What is your ER like.....need advice?

LakeEmerald · Jan 3, 2015

1:5 is a hard ratio with which to ever feel caught up in the ED (not including fast track). With that ratio, you would definitely need more techs/floats to keep things moving. Maybe another ER would be more supportive with techs/floats or a lower ratio.

Our ED has 32 rooms plus 4 screening rooms, and we see about 180-200 patients per day. Our manager tries to keep a 1:3 ratio (regular ED patients) and when times get really tight, we go 1:4. The RNs do most of the diagnostics (bloodwork, ekgs) with scattered tech assistance. I can move my patients faster at 1:3 because I can complete the diagnostics and treatments faster and the MDs can dispo sooner. It's safer because our nurses aren't spreading themselves too thin.

I believe care suffers at 1:4 and above. I find myself trimming the edges off of my customer service to keep everyone safe and medicated. Also, I can't get diagnostics running as fast due to triaging/treating more patients as new ones keep rolling in. I don't know how nurses at other hospitals manage to keep their patients safe and reasonably satisfied with 1:5 ratios. I'm curious to hear what other ED nurses experience.

I'm sorry you are being made to feel that you aren't fast enough. I believe your ratio is barely manageable and unreasonable. Yes, you can do it, but you could do it so much better in a more reasonable environment. It says a lot about your personality that your patients love you.

If you do move, I hope you find a more supportive environment. Best wishes to you.

**canoehead, BSN, RN** · Jan 3, 2015

We work at 1:4, and even if the patients aren't critically ill, they are still getting constant interventions in the ER, and constant reassessments. Even when I'm working the less acute rooms, 4 patients is plenty. I suppose 1:5 is possible, but I certainly wouldn't feel secure. ER patients are too unpredictable.

allnurses Guide · Jan 3, 2015

ENA recommends no more than 1:4. We are officially that, but often a bit more. We have a fast track area where it is much higher, doing line/labs, and a few IV meds but more clinic type patients (the soft 3s and 4s). Have had previous managers say "but you know most of them aren't heavy, so you could do 5 or 6" in the rooms. Ah, no. We also have lost most of our techs and all the secretaries.

Some places will be better, some worse. Routine 1:5 is too much, for that census. Don't be scared off looking into ER jobs elsewhere, ask the staff nurses how many they usually have when you are touring the unit. Floor nursing after the ER is, well, boring :)

AZQuik · Jan 4, 2015

We're 1:4. 1:5 in our CDU.

Occasionally our psych zone will get a fifth in the hallway, but it's usually a regular that just wants a sandwich and a place to sleep. They c/o some type of mysterious knee pain, get an X-ray and a sandwich, then take a nap. Occasionally you will get a fifth stable patient late at night when things slow so we can staff down an on call person.

That said we have a lot of support. There is always a float or two on busy nights, usually a tech and medic per 20 beds, two sitters for the psych area, a clerk for every 20 beds or so when we are busy, 2 phlebotomists, a pharmacist or three, access to a respiratory team usually within 10 min or less, loads of residents, almost always a medic/nursing student who want to help, and of course your orientees who usually want to get their hands dirty.

BSN GCU 2014. ED Residency

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Theocbean · Jan 5, 2015

I wanted to thank you all for your responses! I am beginning to see that my ER is not necessarily staffed well (which is more of an understatement). I have had times (for example) where I have been given 2 patients around the same time who needed a Cardizem bolus and drip (plus fluids and a mag drip and other meds), a patient in DKA (who needed insulin drip, fluids and Q 30 glucose checks) and 2 abdominal pains who were constantly ringing the call light. Once you max out your IV attempts with any patient you have to beg, borrow and steal to find someone who is not too busy to try and they can get a line in but cant get blood you end up asking the lab to draw blood can take up to 2 hours before they even are able to get to the patient. 3 out of 5 of these patients can't ambulate to the bathroom so just getting one of them on and off the bed pan or to and from the restroom via wheelchair can suck up at least 10 minutes of your time (which I don't mind doing but all my other tasks are piling up at this time). I have been this is how most ER's are by a few staff members who also think I am not fast enough. I would feel like Christmas to have 2 techs and 2 float nurses for all 30 patients.

murphyle, BSN, RN · Jan 6, 2015

45-bed adult acute care/10-bed adult minor care/10-bed pediatric acute care, seeing 280-330 patients/day:

An acute care team, of which we run four, consists of one physician (plus or minus a resident or a PA/NP), three RNs, one tech, one secretary and one "tech aide" (these folks handle vitals, transport, patient comfort, and stocking). Up to 15 "active" patients can be slated to a team. We occasionally alter the ratio upward if a team is full of low-acuity hold traffic, and frequently cut the ratio down if it's all Priority II and post-resus. We also typically staff at least two float nurses and a float tech at all hours, and try to staff a fourth nurse and occasionally a second tech per team during peak hours to cover Resus and manage the heavy players. Minor Care gets two PAs, two nurses and a tech; Peds runs two pediatric NPs, three nurses and two techs, with the whole thing supervised by one physician. Those two units are side-by-side, so staff typically float between the two if traffic in one zone is low. Tech aides typically handle psych sits if we can't get house sitters (and with our volumes, the house is usually pretty good about finding us sit coverage). On top of all that you have anywhere from 2-4 nurses and a like number of techs and tech aides at Triage, another nurse and a tech in the Ambulance Bay, and two nurse clinicians running the show (one out at Triage and one in the back). We also get ancillary support from Respiratory (one RT staffed for the department 24/7, two during peak hours) and Pharmacy (EC pharmacist on duty 0700-1600 Mon-Sat).

I agree with the OP that his/her staffing mix seems very lean for the volume and acuity described, and would likewise suggest that the issue of perceived poor performance stems more from departmental short staffing than his/her speed of work. However, I'm a little surprised to hear that other shops are running with 1:3 ratios and staff feel that that's struggling. When we've up-staffed to that degree in the past, we typically see a lot of slack staff and no real improvement in patient care metrics.

Kristen75 · Jan 6, 2015

Your staffing ratios are a dream to me. I work in NYC and there have been nights where I have had upwards to 17 patients to myself. Most nights it is between 10-12. Usually work on a team with two nurses (good nights there will be a third) and each team will have between 20-35 patients per team. If we are lucky we will have a tech. Pretty much do everything by the seat of your pants and pray.

**NickiLaughs, ADN, BSN, RN** · Jan 7, 2015

1:4 in cali, they try to have a float nurse for every 8 patients so the third nurse can do the others lunches or become the ICU nurse if a patient goes south. We also have an RN whose dedicated for the medical resus room and one for the trauma room.

We have about 10 techs on shift, all are trained on doing most of the splints

39 bed ER./ortho devices.

we also have one phlebotomist who tries to do all Th e routine sticks who dont need lines for us

Before you admire the ratios, we see 370 pts a day. So we have to be staffed like that to be efficient.

I came from an ER that had much worse staffing, i was used to having an ICU or two in my 4 pt assignment, missed lunches etc.

I dont know if ill ever feel on top of things but I feel safer here.

murphyle, BSN, RN · Jan 7, 2015

370/day in a 39-bed shop?! That's not just efficiency, that's magic. :wideyed:

You must have amazingly fast inpatient admissions, or be seeing a lot of fast-track traffic, to make that work. How do you keep up that kind of throughput?

dave3000 · Jan 8, 2015

Makes me want to move to CA. I also work in NYC, I had 12 patients at one point last shift - including 5 admitted, 2 critical and a step-down. Not safe, documentation becomes nearly impossible, pt care suffers - I just try to make sure they're all still breathing at the end of the shift.

Lâ™¡vER · Jan 8, 2015

The goal is 1:4 here, but it's not uncommon to run with 5 sometimes 6. We are boarding tons of patients lately too (season in Florida) so you may have an ICU, 2 teles, then 3 ER patients to rotate in and out. Crazy unsafe. The tele patients seem to be the ones getting ignored in that scenario unfortunately. We usually have a free charge, a tech per 10/15 patients, a secretary and 1 doc.