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


Our hospital is an urban, tertiary care, safety-net hospital with 254 medical/surgical inpatient beds and 80 ED beds. The ED is staffed by full-time, board-certified attending emergency physicians who supervise emergency medicine residents, residents from other specialties, and physician assistants. Hospital-stipulated maximum nurse-to-patient ratios were not changed or exceeded during the study period. Nurses work a mix of 8- and 12-hour shifts. The ED is also staffed by patient care technicians and patient transporters.

We conducted a retrospective observational review using Cerner First Net electronic medical record (EMR) database. All EMRs of 105,887 ED visits from January 1, 2015, to December 31, 2015, were queried after institutional review board approval. We included in the analysis all patients discharged or admitted to the medical/surgical inpatient beds in the analysis regardless of inpatient or observational status. Patients admitted to the intensive care unit or the ED observation unit were excluded as the admission protocol to these units varies significantly from general admission; therefore, we could not accurately capture the length of stay (LOS) of these patients from EMR review. A total of 6,602 patients were excluded.

The unit of measure was a 24-hour period starting at midnight. Daily number of patients admitted, discharged, and LWBS as well as the total daily volume in the ED was recorded. Daily nursing hours were determined from nursing staff records for each shift and summed for each day. We measured door-to-discharge LOS in minutes as the interval from the time of presentation to the ED to when the provider discharged the patient. We captured the time of initial presentation by the time the patient was registered at the front desk. The time of discharge was captured by a physician order for discharge placed in the EMR. Door-to-admit LOS was measured in minutes as the interval from the time of ED presentation to when the nurse placed an electronic order that the patient was ready to be transported to the ward. We defined hospital occupancy as the sum of the number of patients in a hospital bed at midnight and the number of patients discharged in the preceding 24 hours divided by the total number of hospital beds. This method was used previously by Forster,[7] which helps capture the true use of inpatient beds during a 24-hour period.

We evaluated the effect of ED nursing hours on throughput metrics using analysis of covariance and controlled for total daily ED volume, hospital occupancy and admission rate. Daily nursing hours were compared across quartiles as a fixed factor. We used daily door-to-discharge LOS, door-to-admit LOS, and the number of patients who LWBS as the dependent variables in each model. SPSS Univariate GLM procedure was used for all analyses.