"
!"
%"
%
"
#
4
6
5
5
"
* 4 +
4
+
5
#
"
% %
*
+
"
4 #
#
3
1
#
;
/ 1
"
+
2+
+
"
"
"
"
*
4 + %"
"
"
+
#
! "$
%
$"
"
"
!
!
*
2
$
$
%
"
&
#
"
"
#
4
6
"
!
!
"
#
%" "
%
%
"
%
2
4
"
%
%" "
"
"
+!% "
"
!
4#
>
*
*
*
4+ !
"
4 + !*
'4* 6
* +
'%
%%%
+ !
4
4
++
"
@
"
?
;
"
*
'4* 6
* +
;
:
4
4
*
*
++
"!
!$
"
!$
!2
!
"
4
4+ !
4+ !
!
1
'4
"
@
,BB>!
A
;
$"
" "
"
"
"
"
"
"
*
%
"
!"
%
"
"
%
! D
+
"
)
"
"
CB
)
&'
(
)
*
$"
"
"
)
"
"
()
"
"
" "
"
"
#
*
4!
%
"
"
"
"
"
+
E !
%
,%,+- %
+"
!" % "
%
"
%
#
" #&
CC
"
'4*
,
'4*
4
+
*
'
"
4
4
4 +
%" 6
'4
+ "
"
%"
3
"
!
"
"
!
%
C,
"
4
C CAAA!
'4* +
*" F
%%%#" "#
# # 0BBB- 0(0C#" +
6
D
% " '4* +!
"
4
9
"
"
"
"-
-
-" #
$
0
!G 2!' 2
*@@ H @ +
C(
4
4
,
6
H
3
"
4
$"
D
!% "
"
%" !
!
" 1
!
"
%" "
C0
4
"
!
"
"
"
"
H6
D
%" "
"
!
%"
!
"
%"
" "
"
C9
"'
$"
4
C(
"'
'4
":
%"
"
!
)
"
$" CB
# #
" 1
"
!
(!
4
"
"
"
"
"
"
C;
"
"
*
+ !
")
3
"
""
5
$
&*%%%#" "
# G"
"
#
6
+
%"
!" "
%
"
"" "
"
"
@@/-
"
"
&*
+
C>
"
H
"@
$"
%"
"
"
#
!% " "
!"
"
%"
I
!
!
" "
&*
"
+
C?
"
'
"
) !" "
"
%" "
" )
%
!
:
!H
*
:+
%"
"
&*
"
+
CA
$"
%
) '
*
%
+F
"
"
"' &
$"
%
"
"
"
"
"
$" *
+
"
&
"
!4
?!,BB;
!
"
"
"
%
&
&
"
,B
$" *
"
+
" "
&
"%
"
4
"
&
"
"
4$
:
*
:+
"
"
,C
' "
4
"
$"
$"
$"
"
"
$"
"
$"
2
2
"
"
"
%" "
"
%"
"
2
2
*
'
%"
%
"
!
"
'
4 +
"
"
%
4
,,
' "
$"
$ "
"
2
&
2
$
"
%
*%%%#" "#
-" # "
+
4
"
'
" "
" "
# # "# !
9B
%"
,(
,9
)
"
)
!
) "
"
!
$
'
!
"
)
- "
!
"!,BB>
,9 "
%
'
&
'
CBB
%"
&
< ,BB?
%
;A
H
&!
:
,
,0
: @
"
'
: %" "
"
:D
"
+
*
0
"
"
D'
"
"
" :EC5
6 C* C+
,
:
"
&
""
"
"
: %
!% ",
"
% !
:D
"
"
) !
"
:D
"
"
,9
:
D
: %
".
I
I
+
%
,
".
.
"
"" "
"
!
%" "
*% "
.
6
"
"
0
"
!
,;
:
5
"
"
!
,BB;!"
,!
A;C
# $" % "
""
"
!
"
,!?C,
CA?9# $"
"
CAA># $" % C!,0>
* :+
!
" "
CAA9# $"
: "
,BB; % 0,J!
"""
"
#
CAA9! : "
,>J
"
"
&78
78$"
"
6
!
!
'
,BB;! ;
,>
%
%
C
"
!
,
"
#
"
!%"
"
"% & *.
5
!,BB;DB>
CBB
%
!
+
" . !>BJ
%"
9BBBBB
%
"
!% "
!
"
,?
$"
.
(
" .!
!
"
0
,B
"
. )
,A
H$"
"
$"
*
"
"
"
D
"
:!
I
- "
<
#
'%
+
%
"
?BJ @@
!
CBBJ "
"
%
!
!
!
"
"
"
(B
H
G
,BB;
"
6D
*
%
+%
# $"
"
%
:
"
*
"
"
!
"
'
78
"
5
$!
6
%
F
"
+ * ,+&#
"% "
%
%
F
! $
"
K
%
%
!
"
"
78
# $"
3
"
)
" 1 "
" $"
F
"
$
%
!'
"
"
!
!,BB;
(C
K
"
"
#
6
!" "
"
$ "
3
3
%
I
"
%
"
K
!
" "
* $ +78
3 %"
$
"
$" %
%
782
$
CAAAL
C*
#
"
"
0
9
6
#
"
2!<
F
(+#
D
#
"
'!
" K
5
!
#
#
F%%%#
<
#
(,
K
$"
$
G
%"
,
%
(
"
I
"
%"
#
$
#
"
%
,
(
"
"
%
%
@ "
"
3
"
"
#
' "
K"
"
3
6
#
((
.,
+
$"
+
"
.,
78
#
/ &,
%
+
1
0
.,
9
*
%
!
!
"
1 # 2$
"
$
#
/ &,
1# 3$
%
" "
#
78
0
*
# $"
#
3
# $"
"
"
I
!<
#.
"
" "
%"
"
%" %
" "
,B"!,BB>
(0
/ 1
+
"
*
2+
%
"%
+
"
"
#
"
"
*
#
+
+
"
"
%" "
5
*
4 +!
%"
+
"
"
%
4
*
+
%
"
3
"
4 +!%
"
#
"
4
%
'4 % " 6
%"
7
'4*
+8
!
#
#
(9
/ 1
+
"
*
2+
%
"%
+
"
"
#
"
"
*
#
+
+
"
"
%" "
5
*
4 +!
%"
+
"
"
%
4
*
+
%
"
3
"
4 +!%
"
#
"
4
%
'4 % " 6
%"
7
'4*
+8
!
#
#
(;
/ 1
+ "
)
2+ "
""
%
"
#
4
"
"
+
"
" "
"
:
"
"
*
!
"
+%
"
#
" ,9
) #
+
+ 4
"
#
"
#
(>
/ 1
+ "
)
2+ "
""
%
"
#
4
"
"
+
"
" "
"
:
"
"
*
!
"
+%
"
#
" ,9
) #
+
+ 4
"
#
"
#
(?
/ 1
+
"
"
%
<
2+
+
+
'
"
"
=
"
!"
%"
%
"
#
4
6
5
5
"
* 4 +
4
+
5
#
"
% %
*
+
"
4 #
#
3
1
#
(A
/ 1
+
"
"
%
<
2+
+
+
'
"
"
=
"
!"
%"
%
"
#
4
6
5
5
"
* 4 +
4
+
5
#
"
% %
*
+
"
4 #
#
3
1
#
0B
/ 1
"
+
2+
+
+
"
"
"
"
*
4 + %"
"
"
!
#
! "$
%
$"
"
"
%
!
*
2
$
$
%
"
&
#
"
"
#
4
6
"
!
!
"
#
%" "
%
%
"
%
2
4
"
%
%" "
"
"
+!% "
"
!
4#
0C
/ 1
"
+
2+
+
+
"
"
"
"
*
4 + %"
"
"
!
#
! "$
%
$"
"
"
%
!
*
2
$
$
%
"
&
#
"
"
#
4
6
"
!
!
"
#
%" "
%
%
"
%
2
4
"
%
%" "
"
"
+!% "
"
!
4#
0,
.,!
(
,
.
+
*
The OMA Section on Emergency Medicine is opposed to the introduction of Alternate Care Providers
(ACPs)[1] into the delivery of Emergency and Urgent Care services in the Province of Ontario and we
are opposed to the assumption of medical and legal responsibility by Emergency Physicians for the
training and supervision (both direct and indirect)[2] of ACPs.
[1] Current and proposed Alternate Care Providers in Ontario include but are not limited to:
Acute Care Nurse Practitioners.
Primary Care Nurse Practitioners (a.k.a. Nurse Practitioners – Extended Class).
Physician Assistants (Canadian and US).
International Medical Graduates (IMGs) functioning in a Physician Assistant role.
[2] Direct and indirect supervision includes:
1. Direct and indirect supervision of an ACP in an ED setting.
2. Direct and indirect supervision of an ACP in an Urgent Care setting.
3. Formal consultations at the request of an ACP.
4. Informal “Hallway” consultations at the request of an ACP.
5. Review of ACP generated diagnostic and laboratory results.
6. Review of ACP performed histories, physicals, assessments and treatment plans.
7. Physician availability for consultations by an ACP in a Collaborative Care Team setting.
The OMA Section on Emergency Medicine Executive, September 27, 2007.
0(
/
"
@
I
%
I
00
$"
$"
6
09