Decreased Nursing Staffing Adversely Affects Emergency Department Throughput Metrics

Zachariah Ramsey, MD; Joseph S. Palter, MD; John Hardwick, MD; Jordan Moskoff, MD; Errick L. Christian, MS; John Bailitz, MD


Western J Emerg Med. 2018;19(3):496-500. 

In This Article

Abstract and Introduction


Introduction: The effect of nurse staffing on emergency department (ED) efficiency remains a significant area of interest to administrators, physicians, and nurses. We believe that decreased nursing staffing adversely affects key ED throughput metrics.

Methods: We conducted a retrospective observational review of our electronic medical record database from 1/1/2015 to 12/31/2015 at a high-volume, urban public hospital. We report nursing hours, door-to-discharge length of stay (LOS) and door-to-admit LOS, and percentage of patients who left without being seen (LWBS). ED nursing hours per day was examined across quartiles with the effect evaluated using analysis of covariance and controlled for total daily ED volume, hospital occupancy and ED admission rate.

Results: From 1/1/15-12/31/15, 105,887 patients presented to the ED with a range of 336 to 580 nursing hours per day with a median of 464.7. Independent of daily ED volume, hospital occupancy and ED admission rate, days in the lowest quartile of nursing hours experienced a 28.2-minute increase per patient in door-to-discharge LOS compared to days in the highest quartile of nursing hours. Door-to-admit LOS showed no significant change across quartiles. There was also an increase of nine patients per day who left without being seen by a provider in the lowest quartile of nursing hours compared to the highest quartile.

Conclusion: Lower nursing hours contribute to a statistically significant increase in door-to-discharge LOS and number of LWBS patients, independent of daily ED volume, hospital occupancy and ED admission rate. Consideration of the impact of nursing staffing is needed to optimize throughput metrics for our urban, safety-net hospital.


Emergency department (ED) efficiency remains a vital aspect of delivering safe, quality care. ED utilization has risen considerably without a corresponding rise in available emergency services.[1,2] To respond to the increased demand, it is imperative to identify factors that contribute to delays in care. Researchers have identified several hospital characteristics associated with worse ED throughput or ED time on ambulance diversion including ED crowding,[3] percentage of ED patients admitted,[4–6] number of elective surgical admissions,[5] hospital occupancy,[5–7] training level of the treating physician,[3] access to expedited diagnostic testing,[8] socioeconomic status of the surrounding neighborhood,[9] and decreased nurse staffing.[10]

Prior studies identified that increased nurse-to-patient ratios correlate with improved patient outcomes[11,12] and that lower staffing is associated with increased left without being seen (LWBS) rates[13] and increased ED care times.[10] Our urban, tertiary care, safety-net, teaching hospital suffered a nursing shortage during 2015 due to an administrative initiative to decrease costs by limiting nurse overtime hours. Without a concomitant increase in hiring, this change caused significant gaps in ED nurse staffing. These gaps led to unpredictable closures of sections of the ED and increased average nurse-to-patient ratios. Our goal was to evaluate the impact of decreased nurse staffing on ED throughput metrics. We believe decreased nurse staffing adversely affects these metrics.