Will More Physicians or Nurses Help Your Emergency Department Flow?

By Debra Wood, RN 

Long patient wait times and crowding remain a vexing problem as a seemingly ever-increasing number of patients seek care in hospital emergency departments. Solutions vary depending on the department and the cause of the bottlenecks. 

“Emergency department crowding is a pervasive problem across the country,” said Kenneth K. Lopiano, PhD, co-founder and principal collaborator at Roundtable Analytics in Research Triangle Park, North Carolina. 

Roundtable Analytics has developed an ED simulation tool in collaboration with the University of Florida that helps ED leaders determine what additional resources will add the most value. 

Different hospitals, different problems

Another physician could reduce delays in care in community hospitals, while more beds and nurses will ease crowding in academic medical center emergency departments, according to a study using the decision-support simulation tool. 

“The demands and challenges ED settings face are different,” explained Joshua E Hurwitz at the University of Florida and lead author of the BMC Medical Informatics & Decision Making article. “Operational changes, such as adding staff or beds, are going to have profoundly different effects on flow.”

The factors affecting whether another physician or more nurses and beds will reduce crowding include available resources, whether the department has a fast-track program, and the percentage of patients admitted to the hospital and boarding in the ED. For instance, on average only 12.8 percent of patients in community EDs, without fast track, are admitted and average boarding time is 1.63 hours. In an academic center, 25.8 percent of patients are admitted and will spend on average 4.43 hours waiting for an inpatient bed, said Lopiano, a co-author of the paper.  

“The way patients spend time is very different, and the mix of patients contributes to the throughput process,” Lopiano said.

Stephen Schenkel HB The concept makes sense based on the resources considered, said Robert Hitchcock, MD, FACEP, chief medical informatics officer at Dallas-based T-System, which provides ED documentation and workflow software and services. However, with closer analysis he found that the majority of the gain in throughput occurred from time in the waiting room to the bed. He questioned what would happen if other variables were considered, such as speeding laboratory time, adding midlevels or using a scribe.

Stephen Schenkel, MD, MPP, chair of the department of emergency medicine at Mercy Medical Center in Baltimore, said he thought adding a physician in a community ED but nurses in an academic setting was too simplistic a solution, since flow issues are local and variable by time of day. 

Deena Brecher QuoteDeena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, president of the Emergency Nurses Association (ENA), added that a lack of beds often causes bottlenecks in the academic setting.

Adding nurses, said, “allows us to have more eyes in the waiting room and reassess patients waiting for care. Adding nurses may help you put patients in other places.” 
ENA guidelines call for at a minimum two nurses in an ED at all times, even in the smallest department. Larger departments will need more based on volume and length-of-stay data for each facility.

Crowding can adversely affect the patient experience and delay care for patients presenting with atypical symptoms, leading to deterioration in their condition before treatment becomes available, she added.  

“Crowding is a huge issue that requires an organizational approach,” Brecher said. “The emergency department is the safety net for our entire healthcare system.”

Other solutions

Overall, improvements to the healthcare system, such as more primary care physicians and more mental health services and crisis centers, are needed to keep patients without emergency needs out of the ED, Brecher said. Emergency rooms are closing, adding to the problem.

Within an organization, changes to inpatient throughput can relieve ED crowding.
Researchers recommended adding a fast-track program, if the emergency department mostly treats lower-acuity patients. The fast track bay, staffed by midlevel providers such as a physician assistant (PA), not only moves through low-acuity patients more quickly, but also frees up a bed in the main treatment area. 

“Staffing with PAs can potentially reduce waiting times, length of stay and potentially the cost of treating patients,” Lopiano said. 

Brecher suggested adding a provider—midlevel or physician—at triage to assess the patient and immediately start care, order studies as needed and discharge non-urgent patients, perhaps with a prescription. 

ED physicians are required to complete more documentation and clinical quality measures than in years past, creating more administrative duties. Enterprise systems have been found to reduce throughput compared to ED-specific electronic medical records systems, according to a 2013 KLAS research study, 

Try out the modeling tool

The modeling platform that the team developed is accessible online for free. It allows emergency department leaders to evaluate such changes without affecting real patient lives. Each hospital can plug in the variables for its ED and determine whether an additional physician, midlevel provider or more nurses and beds would help its ED flow.

Hitchcock plugged in variables for several EDs he is familiar with and found, at least on the surface, the model felt right. He encouraged other providers to give it a try.

“Anytime you use data to drive decision-making, you will make better decisions,” Brecher said. By using such a tool, she said, someone can see the intended and unintended consequences of proposed changes before making them.

Try it yourself at: http://spark.rstudio.com/klopiano/EDsimulation/