Emergency Department
The Emergency Department (ED) is an area of high natural variability. There is no predicting how busy a particular day or night may be. However, volume per hour curves exist which can help the ED know when to expect an increase. It is usual to be relatively slow between 7 am and 11 am, then a bit of an increase until 1 pm, then becoming very high volume consistently until about 12 mid-night or 1 am, and then rapidly ratcheting down to minimal levels until the am and the cycle repeats (Figure 4.1).
This cycle is fairly common 7 days a week, 365 days a year with some minor exceptions. This is important because it presents an opportunity. The period of lower volume presents a chance to decompress the ED before the next rush of incoming patients. This should be the time to clear the ED of any and all admissions who are still occupying its beds. But on many days, there’s a problem. While the ED has spent Sunday, for example, admitting patients at a normal pace, on Monday morning, they have no beds to send them to. These patients, often called boarders, become admissions with no assigned inpatient bed occupying space in the ED. This occurs often when the higher priority Operating Room and
Figure 4.1 Average hourly admissions of a Western New York hospital with visits greater than 100k.
Cath lab, along with Directs and Transfers, take available inpatient beds, leaving ED admits in the ED. Obviously this scenario occurs predominantly in those institutions which have high bed occupancy utilization but even in lower occupancy models the process can be almost identical.
The ED is a complex admission environment admitting virtually all patient types:
- (1) Acute Medical Inpatients
- (2) Acute Surgical Inpatients
- (3) Extended Recovery Surgical Patients (Outpatients)
- (4) Urgent or Emergent Cath Lab Patients
- (5) Medical Observation Patients
Of these five “admission” types, only two are considered to be pure inpatients. The determination of “Inpatient,” “Outpatient,” or “Observation” status varies by payer and patient type. Commercial insurance, Medicaid, and Medicare all vary. Medical patients are routinely given observation status, while elective surgical and Cath patients rarely meet the designation of observation but rather fall into the extended recovery arena.
Figure 4.2 Total admissions for all demand streams by day of week for a Western New York hospital.
This can make assignment and location of ED admissions extremely difficult if the primary desire is to optimize bed capacity and resources. The reason for this is the variability of acuity of patient types and the impact these patient types can have on associated staffing ratios. Placing outpatients in inpatient beds wherever they are available will impact the overall volume of patients cared for by both nursing and provider staff (Figure 4.2).
Complex acute medical and surgical cases require smaller ratios for nursing, with the classic example being ICU in which patient to nurse ratios rarely exceed 2:1. With ratios like that, it only takes a few poorly placed patients to create a significant staffing problem.
