how much nursing is adequate?

[Perrotfish]

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I have seen more variation in the nursing staffing in the ED than in any other department of the hospital. Is there any consensus opinion about what the maximum bed to nurse ratio should be? How many nurses do feel are adequate in nurse only eds? What about in eds where nurses have LPN assistants who can start I vs and give PO (but not IV) meds? Do you know of any studies to support a standard of care for nursing coverage?

 

[deuist]

We currently have an 8:1 ratio, which I think explains many of the problems we face regarding throughput and nursing satisfaction. If we could get that ratio down to 4:1, things would be a lot better. That, an extra CT machine.

 

[Arcan57]

We currently have an 8:1 ratio, which I think explains many of the problems we face regarding throughput and nursing satisfaction. If we could get that ratio down to 4:1, things would be a lot better. That, an extra CT machine.

Throwing nurse staffing at an inefficient system may just make the payroll jump without marked improvement in throughput. Queue theory holds that increasing capacity at places that aren't the rate limiting step actually makes things worse. If you have an inability to get xrays read or if your lab takes 75 minutes to process a sample, doubling nurses won't double throughput. Since nurses are overburdened with useless regulatory documentation (which is being added to basically every quarter) it seems like off loading nurse duties with tech would work. Unfortunately what happens is there is usually a less than 1:1 tech/nurse ratio and any duties you assign the techs became in effect "tech only" jobs. So now instead of two nurses drawing blood simultaneously, you have two nurses telling one tech to draw blood at the same time. This also reinforces erosion of core nursing skills, so on days when you're understaffed with techs suddenly blood can't be obtained on any of your patients.

The preceding paragraph was largely cynical (and borne out by multiple rounds of flow improvement projects). If you're running regularly at 8:1, you probably do need additional nursing resources. Implemented correctly, techs can improve flow if nurses are your busiest server. But just throwing payroll at the problem doesn't help if the system is broken. An example of this that most of the attendings have felt is when an additional swing doctor is added at the request of the hospital because of high volumes during peak hours. If you're holding patients everyday from 2p-7:30p and your ED is clogged with admitted patients, adding a swing doctor to come in at 1p just screws everybody's productivity without significantly changing the metrics.

 

[med2UCC]

An example of this that most of the attendings have felt is when an additional swing doctor is added at the request of the hospital because of high volumes during peak hours. If you're holding patients everyday from 2p-7:30p and your ED is clogged with admitted patients, adding a swing doctor to come in at 1p just screws everybody's productivity without significantly changing the metrics.

We've just implemented a 16:00-22:00 swing shift for that very reason and are finding that on some days it helps but on most i just increases socializing time for all, as the beds are full of patients and no one comes in from the waiting room. Lower productivity all round and no better "left without being seen" numbers. And rarely better outcomes for the 17:00-01:00 doc, who ends up staying late trying to clear the board so the overnight solo doc doesn't get slammed. Oh well, back to the drawing board.
M

 

[OccupyTheED]

. . . Unfortunately what happens is there is usually a less than 1:1 tech/nurse ratio and any duties you assign the techs became in effect "tech only" jobs. So now instead of two nurses drawing blood simultaneously, you have two nurses telling one tech to draw blood at the same time. This also reinforces erosion of core nursing skills, so on days when you're understaffed with techs suddenly blood can't be obtained on any of your patients . . .

In my 6 months as an intern I have seen this scenario play out far too often, at times when I ask a nurse for labs, an IV, repeat vitals, orthostatics etc, they pass the duty off to an overworked tech and it slows down my workups tremendously. If only somehow we could hold others in the ED accountable to the same level that we as physicians are

 

[Arcan57]

We've just implemented a 16:00-22:00 swing shift for that very reason and are finding that on some days it helps but on most i just increases socializing time for all, as the beds are full of patients and no one comes in from the waiting room. Lower productivity all round and no better "left without being seen" numbers. And rarely better outcomes for the 17:00-01:00 doc, who ends up staying late trying to clear the board so the overnight solo doc doesn't get slammed. Oh well, back to the drawing board.
M

It can work if you have space in the lobby to see patients and they are willing to dedicate a tech and nurse to assist you (this is a discussion to have with the COO/CEO about the benefit of matching provider/nursing resources). A solo doc without assistance can clean out some patients that would normally be screen outs, but the activation energy to go out to the lobby is quite high for most docs. It's easier to sit in the back with your 2 active patients, especially because on days when you're holding very little gets done without your direct involvment.

 

[Arcan57]

In my 6 months as an intern I have seen this scenario play out far too often, at times when I ask a nurse for labs, an IV, repeat vitals, orthostatics etc, they pass the duty off to an overworked tech and it slows down my workups tremendously. If only somehow we could hold others in the ED accountable to the same level that we as physicians are

You can. It involves having a nurse manager that holds the nurses accountable and the willingness to replace (at least) 30% of your current nurses. It's not something that's doable as a physician, because the 30% of nurses that need to be given opportunities to succeed elsewhere are more then enough to sink you at that hospital. Being confrontational to a nurse on shift about anything that isn't life threatening is an excellent way to make enemies that can destroy you with their charting and passive-aggressive behavior. Go to the nurse manager (or charge nurse if you have a good relation with them and trust them not to run to the undeperforming nurse) and give specific instances of subpar behavior. If your nurse manager refuses to do anything, then you need to look into getting a new nurse manager. Mediocrity infests institutions that tolerate it.

 

[deleted92121]

I work as a paramedic in a 40 bed Level II trauma center with about 60k visits a year. We frequently have multiple high acuity patients (level 2 or 1 on the ESI triage scale).

Our current staffing is 4 patients : 1 nurse. We have PCA who transport, stock, change bedpans, and a lot of other tasks. They are involved with patient care but mostly do the nurses scut work. There are two or three PCA on the floor.

Our department runs smoothly though because of how paramedics are utilized. We triage, start lines, administer IV meds, intubate (not unusual when we are single coverage doc and the crap hits the fan), splint with orthoglass, and we do take patient assignments when nursing staff is down or the need exists. I really do think of us as the swiss army knife of the ED. There are a few things we cannot do for legal reasons but not a big deal. Typically there are two medics on the main floor and two on the quick care side.

As far as optimal staffing goes, it appears that 3:1 is what many ED in my area are going for with proper ancillary staffing. I am not sure of any studies out but our satisfaction scores have skyrocketed with going from a 6:1 to 4:1 staffing and adding additional staff on. Purely anecdotal but there may be something there.

 

[southerndoc]

We currently have an 8:1 ratio, which I think explains many of the problems we face regarding throughput and nursing satisfaction. If we could get that ratio down to 4:1, things would be a lot better. That, an extra CT machine.

8:1? Seriously? What kind of acuity do you have?

We have 4:1 nursing, and the worst I've seen is 5:1 at any hospital I've worked at.

 

[la gringa]

8:1? Seriously? What kind of acuity do you have?

We have 4:1 nursing, and the worst I've seen is 5:1 at any hospital I've worked at.

sounds like where i trained... but when you have residents doing some ancillary tasks and huge waits for beds, and no P-G type stuff about which to worry, you can tolerate it. doesn't work in the community!!!

i've found that for every nurse that can handle 5:1, there is one who can hardly handle 3:1... ughhhh frustration.

 

[Perrotfish]

A follow up question: how do you let ancillary staff take lunch breaks? I have seen EDs where everyone leave at once with just a handful to crosscover, like the floors. Others where lunch is basically 'if and when', and still others with dedicated floats relieving people one by one for meals. How do you keep the floors running and still get everyone to eat? How long do you think is a reasonable ancillary staff shift, how long is a resonable break, and how many breaks should they get in an ED enviornment?

 

[EM2BE]

A follow up question: how do you let ancillary staff take lunch breaks? I have seen EDs where everyone leave at once with just a handful to crosscover, like the floors. Others where lunch is basically 'if and when', and still others with dedicated floats relieving people one by one for meals. How do you keep the floors running and still get everyone to eat? How long do you think is a reasonable ancillary staff shift, how long is a resonable break, and how many breaks should they get in an ED enviornment?

Current location relieves each other with a float covering each person one by one for nursing. Techs take breaks individually as well but no cross coverage. Nurses have to do more during their breaks. I think they get 30 min and the nurses still have their go-phone so they can be reached about any pt questions. Maybe one or two smoke, so those breaks are limited as well. After a rough case /pt leaves the ED to their destination (morgue, ICU, police, transfer), the nurse will be relieved for a period to take a breather and until the documentation is done.

As far as ratio (community ED), we are 5:1. If their are no techs, they try to do a smaller ratio but sometimes we are short nurses at the same time. Worst scenario I have seen was charge plus one nurse, no techs, 20 beds. Not a good time at all. That only happened because there were scheduling issues - high turnover period, not enough replacements from those that left, near graduation time (techs that were in nursing school graduated and were studying for nursing boards), huge hospital changes (change in ownership), summer time so some vacations were set.

One thing I have seen that really helped a ton in the past that may help is when we had a good number of boarders and short nurses, they had a nurse from the telemetry floor come down, moved all the patients to one pod, and she was the nurse for the boarders. Made them get better care (nurse that is used to scheduled dosings and not just stat orders), no new patients for her to worry about triaging, and the ED nurses were freed to do the normal things in their comfort zones. Flow was great even though we were down 5 beds.

 

[AlmostJesus]

I work as a paramedic in a 40 bed Level II trauma center with about 60k visits a year. We frequently have multiple high acuity patients (level 2 or 1 on the ESI triage scale).

Our current staffing is 4 patients : 1 nurse. We have PCA who transport, stock, change bedpans, and a lot of other tasks. They are involved with patient care but mostly do the nurses scut work. There are two or three PCA on the floor.

Our department runs smoothly though because of how paramedics are utilized. We triage, start lines, administer IV meds, intubate (not unusual when we are single coverage doc and the crap hits the fan), splint with orthoglass, and we do take patient assignments when nursing staff is down or the need exists. I really do think of us as the swiss army knife of the ED. There are a few things we cannot do for legal reasons but not a big deal. Typically there are two medics on the main floor and two on the quick care side.

As far as optimal staffing goes, it appears that 3:1 is what many ED in my area are going for with proper ancillary staffing. I am not sure of any studies out but our satisfaction scores have skyrocketed with going from a 6:1 to 4:1 staffing and adding additional staff on. Purely anecdotal but there may be something there.

Im a medic and I work in the ED as well, although I work in a small town ED (5 beds) where I am also responsible for ambulance. They use us in cooperation with the ED nurse, so we can leave on short notice if we have to.
I take my own patient assignments from start to finish, start IVs, give meds (PO/IM/IV/IVPB), intubate, EKGs, monitor for light/moderate sedations, etc. I do not do catheters, access ports, anything gyn, or overly complicated cases.
It is a great way to keep my skills up since our ambulance is so slow. I know at our tertiary referral centers, they use their flight paramedics/nurses extensively in the ED for relief, etc.
A well educated paramedic that has some background in some nursing skills is pretty well suited for working in the ED IMO. They could really help with maintaining staffing, especially if you are up to 8:1. You could easily go to 8:1 with a paramedic directly assigned to you.