Staffing an ED Appropriately and Efficiently

Many EDs Vary 40% Between Their Slowest and Busiest Days, So Peak Load Crises Are Inevitable. But How Many Are Tolerable?

August 2009

By Martha Collins
ACEP News Contributing Writer

Having the right mix of physicians, nurses, midlevel providers, and support staff in the emergency department can help ensure emergency department efficiency, patient satisfaction, cost-effective care, and medical-legal safety. But just how do you know that you are staffing your emergency department appropriately and efficiently?

"When it comes to ED staffing, there are strategic drivers and tactical drivers. The strategic drivers are quality of care, patient safety, and the level of service you want to deliver. The tactical drivers are patient volume, acuity, patient length of stay, admit holds, physician capabilities, and non-physician staffing," said Kirk B. Jensen, M.D., MBA, who is chief medical officer for BestPractices, Inc. Dr. Jensen also is a faculty member of the Institute for Healthcare Improvement (IHI) in Boston, and chair of IHI's collaborative on Improving Flow in the Acute Care Setting and Operational and Clinical Improvement in the ED.

"The ED by its nature is often either overstaffed or understaffed because patient volume is not evenly distributed. Many smaller EDs have as much as a 40% variation between their slowest and busiest days, so peak load crises are inevitable. The real question is how many are tolerable? How far do you bend before you break?" Dr. Jensen said.

What are the best ways to reconfigure staffing models as volume increases, and how do you identify the critical inflection points at which another attending physician is required?

"First and foremost, you've got to deal with the fact that there are 8,760 hours in a year and the ED is open every one of those hours," Dr. Jensen said. "You have to decide what a reasonable workload is for your facility and your physicians, and once you exceed that workload, then you need to add coverage."

"In the past, the numbers often quoted were 2.3 to 2.8 patients per hour. We are now living the new reality of patient complexity, acuity, customer service expectations, skilled workforce shortages, crowding, boarders, and risk management," he said. "To the extent that a range can be established, it would be 1.8 to 2.8 patients per provider per hour."

In matching your staffing capabilities or capacity to demand, you reach an inflection point. "If, on average, your doctors can see 2 patients an hour, and your department is averaging anywhere from 1.5 to 2 patients an hour, you're fine. But somewhere around 2.1 or 2.2 patients per hour, you reach an inflection point at which you have to beef up staffing," Dr. Jensen said.

Consider the following examples of the number of patients per hour (PPH):

  • 2 PPH 8,760 hours/year = 17,520 patients per year.
  • 2.5 PPH 8,760 hours/year = 21,900 patients per year.
  • 3 PPH 8,760 hours/year = 26,280 patients per year.

So, for example, 18,000 visits during the 8,760 hours in a year equals 2.05 patients per hour, which might seem to be within an appropriate volume for a single-coverage emergency department. "However, the typical ED processes 64 percent of the daily ED patient volume from 10 a.m. to 10 p.m. So during that time frame, the typical 18,000-visit ED is actually processing 2.63 PPH, or the functional equivalent of a 23,039-visit ED," Dr. Jensen noted.

"For a single-coverage ED, consider adding coverage when ED patient volume begins to exceed 18,000 visits per year and when peak load crises and their consequences become more frequent," he said. Such consequences include the following:

  • Elevated patient throughput times.
  • An unacceptably high left-without-being-seen rate.
  • Unacceptably low patient satisfaction.
  • Concerns about emergency department clinician behavior in a stressful environment.
  • Low rates of clinician satisfaction and retention.

Maximize the lowest-cost staffing alternatives first. When the inflection point indicates it's time for double coverage, use the least-expensive resource that can successfully accomplish the mission.

"For an average ED, up to 30% of patients can be seen independently by a physician assistant or nurse practitioner," Dr. Jensen said. Midlevel providers (MLPs) "are usually significantly more productive in a dedicated fast track than when they are assisting the emergency physician in the core."

Utilizing MLPs for fast track and uncomplicated pediatric patients helps increase flexibility, independence, and productivity. "The quality of the midlevel provider is the biggest predictor of success," Dr. Jensen added.

"Consider a team-based patient intake process--a physician sees the patient, an MLP does the processing work, and the physician discharges the patient," Dr. Jensen suggested. This can be a way to optimize efficiency, service, and quality.

Also consider pediatric emergency physicians and emergency physician residents. "Senior-level residents are a net plus because they can actually help with flow, but first- and second-year residents tend to slow you down," Dr. Jensen said.

"When setting goals and targets for staffing, it helps to benchmark your ED against other hospitals with similar acuity and volume," Dr. Jensen said. "There are many sources for benchmarking data, including other EDs in your area."

Some benchmarking resources include the following:

Appropriately configuring staffing patterns based on volume and acuity is the key to emergency department efficiency, as well as to overall patient satisfaction.

"There are two ways of looking at how staffing affects operational efficiency and service. For one, the more efficient your doctors are, the less coverage you need. On the other hand, if you're trying to drive throughput or flow through any system with fixed capacity, such as the ED, and if your space is limited, then you actually need higher staffing levels to drive throughput," Dr. Jensen said.

"So, for example, if ED beds are a rate-limiting step, which they are for many EDs, then you actually need more staff to drive efficient throughput than you would if you had all the beds you needed."

Part of the "new reality" of patient care is that patient expectations are higher than ever, and with the aging baby boom generation, expectations are likely to increase even further.

"The four key drivers of patient satisfaction are length of stay, the quality of the interactions with providers, the quality of the explanations, and pain management, all of which are affected by appropriate and efficient ED staffing," Dr. Jensen said.

"Additionally, what puts you at risk for medical-legal issues are incidences of misdiagnosis and misadventures in therapy, and the possibility of such incidents is diminished with sufficient coverage."


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