By Eric Bachenheimer, MBA, MHSA, FACHE 
It has been about three years since CMS enacted its first emergency department-specific metrics that would become part of the mandatory reporting for U.S. hospitals. Since that time, hospitals have increasingly focused on initiatives designed to improve these public-facing metrics, such as arrival-to-provider, arrival-to-departure times and patients’ leaving the ED without being seen by a provider. Many approaches entail improving provider productivity or perhaps introducing new processes to help improve the length of stay in the ED. However, one of the key items often overlooked is the staffing of the ED itself (physicians, nurses and ED techs).
Variability is the nature of the ED – at any moment there could be 15 patients who present for treatment – or none! The number of patients coming to the ED at any given time is based upon hundreds of variables, from the temperature, rain/snow, day of week and traffic or community events. No two days are alike, and yet many emergency departments staff their departments the same way, 7 days a week! Appropriate staffing of the ED may not be easy, but it is critical to ensure appropriate coverage to adequately treat patients who seek care. So, how can we consider the best way to staff the ED?
Analyzing Supply and Demand in the ED
Many may be familiar with the concept of “supply and demand,” which stems from the principles of economics to determine market pricing for a particular good or service. When our ED consulting team evaluates the efficiency of an ED’s operations, one of the first things reviewed is the supply and demand, but in a different way than in economics, to consider if the emergency department is properly equipped. Here’s where the math comes into play.
Queuing theory tells us that if the customer arrival rates within an operation is greater than the ability to service customers, then there will be a queue, or waiting within the system. In an ED, this means patients experience wait times to be seen, and some may even walk out or elope. It is thus important to understand the numbers — how many patients are arriving by hour of the day and day of the week, and how long are they staying in the ED?
In addition to this, we also need to understand the patient population a bit more to consider the patient acuity of these arrivals. Are the patients coming in during the day presenting with sore throats and sprained ankles or are they coming in with chest pain and respiratory distress? The greater the patient acuity is, the greater the level of care that is needed to be provided by ED staff.
Once there is an understanding of the arrival rates by hour of day and day of the week and the patient acuity, the next item to evaluate is the efficiency of the operation by noting the ED cycle times (time it takes from ED patient arrival until the time they depart). Those EDs with longer patient cycle times will need to ensure there is enough staff to care for those patients. This explains why minimizing cycle times by making the ED a more efficient operation will lessen the staffing requirement.
After this information has been obtained, one can identify the “demand” side of the equation, which illustrates what we need to provide care to our patients.
The final step is making sure that the proper ED “supply” of physicians and nurses is available by hour of day and day of the week to address these needs efficiently. Physician staffing can be evaluated in terms of patients per physician or patient per provider hour to ensure there are adequate levels of staff. Nurse staffing can be evaluated to ensure that there are enough nursing hours worked in the day to provide the nursing function for patients in the ED. ED techs can be considered an extension of the nursing function to help offload the nurse, so long as there are no duties being performed by the techs that require a clinical license.
It’s important to note that it’s not possible to develop a staffing strategy using a pure mathematical approach because the ED may see a 4-hour surge, but workforce planning realistically prevents us from having a shift that lasts only 4 hours (although some ED staff would like that!). So, there needs to be a combination of mathematical logic combined with the pragmatic realities of ED shifts.
Robert Wood Johnson – Somerset employed the aforementioned approach towards evaluating the provider staffing of its ED Fast Track area and discovered that the number of associate practitioners was correct but that the shifts were not aligned with the patient arrival rates. Several of the morning shifts were shifted to begin 1-3 hours earlier than the current state in order to adjust for the patient demand. The results were that the Fast Track was able to achieve and sustain a median turnaround time of less than the 2 hour goal, and on many days, better than 90 minutes. Just as one should never seek to drive 500 miles with a quarter tank of gas in the car, ED leaders should be cognizant of their current staffing levels to ensure they have the right staffing levels and mix to address the patient demand for their services.
Eric Bachenheimer, MBA, MHSA, FACHE joined Emergency Medical Associates in 2004 and is the Director of Client Solutions for the ED Solutions team which advises and assists clients with achieving operational efficiencies, process redesign, enhancing patient satisfaction, and ensuring regulatory compliance. He has more than 10 years of experience in the emergency department industry. He holds a master’s degree in health services administration from the University of Michigan, a master’s degree in business administration from New York University, and a bachelor’s degree from the University of Massachusetts at Amherst. He is a certified emergency medical technician and has worked in EMS for nearly 15 years. He is a Fellow in the American College of Healthcare Executives, and serves on the editorial advisory board of ED Overcrowding Solutions. Bachenheimer also is an active member of the American Association of Healthcare Consultants and the Healthcare Financial Management Association. If you’d like to contact the author, Eric can be reached at bachenheimere@alpha-apr.com.
