Don’t rely on staffing ratios alone: Here are cutting-edge strategies to use

Avoid being shortsighted when it comes to staffing

Do you staff your emergency department (ED) based solely on ratios? Do you use staffing productivity measures that only address paid nursing hours per patient visit? These methods are not effective in the ED and actually can endanger patients, warn staffing experts, who point to a growing trend toward state-mandated ratios for nursing staff.

"They do not look at variables unique to emergency nursing, such as acuity, length of stay, and staff skill mix," says Carl E. Ray, BSN, RN, senior clinical analyst for Sentara Healthcare in Virginia Beach, VA, and a member of the Des Plaines, IL-based Emergency Nurses Association (ENA)’s Staffing Best Practice Workgroup.

Ray gives this example: Some ratios have set a one-nurse-to-one-patient ratio for trauma and critical care patients, yet it takes at least two nurses to care for that patient during the first hour they are in the ED. "Length of stay is also crucial because as long as patients remain in the ED, they require nursing care," he adds. "This is especially true in today’s hospital environments where patients are held for long periods in the ED while waiting for inpatient beds."

The dollars saved in keeping a low ratio in the face of increased patient volume, admissions, and ED inpatient holds will be spent later on contract labor, the costs of ED nurse attrition, and potential risk management expenses, warns Camilla L. Jones, RN, director of emergency and transfer services at Lewis-Gale Medical Center in Salem, VA. "In a nutshell, shortsightedness regarding appropriate staffing can destroy your competitive advantage," she says.

Here are ways to effectively staff your ED:

• Use the new ENA staffing tool.

New staffing guidelines developed by ENA give you the nursing full-time equivalents (FTEs) needed to staff an ED based on patient volume, patient acuity, and length of stay, says Ray. (For more on the staffing guidelines and tool, go to the ENA web site, The workgroup has developed an ENA Staffing Tool in an automated Excel Workbook format based on the guidelines. By inputting data into the tool, you will be given the number of FTEs needed to staff your ED, explains Ray. He notes that the tool takes census changes specific to the ED into account. The census usually peaks about noon, with a second, larger peak in the early evening, and a dramatic drop late at night, Ray says.

• Obtain extra staffing for high-acuity patients or inpatient holds.

Jones developed a staffing formula to use when the ED has high-acuity patients who require extended care and/or if inpatients are held in the ED. "I created the formula to communicate the extra man-hours needed to cover effective patient care and justify them mathematically," she says. When justifying your staffing needs, a general statement such as "we were swamped" is not as effective as a formula that objectively converts the extra length of stay into a productivity value, emphasizes Jones.

Your ED’s admission rates are another indicator that can be used to adjust man-hours to an appropriate level, Jones says. "If an ED typically runs at two man-hours and has typically experienced admission rates of 10%, it is only logical to assume that it will take more staffing resources to manage admission rates of 20% or greater," she says. The location of the patient’s admission also is relevant, Jones says. "For example, if the ED is holding critical care patients, this will drive staffing requirements up," she says.

• Determine what man-hour per stat ratios to use.

The ratios you use will depend on the services your ED offers, such as forensics, a chest pain center, and interfacility transfer services, says Jones. "The fact that EDs can’t be compared as apples to apples has further complicated the standardization of ED staffing," she says. "There continue to be many methods out there that are used, even within local communities and market divisions." Jones advises against using a nurse-to-bed ratio to calculate staffing in the ED setting. "Patients can continue to enter beyond the room capacity," she notes.

Jones monitors man-hour per stat ratio trends that occur monthly, weekly, daily, and hourly, and staffing patterns are staggered, based on trend averages. Incentives are offered to staff willing to work extra hours if patient load goes beyond average capacity or if patients are held, Jones reports. "In addition, leadership staff maintain an on-call status so that extra resources can be made available on the spur of the moment if needed," she says. "We all share this responsibility."

• Use different ratios for various patient groups.

Consider staffing differently for three groups: acute emergent patients who usually are admitted, urgent and nonurgent patients who usually go home, and admission holds who can’t get an inpatient bed, suggests Jerry Keyes, RN, director of emergency services for Florida Hospital Celebration Health in Orlando. "Each one of these patient types needs a different staffing ratio," he explains.

Keyes suggests looking outside the ED to the surgery area; the best performers separate outpatient and inpatient surgical patients into two categories because processing and staffing are different. He says that the same approach should be used in the ED, and he points to the success of fast tracks for minor care patients. "Thus, this group gets faster treatment than they would mixed in with the acute group," he says.

• Track changes in acuity to justify additional staff.

Cindy Wage, RN, BSN, nurse educator of the ED at Trinity Medical Center in Rock Island, IL, has demonstrated increased acuity levels linked to tasks routinely performed by nurses. She says that doing this has supported the need for additional nursing staff. "I just kept some of my own stats on things that we do every day that no one seemed to take into consideration," she says.

Wage gives the example of nurses doing an average of 600 electrocardiograms each month. She used this statistic to show administrators that acuity levels had changed since the hospital started its open heart program. "We have an average of [less than] 40 minutes from the door to the cath lab for acute myocardial infarctions," she reports. However, Wage says that the extra time nurses spent on electrocardiograms, which contributed to this impressive statistic, was overlooked until she pointed it out.

Wage also tracked the time nurses spent in answering radio calls from ambulance services, and transferring ED medical/surgical admissions to the units. The ED manager and director took Wage’s findings to the vice president of nursing to discuss the budget plans for the year. "I was able to have our nursing care hours increased," she reports. "We are now budgeted for one additional nurse for both days and second shift."

• Provide the same level of care to admission holds as inpatient units.

Keyes says that the most pressing staffing issue in his ED is measuring the workload for admission holds. "We need an inpatient acuity system to ensure equal patient care standards are met," he stresses. Keyes says that his ED is negotiating with the inpatient units to supply nurses to care for admission holds. Either revenue will be transferred from the inpatient units to the ED, or the cost of the ED’s labor will be transferred to the inpatient units, he explains. "Too often, we hear of ED staff caring for these patients with fewer care hours per day than the inpatient setting," he says. "That is foolish and opens you up to criticism by [the Joint Commission on Accreditation of Healthcare Organizations] for having different care standards in different settings."


For more information about staffing ratios, contact:

• Camilla L. Jones, RN, Director of Emergency and Transfer Services, Lewis-Gale Medical Center, 1900 Electric Road, Salem, VA 24153. Telephone: (540) 776-4850. Fax: (540) 776-4849. E-mail:

• Jerry Keyes, RN, Director, Emergency Services, Florida Hospital Celebration Health, 400 Celebration Place, Celebration, FL 34747. Telephone: (407) 303-4034. Fax: (407) 303-4334. E-mail:

• Carl E. Ray, BSN, RN, Senior Clinical Analyst, Sentara Healthcare, P.O. Box 6442, Virginia Beach, VA 23456. Telephone: (757) 668-5169. Fax: (757) 668-4126. E-mail:

• Cindy Wage, RN, BSN, Nurse Educator, Emergency Department, Trinity Medical Center, West Campus, 2701 17th St., Rock Island, IL 61201. Telephone: (309) 779-3232. Fax: (309) 779-2105. E-mail: