Nurse to patient allocation in ER what is the criteria

[Ouss]

The literature suggest a 1:4 patient ratio in the Emergency Room, with no mention about their acuity, Triage sets the initial acuity for priority in bed allocation yet this does not really translate into the acuity of the patient once inside. How would you best evaluate the acuity of your patient once on the ER bed and thus allocate the nurse to patient ratio ?

[Lunah, MSN, RN]

Triage sets the initial acuity for priority in bed allocation yet this does not really translate into the acuity of the patient once inside.

If not, then you have a triage problem. They shouldn't be that markedly different. Are you using ESI?

[Ouss]

Yes we are using ESI, yet an ESI lvl does not really reflect the acuity of the patient once admitted to an ER bed. Assuming that it does how would you decide on the nurse to patient ratio example 1 nurse to 3 patients with ESI 3.

[Gary Mendoza]

The way they do it in California (and I like it) is 1:4 max for regular ER patients (ESI's 3-5) , 1:2 max for ICU patients (I would say some level 1's and level 2's) , we all know someone can come in and not present as critical, be triaged a level 3, I've even seen them be triaged level 4's sometimes, especially when the triage nurse isn't very knowledgeable in the triage requirements or not a very experienced, knowledgeable, observant triage nurse. Then, 1:1 for trauma patients and critical ICU patients (ESI 1's).

Things change quickly in the ER, as we know, so what came in as a level 3 can quickly change to an ICU patient. When that happens, notify your charge and they should reorganize and/or find you support. That's what they are there for.

[Ouss]

Thanks for sharing Gary, I totally agree with you and in California the nurse to patient ratio is mandated so there is no need for the ED to justify FTEs or to accrediting bodies as why this ratio was followed. In our case we need to justify ( evidence based) why we chose to give 1 nurse 3 or 4 ESI 3 patients. On the other hand I also agree about the charge nurse jumping in and making changes yet wouldn't it be great if there was a tool that guide them how to do it ?

[MunoRN, RN]

The ESI triage process isn't intended for determining nurse staffing ratios, it's only purpose is to determine how quickly the patient should be seen by the MD. There is certainly some correlation between ESI level and the amount of nursing care the patient requires, but it's not a particularly useful way of determining the nursing workload that patient will create.

[Gary Mendoza]

Thanks for sharing Gary, I totally agree with you and in California the nurse to patient ratio is mandated so there is no need for the ED to justify FTEs or to accrediting bodies as why this ratio was followed. In our case we need to justify ( evidence based) why we chose to give 1 nurse 3 or 4 ESI 3 patients. On the other hand I also agree about the charge nurse jumping in and making changes yet wouldn't it be great if there was a tool that guide them how to do it ?

I would suggest you contact the ENA (Emergency Nurses Association) and ask if they have any evidenced based info. I know there have been studies and they should have them, if not them then the ANA (American Nurses Association) should have them.

As far as a guideline for charges, that would be nice, but experience is the best guideline. You can have written guidelines, but they will never be able to cover all situations for an ER.

[Ouss]

Ya, it's that link between ESI and patient acuity after reaching an ER bed that needs to be determined. How would you assess workload and then estimate the number of nurses needed to cover it.