Staffing Ratios in the ED

[Melissa Mills, BSN]

You enter the emergency department (ED) right at shift change. But, tonight's different - instead of going to work - you signed in as the patient.

As you register, you hear one of the nurses state that there were two call offs and no staff available to float from another department. As you look around, you don't notice anyone in the waiting area reacting, except you. You even quietly wonder if it would be best to go home and wait it out until the morning to see your primary doctor.

As a nurse, you know that limited nursing staff will probably mean you are in for a longer than average wait time. One recent study has confirmed what you already knew - poor nurse staffing numbers in the ED increases patient length of stay and decreases patient satisfaction.

The Findings

This study was conducted in a high-volume, urban public hospital. The researchers conducted a retrospective observational review of the electronic medical record database for a 12-month period in 2015. They reported nursing hours, door-to-discharge length of stay, door-to-door admit length of stay and the percentage of patients who left without being seen.

The mean number of daily visits in the ED was 290, with a range of 219 - 425. The median number of nursing hours per day were 464.7 hours.

The study found that poor staffing models in the emergency department increased the door-to-discharge length of stay and increased the number of patients who left without being seen. No change in door-to-admission rates was observed. Could this be because the receiving unit was adequately staffed? There was no reason given in the study, but it makes sense that if the receiving unit was fully staffed, they could receive the patient timely from the poorly staffed ED.

Other variables, such as the daily ED volume, hospital census, and ED admission rate did not change the length of stay statistics observed in the study.

What We Know About Staffing Ratios

Nursing ratios equate to positive patient outcomes and safety. Adequate staffing has been proven to show a reduction in:

• Patient mortality
  
• Patient readmission rates
  
• Medical and medication errors
  
• Patient length of stay
  
• Patient costs related to unplanned readmissions
  
• Preventable events, such as pressure ulcers, falls, and other hospitalization complications
  

Not only does poor staffing affect patients, but it also affects nurses too. A Medscape survey found that 57% of nurses polled believe that patient care is suffering. And 53% of said that at the end of a typical shift, they don't feel satisfied with the care they provided. This is a problem that can't be ignored.

So, we know that safe staffing levels are a requirement for quality patient care. But, whose responsibility it is it to enforce?

Federal Rules

Medicare-certified hospitals are required by law (42CRF 482.23(b) to "have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed." This regulation can provide some guidance to hospitals but leaves quite a bit of room for interpretation.

In fact, because of the loose language in the regulation and the lack of enforcement by Congress, many states have started taking the matter into their hands by creating safe staffing laws.

Staffing in Your State

Does your state have a mandatory staffing law?

There are currently fourteen states that offer official regulations for nurse staffing. These states include California, Connecticut, Illinois, Massachusetts, Minnesota, Nevada, New Jersey, New York, Ohio, Oregon, Rhode Island, Texas, Vermont, and Washington. Seven of these states also require hospitals to have staffing committees who are responsible for nurse-patient ratios and creating a staffing policy. These seven states are Connecticut, Illinois, Nevada, Ohio, Oregon, Texas, and Washington.

While it's good that many states are adopting regulations, it seems there isn't any consistency from one state to the next. Massachusetts requires a 1:1 or 1:2 nurse to patient ratio in the ICU. Minnesota requires that the Chief Nursing Officer develop a staffing plan and California stipulates a minimum nurse to patient ratio be maintained. And, five states require public reporting of staffing ratios.

Nurses Taking Action

Like many issues - if you want something done right - you have to do it yourself. This may be the motivation behind recent movements.

The American Nurses Association (ANA) supports the empowerment of nurses to help solve staffing issues by creating staffing plans specific to each nursing unit. They have identified key factors that influence nurse staffing, which include:

• Number of admission, discharges, and transfers
  
• Skill level of nursing and non-nursing staff
  
• Patient complexity, stability, and acuity
  
• Layout and physical space of the nursing unit
  
• Availability of resources and other technical support
  

Another recent movement in the battle to find common ground on the subject of nursing ratios is NursesTakeDC. This nurse-driven movement strives to make safe staffing ratios a reality for nurses across the United States.

You might think that this was just a one-time event that happened earlier this year, but NursesTakeDC is committed to planning future events, providing further education, and supporting current and future legislation.

Where Does This Leave Us?

It may seem we're still a long way from making real change and impact on nurse-patient ratios. But remember - we've made strides in the past 10 or 20 years. Today more than ever, we need education on this topic to the general public, the healthcare community, and lawmakers.

How do you feel about the staffing assignments in your facility? Do you have any personal stories about how staffing impacts patient care? We would love to hear more about your thoughts on this critical issue.

[That Guy, BSN, RN, EMT-B]

Another study with the punchline of "No ****". You mean it takes me longer to get my patients going when I have 7 of them as opposed to 4?

[SpankedInPittsburgh, DNP, RN]

Once again without mandatory and objective staffing limits all this stuff is useless noise. I don't trust a committee of nurses with mixed motives to come up with any sort of sensible answer to anything. They will form a consensus opinion that pleases the powers that be as always which is why not much ever comes out of these committees which are largely made up of "upwardly mobile" nurses who want to be part of management themselves someday