ED staffing ratios

[EDdad]

I am an ED RN in a fairly busy ED in Washington state. We just implemented a fast track model in our ED, and are now looking at our staffing ratios to see if they need an adjustment, based on RN feedback. The model puts low acuity and easy 3's through the Fast Track, and this leaves higher acuity patients clustered on the back end. We have always been a 4:1 RN ratio, but staff is asking if we should go to 3:1 on the back end. The Fast Track is capturing a significant number of the easy 3 chip shots, so it does appear that back end RN's have an increased load. However, I am tasked with looking at evidence for current best practice staffing models, and possibly looking at acuity based staffing options. I'm looking for feedback from others with experience in comparable staffing ratios, specifically those that are at 3:1, Fast Track models, or use acuity based staffing.

[twinmommy+2, ADN, BSN, MSN]

I'm interested in following this definitely.

[foragreatergood]

In our dept the fast track area RN has 5 patients but they are all 4's and 5's. No easy 3's, no kidney stones, migraines, they don't even want the severe back pains. The rest of the dept is 4:1. We have been trying to get this better balanced. It seems if you are weeding out the easy 3's to fast track, that means the main ED is getting all 2's with some 3's. moving to 3:1 seems appropriate.

[NurseHeart&Soul, MSN]

Are you an ENA member? I think you would get the best response and potentially some associated data from other facilities if you join the ENA forum called the ENA Huddle Digest.

Completely agree with the previous poster. When the Fast Track is working the nurses in the main part of the ED end up with a very high acuity assignment. Could you do a retrospective review of what assignments looked like as far as acuity level distribution before adding Fast Track and what they look like now? Food for thought. At least then you'd have some data to show what has happened by having a Fast Track.

[CX_EDRN]

We are generally 1:3, but often 1:4 overnight. In fast track we can be 1:4-5, but we are very high acuity and rarely see ESI 4s and 5s. We try for soft 3s in fast track but it's not always possible. It sucks when you're over there without a strong team because of that.

[akulahawkRN, ADN, RN, EMT-P]

An ED where I recently worked implemented a Fast Track type of program around a year ago. The nurses assigned to the FT area usually had a 1:4 load, almost always easy 3's, 4's and 5's. This meant the rest of the ED usually ended up getting all the higher acuity patients. Accordingly the rest of the ED was staffed 1:3. Sounds like doing 1:3 staffing for the non-FT area is a good place to start as the average acuity level will rise as lower acuity patients are "diverted" to Fast Track. Something also to look closely at is the ability of the "main" ED to flex their staffing to 1:4 in the event a nurse has to go to 1:1 or 1:2 because of patient acuity or have a float nurse that can take over a 1:1 patient or the balance of an assignment due to a patient's high acuity.

[Veldtor, BSN, MSN]

I am an ED RN in Level 1 Trauma center with a Main ED, Fast track, Critical care room, and Trauma Center. In our fast track we do mostly 4s and 5s with a few easy 3s. There is usually 2 Nurses, who team nurse with two PAs or NPs and upwards of 20 patients at any given time. Our main ED ratios depend on staffing, but usually are 5:1 up to 7:1. But for us we usually can place a high acuity patient into the Critical Care room, which has 3 beds.

[Lev, MSN, RN, NP]

I just switched jobs and haven't actually started on the floor at my new one, but I can speak to my old job. Fast track opened at 630am and stayed open no later than 130pm. Sometimes closed at 11pm, sometimes earlier, depended on staffing. Fast track saw 4s and 5s with a PA only. If there happened to be a physician available, fast track also saw "soft" threes. I have had up to 9 patients at a time in the fast track area. That left the main ED open to take the 1s, 2s, and 3s at a 4:1 ratio, up to 5:1 (we switched to team nursing). Sometimes at 230am we would take the remaining 4s and 5s in the main ED, at a 4:1 ratio too.

[NotYourMamasRN]

I have worked in several ER's set up like yours is now. Most staffed the back end at 4 to 1 with the exception of ICU level patients stuck in the ER for a hold or awaiting bed assignment. Usually in that instance they would go to 2-1 or 1-1 depending on the situation. Fast track was usually between 4-6 t0 1. I found that ratios in the ER were always extremely fluid, just like the work environment. A good charge knew her nurses, their strengths, what they could handle, and the patients in the waiting room. They made adjustments as necessary.

[R5RN, BSN, RN, EMT-P]

Our fast track ratio is 9:1 and takes 4s, 5s, and "soft" 3s that frequently end up being not-so-"soft" (migraines, male abdominal pains, bounce back pedi abdominal pain, etc). Our main ED has 4-5:1 but we are pretty good at getting an assignment covered by charge or a float if you need to go 1:1 with a pt. Our psych area is, unfortunately, essentially unlimited. I've had 13:1 in psych.

[GCom24, ASN, RN]

Just to help vary your sample:

26-bed ER, two of which are trauma rooms. We run Fast Track in 8,9,10, and "MSE." Room 9 has 4 chairs in it for lowest of acuity patients. So Fast Track, maxed out, would be seeing 7-8 patients. One nurse, one mid-level. The rest of the ED is supposed to operate at 1:4. However, we can and will, place patients in the hallway. So it could be 1:5. Our Fast Track closes at 2300. We never, never, n e v e r go on diversion. Nurses that have been there 10, 20, and 30 years say that they have seen it happen once or twice. But this is how we do it. We're the only ED serving a pretty large catch man area in the south east. Not a trauma center, but we take everything and transfer as needed obviously.