Are ED nursing staff levels under attack?

Data and increased efficiency can save jobs

When administrators search for a way to reduce costs, the emergency department (ED) nursing staff is often the first place they look.

"ED staffing is under attack by corporate hospital chains trying to cut their expenses, and in any hospital, the nursing budget is the biggest single variable cost," says Robert Herr, MD, MBA, FACEP, former corporate chairman of emergency medicine for FHP International and currently a Salt Lake City-based consultant in emergency medicine human resources management.

Comparative data showing there are more nurses than needed in the ED are often misleading, says Herr. "All EDs are unique," he emphasizes. "Whatever number administrators come up with doesn't necessarily reflect the realities of your ED. EDs have dramatically different needs for staffing depending on patient acuity and most importantly, [the ED's] efficiencies."

When looking to re-engineer this critical part of your facility, keep in mind the special needs of the ED, and also remember that this often serves as your facility's front door. If you botch the patient experience here, you might not get a second chance to make a good impression.

Rise to challenge: Increase efficiency

ED managers should consider the pressure to cut staff and costs as a challenge to become more efficient, says Herr. "Turn administration's interests toward improving efficiency rather than cutting staff," he recommends.

Administrators may determine a proposed number of nursing staff positions by patient volume, but length of stay should also be considered, says Herr. "When you present those numbers, administrators may respond that the average length of stay per patient is too long," he notes. "They may come back and say that it should be one hour instead of two hours, but that only gives you the chance to focus on cutting down your length of stay by becoming more efficient." (For more information on using length of stay data to determine staffing needs, see related story, p. 62.)

In many cases, ED inefficiencies are linked to other areas. "You need administrative support to confront lab turnaround time or how quickly a patient gets admitted and out of the ED," Herr says.

Focusing on reducing the patient's length of stay can give you that support, He adds.

"If administrators want the ED to be used for observation because it would save the cost of admitting that patient to the ICU, they have to understand that will increase the average length of stay and correspondingly increase the staff," he explains. "Tell them you can observe patients, but you need the staff to do it. That forces them to make a conscious decision about what they want the ED to be."

It's dangerous to cut nursing staff before the ED's efficiency is increased. "There are ways to trim the fat without compromising patient care, but fewer staff working with an inefficient system is dangerous," Herr warns. "You need to make your system of moving patients more efficient and only then focus on what your staffing needs are."

ED nurses should be active partners in avoiding staff cuts. "Your employees will drive you to success or failure, and they need to actively participate in operating within the boundaries of the budget," says Janet Johnson, RN, BSHA, CEN, CFRN, ED director at Central Peninsula General Hospital in Soldotna, AK.

When Central Peninsula's in-house nursing staff were cut substantially, ED nurses were told they could expect a similar fate - unless they acted immediately to increase productivity.

"Administrators told us to keep our productivity near 100%, or they would find someone else who could," Johnson recalls.

Staff were motivated to keep their jobs

Finding themselves under the gun, the nurses were determined to keep their jobs. "We found ways to toe the line and stay within our budgetary guidelines," she says. "As a result, our nursing staff wasn't cut. The in-house staff felt like we were getting away with something, but the difference is, we made our own cuts."

The nursing staff agreed to balance any overtime hours with missed time. "If a nurse does two hours of overtime, she makes it her own personal mission to look for opportunities go home for two hours when the census is low," Johnson explains.

Staffers are kept informed with periodic reports on the staffing budget and productivity. "We use our newsletter to report our progress with the staff budget, revenues, and the net income the ED brings to the facility," she says. "If they see the ED was over budget one month, nurses will actually come to ask why it happened."

When nurses change schedules to reflect the ED's needs, that sacrifice is acknowledged with a handwritten greeting card.

"I thank them for helping the team out and sometimes also send a card to their family," Johnson says. "I also put a little smile on their time card, write "thanks" and put my initials - so they know their efforts are appreciated."

To boost productivity, Johnson pitches in by working on the floor. "When I help out on the floor, it's a gift to productivity," she notes. "If the staff is tired from working a lot of hours, they let me know, and I can balance that out some."

As a result of decreased overtime and increased productivity, staffing expenses now fluctuate in step with revenues, she explains.

That trend is worth underscoring to administrators. "When our budget report showed that revenues were down but staffing expenses were down equally, I immediately picked up the phone and pointed it out to our CFO," says Johnson.

When patient volumes fluctuate seasonally, information systems can help assess changing staff needs. During the summer, Central Peninsula's ED census nearly doubles, but extra staff is added only when necessary. "We track our hourly volume and start adding staff gradually," she says.

If patient volumes drop without warning, nurses should be sent home, says John Senteno, RN, clinical director of the ED at St. Mary Medical Center in Long Beach, CA. "If things are slow, we might ask somebody to take the first four hours of a 12-hour shift off or go home four hours early," he explains. But you don't want to go too far - always keep in mind there could be a train wreck."

To maximize productivity, have nurses begin their shift during peak volumes, recommends Herr. "Have busy times occur at the beginning of a shift rather than at the end," he says. "If volume begins to pick up in the afternoon when the doctors' offices are closing, have a new shift come in at 3 p.m., and ease the burden from staff who have worked all day."

Encourage the previous shift to go home exactly on schedule, Herr advises. "Let the day shift go home on time, so you're not accumulating overtime," he says.

However, ED managers should watch out for ominous warning signs that the current shift has been cut too far, warns Senteno.

"We religiously track our throughput time, medication errors, and patient complaints so we can identify problems," he says. "Problems in any of those areas can all be indications that you have cut too much."

It's difficult to directly link poor patient outcomes with staffing cuts. "Patient care certainly languishes when there is inadequate nursing staff or when nursing duties are delegated to paramedic personnel who sometimes go far beyond their capabilities, but it's difficult to show concrete evidence of harm," says Herr.

Still, poor patient care can usually be indirectly linked to an inadequate staff, says Senteno. "If you track errors and complaints, you can go back and use that statistical data to argue your point for staffing."

If all else fails, it's an ED manager's responsibility to refuse to cut staff to dangerous levels, Senteno stresses. "Administrators who are confronted with the finances of the hospital are working their tails off to remain as profitable as possible, but there are times when you need to look someone straight in the eye and say, 'I'm sorry, but our RN staffing is as lean as it can be, and I can't cut any more,'" he says.

Here are ways to accurately determine staffing needs and keep administrators happy:

· Keep your standards flexible.

St. Mary's ED computes its own labor standards and productivity index to determine the number of nursing work hours needed per patient, but the number remains flexible. "It's a statistical tool we use to keep us on the straight and narrow, but we can flux downward or upward depending on how busy we are," says Senteno.

"Managed care in this state has made it very difficult for patients to come to the ED, so our numbers went down," says Senteno. "If we had staffed at the same level every single day with our lower volume, then our actual productivity would have been a lot worse than my targeted budget goal of 2.4 hours per patient."

· Beware of benchmarking data.

Benchmarking data is often used to determine an ED's needs, but it can be misleading if used incorrectly. At first, administrators compared St. Mary, an inner-city trauma center, with suburban rural EDs. "Because we weren't being compared with anything that looked close to us, it came up that there was a lot of room for further staff reductions, which wasn't the case," Senteno recalls.

"When administrators benchmarked us only to other trauma centers, we came up fine," he says.

· Compare your staff needs with other EDs.

When disputing data presented by administrators, come armed with some numbers of your own. "We compared our ED with other rural facilities that looked like us, with the same volume and acuity, to show how we compare with national trends," says Johnson. "It's also helpful to compare your ED's staffing equations with colleagues, so you can look at that data and adapt it to your facility."

Explain situations that affect productivity. If training hours are included in your productivity rating, make sure administrators are aware of it.

"On the comment section of our time card sheet, I list any special classes or training that were taken by the nursing staff, so I have a record of it. That way, when administrators call to ask why there was overtime, I have the answers at my fingertips," Johnson says.

· Other departments that charge time to the ED can affect your productivity.

"The hospital security guards charged the ED when they came to guard patients, so I worked with our CFO and came up with a revenue in the ED for patient guarding. Now we can charge that cost back out," says Johnson.

· Use graphs to demonstrate changes that impact staffing needs.

Graphs can clearly show administrators how staffing needs have changed. "We used graphs to show administrators that our high-acuity patients have doubled over the past two years, while our low-acuity patients are dropping steadily," says Johnson.

By communicating consistently with evidence of staffing changes, administrators are more likely to accommodate extra staff when urgently needed, says Johnson. "If a seven or nine person car crash increases our staffing needs, administration supports us with increased staff during that time," she notes.

· Staff for peak flow.

Although the ED's volume is unpredictable, there are usually consistent periods of increased volumes. "Patient visits to the ED do follow some type of a rhythm, although it looks more like an idioventricular rhythm than it does a sinus rhythm," says Herr.

Some administrators insist the ED should be staffed for low or average patient volumes, but that's a serious mistake, argues Herr. "When you're caught short on a busy shift, the nursing staff winds up putting in overtime," he says. "As a result, your nurses will burn out, use all their vacation, comp, and sick time, and end up quitting."

· Emphasize common goals.

Stress that it's in the hospital's best interest to deliver quality ED care with an adequate staff. "Administrators make promises about the care given by the hospital to everybody in the community, and have to deliver on that promise," says Senteno.

· Be honest about your needs.

It's a bad idea to ask for more nursing staff than you actually need, advises Johnson. "That only makes administrators mistrust you," she advises.

· Put your ED's staffing standards in writing.

At Central Peninsula, the ED's nursing staff standards are outlined in a formal written policy. "Our policy states that the ED will be staffed based on the standards of the Emergency Nurses Association," says Johnson. "It justifies those training needs, since they are from our salary budget and directly affect productivity."