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The problem comes when staffing decisions are made based on flawed data, says Janiak. "Our primary concern is that institutions are currently relying on commercial companies that in our view really don’t have good data," he argues. "Their problems revolve around how they gather the data and how compare it; we don’t think they compare apples to apples."
The ED needs to be staffed at all times for the worst-case scenario, McClay says. "If you’re staffing on an average basis, there will be times when the system is overwhelmed," he says. "The ED is a safety net for the community, and the hospital is in the business in providing that safety net."
A certain level of staffing may work very well 80% of the time, but during the 20% of the time an ED is extremely busy, it may be a disaster. "Is that an acceptable thing to have happen?" asks Janiak. "During the disaster is when patients write angry letters to the administrator, who then calls you up and says, You jerks kept my board of trustee member there for three hours’ without ever asking, How come I didn’t give you enough staff?’"
Typically, benchmarking data come from surveys done on the hospital as a whole, without considering the individual staffing needs of the ED, says McClay. "When they do it on a departmental basis, they don’t get real numbers for what is going on in the ED," he explains.
As a result, the data tend to overlook additional resources needed in the ED. "There was no allocation of time for the radiology department dedicated to the ED, for example," says McClay. "Some EDs did x-rays right in the department, and radiographers were actually providing some clinical services, while other sites put the patient on a gurney and transported them across the hospital to an x-ray suite, and a nurse goes with them. One model provides you with extra manpower, and other takes it away."
The data doesn’t reflect the actual amount of time spent in the ED by various personnel, he says. "In some hospitals there may be respiratory therapists that are actually under the ED’s cost center, so they would be reported as an ED cost. But in others they are not, so they wouldn’t be. As a result, the entire respiratory therapy team’s cost may be attributed to the ED," says McClay. "We need to find out how much time they actually spend in the ED. What do they do? Do they come down and draw blood gases or set up ventilators or respond to codes and bag the patient?"
Valid comparative data are difficult to determine because every ED is markedly different, says Janiak. "There’s such a cultural difference in the way each ED, based on the way the medical staff interacts with the ED staff," he argues. "How long are patients routinely kept there? How much of a workup is done? Are the physicians interested in evaluating every nuance of a patient’s complaint with testing, or do they just want to get the patient along to the next step? Without saying which is right or wrong, if you have two different approaches you’re measuring, you’ll find different numbers?"