Fewer RNs, more support staff in the ED?

mwboswell · May 20, 2009

Its been shown that higher RN to patient ratios have better outcomes.

Those studies were done on inpatient units not the ED.

I've read some of these studies and to clarify these were done with inapatient settings not the ED.

One could not replicate (nor extrapolate) the same studies to the ED due to the varied patient load and other variables present.

So I don't think we can make any assumptions here based on those

mwboswell · May 20, 2009

The difference being, EBM is now a standard way of basing our medical decisions. Why should it be any different with staffing considerations? When debating the optimal staffing solution, would EBM not be a proper way to objectively justify or disprove our theories?

This was one of the "take home points" from my Master's Thesis years ago.

I did a meta-analysis of increased trauma during the full moon period (seriously!)

I found no correlation at the end of the meta-analysis.

Part of my pre-analysis hypothesis was that if "everybody" thinks it's busier during the full moon, AND if the evidence supported that, then why don't we bump up our staffing numbers during the full moon. I postulated that you'd have a hard time finding any administration openly admit that they would do this because even as much as they "believed" it, it would still seem superstitious and who would believe THAT health care system with their loved ones? (unless the evidence supported it)....

mwboswell · May 20, 2009

What really bothers me is that patient acuity isn't a factor in determining our staffing. I was just saying this the other day -- there should be a weighted score based on acuity. As it is, a cardiac arrest has the same weight as a patient who comes in for suture removal. I think that is ridiculous. Since we use a five-level triage system, there SHOULD be a way to assign a multiplier to the patient numbers, like a Level 5 = 1, Level 4 = 1.25, Level 3 = 1.5, Level 2 = 1.75, Level 1 = 2. Because there are days where we might see only 40 patients, but many of them were heading for the celestial care unit, or needed moderate sedation, or were vented, one-to-one pts headed for ICU, that kind of thing. We need to see something close to 50 pts. in a 24-hour period in order to be "productive" at full staffing.
Does anyone out there factor acuity into their numbers?

Lisa,

I'm not well versed on the acuity rating thing, but I do know the ENA has some "guidelines" for this. I haven't read them myself and I can't speak to them. Maybe if you browse the ENA website it might give you some information (www.ena.org).

But you're right, staffing based on acuity makes sense.

It works well on the inpatient side, but of course things are more predictable there.

In the ED it's varied and inconsistent and difficult to find the "perfect" way to staff.

Cleveland ED Nurse · May 22, 2009

From my experience it doesn't work. We had our staffing 'realigned' to 'right size' our staffing based on productivity and national benchmark data 2 years ago. They eliminated RN staff and added Paramedic staff and expected 'teams' to care for groups of rooms in an efficient manner. If I have to listen to a Paramedic tell me one more time that a specific patient care task is 'not in their scope of care' I don't know what I'll do. The RNs are working harder than ever trying to care for acute ED patients along with admission holds while the medics stand around talking and waiting for a task that they want to do to come up. They want to start IV's, draw blood and be involved in resuscitation but there is more to caring for ED patients than dealing with the initial workup tasks and codes. They don't answer call lights unless they are forced to. They tell us they won't clean patients who have soiled themselves and half the time you can't find them to ask them to do a task. In the prehospital environment, they have more autonomy working under a set of guidelines and the direction of their medcontrol physician. In the hospital, they have yet to learn that the RN is the one who can delegate tasks to other staff. They were told by the Director that they were 'members of a team' and nobody was more important than the next. I don't know where he practiced before but this concept didn't fly in our ED. We ended up with angry, overworked, burned out nurses and a group of lazy medics who won't do anything that other medics aren't doing.

Because they were seen by administrators standing around, they eliminated medic positions and now we have fewer nurses AND fewer support personnel. We don't have enough nurses to care for the patients and staff Triage so there is now a medic in triage at all times and a nurse in triage only on evening shift. If triage is so busy they need a second person, there goes another medic and there is one left to transport patients to xray, admissions to the floor and draw blood cultures.

Our productivity statistics don't include the admission holds because we stop getting credit for them as soon as an admission order is entered into the system. This may be an unstable ICU hold who is having meds titrated to maintain vital signs, insulin drips and frequent accuchecks, ventilator care, I&O management... It takes most of the assigned nurse's time but we don't get credit for it in our staffing so you end up not having enough staff to take care of all the patients. Until support staff understand what support staff means, this system will not work and it doesn't recognize everything that the RN is doing to assess and stabilize their patients. The director who came up with this right sizing plan left last summer, we have lost many of our experienced nurses because of the unsafe situation and are reliant on high priced agency staff for our off shifts. I don't see that the hospital saved any money by changing the staffing matrix, the cost of the agency staff is still billed to the department budget, it just comes under a different heading.