Emergency Rooms Short Staffed Nursing

Effects of Short-Staffed Nursing in Emergency Rooms

Effects of Short-Staffed Nursing in Emergency Rooms

Introduction

The emergency department’s efficiency is a critical component of delivering quality and safe care within the health sector. The utilization of the emergency department significantly increased minus the corresponding increase in the available emergency services (Ramsey et al. 2018). As a result, to attend to the increased demand, it is proper to evaluate the various factors contributing to care delays (Schull et al. 2003). Scholars have established multiple hospital features associated with worse emergency rooms or emergency room time on ambulance plus emergency room crowding, hospital occupancy, the proportion of emergency department patients admitted, treating Physician’s level of training, elective surgical admission number, socioeconomic status of the neighborhood, decreased nurse staffing, access to expedited diagnostic testing, and hospital occupancy.

However, there is a lack of relevant data to connect hospital occupancy to overcrowding. According to Schull et al., hospital bed closures in Canada correlated with the rise in emergency room overcrowding within Toronto (Polevoi et al. 2005). Nevertheless, that finding was made in the context of concurrent changes within Toronto’s health services, like the closure of multiple emergency rooms (Ramsey et al., 2018). Also, some research studies seem to agree with the theory that hospital overcrowding determines the decision to admit.

Besides, it is critical to understand if bed availability impacts the disposition and length of stay within emergency rooms. Data regarding such relationships could assist in developing mechanisms for reducing overcrowding (Lucas et al., 2009). Moreover, if hospital occupancy varied with disposition, there would be a vivid indicator that hospital overcrowding results in low-quality emergency room care.

Statement of the problem

When healthcare facilities and the emergency rooms have inadequate staff, patients’ welfare is compromised. Also, overwhelmed staff could overlook some details or may not be fully attentive and engaged with patients. As a result, patients may be dissatisfied with the providers’ performance (Ramsey et al., 2018). Moreover, emergency rooms face multiple critical problems within the modern healthcare environment (Lucas et al., 2009). Simultaneously faced with growing public demand and decreasing hospital resources, emergency rooms usually undergo long overcrowding periods and extended waiting times. Reducing the delay between the initiation of therapy and the onset of symptoms is vital for enhancing outcomes for critically ill patients (Ramsey et al., 2018). Also, overcrowding pushes emergency rooms to work beyond their staff capacity, thus, leading to delays in diagnosis and treatment, affecting the quality of patient care (Lambe et al. 2003). The effect of overcrowding on the emergency room’s quality care and public health has recently received global attention, pushing for urgent calls for reform (Schull et al. 2003). Consequently, there is a critical and urgent need for mechanisms to improve patient flow to minimize the overcrowding burden with emergency rooms and enhance the general quality of emergency care.

Conversely, those supporting enaction of minimum nurse-patient ratio in emergency rooms believe that it would be able to lower nurse workloads to a manageable level, so that patient care, disposition, and evaluation activities can be accomplished within an appropriate time, hence, improving the patient flow and throughput within emergency rooms (Wiler et al. 2012). This paper discusses the effects of short-staffed nursing in Emergency Departments (Schull et al., 2003). Details include how patient wait times are affected, how patient treatment times are affected, and how patient satisfaction is affected if wait times are increased due to nurse staffing shortages.

Research Hypothesis

1. Short-staffed nursing in emergency rooms increases patients’ wait times.

2. The short-staffed nursing prolongs the patient treatment times in emergency rooms.

3. The increased wait times due to nurse shortage do not lower patient satisfaction.

Research Question

Central research question.

· What are the effects of Short-Staffed Nursing in Emergency Rooms?

Specific questions.

· How does Short-staffed nursing in emergency rooms affects patients’ wait time?

· Does Short-staffed nursing in emergency rooms impact patients’ treatment time?

· How is patient satisfaction affected if wait times are increased due to nurse staffing shortages?

Literature Review

Health researchers have reported connections between nurse staffing and patient care outcome and satisfaction (Polevoi et al. 2005). Nevertheless, nursing staffing and care were background variables in multiple such studies and not the main study’s focus (Ramsey et al., 2018). Also, nurses are the largest group of hospital workers in charge of most patient care. Therefore, it is essential to investigate the effect of their work both on patient safety and healthcare quality (Schull et al. 2003). A developing evidence body suggests that a lack of enough nurse staffing within emergency rooms and hospitals could result in adverse events like health-care-related infections, patient falls, in-hospital mortality, and medication errors (Ramsey et al. 2018). According to Aiken et al. increased proportion of nurses with bachelor’s degrees and enhanced nurse staffing reduced the possibility of death among hospitalized patients within thirty days from the admission date (Lucas et al. 2009). Scholars have claimed that enough nurse staffing determines the patient surveillance quality since it enables more time for nurses to spend on indirect care.

On the other hand, the lack of an adequate number of nurses impacts patients’ satisfaction. For instance, according to scholars, whenever a patient has a negative perception of nursing care, it equals missed care due to a shortage of nursing staff (Polevoi et al. 2005). As a result, patients lose confidence whenever they leave before being seen (Rathlev et al. 2007). Notably, patient satisfaction data are utilized by administrators in charge of emergency rooms to track aggregate information over the period, assess the performance of individual practitioners, establish financial incentive plans, and study the interventions (Ramsey et al. 2018). According to the literature, there are six aspects of emergency care resulting in a lack of satisfaction by the patients (Schull et al. 2003). One, failure to receive help whenever needed, not being informed when one can resume normal activities, lack of information about waiting times, failure to understand when one is supposed to return to the emergency room, failure to receive an explanation of the test results, and a poorly explained problem.

According to earlier studies, an increased nurse-to-patient ratio directly enhances patient outcomes. At the same time, understaffing is associated with a rise in patient left without being seen rates and emergency room care times (Schull et al. 2003). Several teaching hospitals, safety nets, and tertiary care have suffered nursing shortages due to administrative initiatives to reduce costs by decreasing nurse overtime hours (Ramsey et al., 2018). Minus a concomitant increase in hiring, this shift has resulted in substantial emergency department nurse staffing gaps (Polevoi et al. 2005). The gaps resulted in unpredictable closure of parts of the emergency departments in several hospitals and a rise in average nurse-to-patient ratios (Rathlev et al. 2007). Scholars have established multiple hospital features associated with worse emergency rooms or emergency room time on ambulance plus emergency room crowding, hospital occupancy, the proportion of emergency department patients admitted, treating Physician’s level of training, elective surgical admission number, socioeconomic status of the neighborhood, decreased nurse staffing, access to expedited diagnostic testing, and hospital occupancy (Lucas et al. 2009).

On the other hand, overcrowdings within emergency rooms are a critical global challenge and can decrease the quality of care (Schull et al., 2003). North America, Australia, and Europe have reported overcrowding in most emergency rooms (Polevoi et al. 2005). According to several editorials and surveys, there are increased emergency department congestions within hospitals leading to a national crisis because it hinders the delivery of emergency medical care in an effective and timely manner (Ramsey et al. 2018). Besides, within the understaffed emergency room or healthcare facility, the same proportion of work falls to fewer nurses forcing them to work for long hours (Forster et al. 2003). This can result in mental breakdown and physical and emotional health challenges (Chang et al., 2015). As a result, sick nurses may not attend to work, worsening the staffing deficiency.

Additionally, nurses constantly exposed to work-related stress can develop health complications like hypertension, musculoskeletal disorders, heart disease, depression, anxiety, and exhaustion (Schull et al. 2003). Further research should be conducted on the cost-effectiveness of a rise in nursing hours related to lost revenues from patients who left without being seen (Lambe et al. 2003). Lastly, understanding the nurse staffing effect on patient satisfaction is critical for more research studies.

In recent decades, there has been an increasing concern about nurse staffing deficiency and scaling patient workloads that threaten the patient care quality in emergency rooms (Polevoi et al. 2005). Some studies have proposed increasing nurse-patient ratios to address nurse staffing deficiency within emergency rooms (Recio-Saucedo et al., 2015). For instance, in 2004, California implemented the minimum nurse-patient ratios due to Assembly Bill 394 of the safe staffing law (Lambe et al. 2003). The law put the minimum staffing ratios in all hospitals, including the emergency rooms (Ramsey et al. 2018). Moreover, emergency rooms face multiple critical problems within the modern healthcare environment (Schull et al., 2003). Simultaneously faced with growing public demand and decreasing hospital resources, emergency rooms usually undergo long overcrowding periods and extended waiting times (Chan 2010). Reducing the delay between the initiation of therapy and the onset of symptoms is vital for enhancing outcomes for critically ill patients.

Besides direct patient care, nurse staffing is vital for emergency room patient flow, operations, and efficiency (Polevoi et al. 2005). The minimum staffing regulations may be specifically problematic for the emergency rooms due to possible fluctuation in patient load, census, and acuity minute by minute (Schull et al. 2003). Therefore, multiple emergency rooms have marked timeout periods of compliance with the appropriate nurse-patient ratios (Ramsey et al., 2018). On the contrary, some scholars have claimed that minimum nurse-patient ratios within emergency rooms may affect patients negatively by lowering the number of available areas for patient care that cannot be staffed to achieve the ratio requirements.

Method

Study Setting.

This study was conducted within a hospital with 500-bed acute care and 254 surgical/medical inpatient beds, and 80 emergency room beds. It provides tertiary, secondary, and primary care to a catchment area of about five hundred thousand residents, and its emergency room accommodates approximately 50,000 visits every year. The emergency room is staffed by full-time emergency physicians who are certified with multiple accredited pieces of training. The physicians also supervise residents from different specialties, physician assistants, and emergency medicine residents. The hospital’s usual maximum patient-to-nurse ratios were not exceeded or altered during the study period. Providers worked a mix of 8- and 12-hour shifts. Patient transporters and patient care technicians also staffed the emergency room.

Study Design and procedure

The study used Cerner First Net electronic medical record (EMR) database to carry out a retrospective observational review. All the electronic medical records of 105887 emergency room visits from June 2021 to March 2022 were queried upon approval by the institutional review board. The study analyzed all patients admitted or discharged to the surgical/medical inpatient beds regardless of observational or inpatient status. Individuals in the emergency room observation unit or intensive care unit were excluded because the process of admission to such units varies significantly from the general admission. As a result, the study could not accurately capture the patients’ length of stay (LOS) from electronic medical records review. Consequently, the study excluded a total of 6602 patients.

The measuring unit was a 24-hour time beginning at midday. The daily number of left without being seen (LWBS), patients admitted, discharged, and total daily sum in the emergency room were captured. The daily nursing hours were established from each shift’s nursing staff records and summed for each day. The study evaluated door to discharge length of stay in minutes as at the interval of time the provider discharges the patient from the time of presentation to the emergency room. The study recorded the time when the patient was registered at the front desk and the time of the initial presentation. A physician recorded the discharge time and placed the discharge order in the electronic medical record. The measurement of the door to admit was taken in minutes at the interval of when the nurse placed an electronic order indicating the patient is ready to transfer to the ward and from the time of emergency room presentation. The study defined hospital occupancy as the total number of patients within the hospital bed at midnight, together with the sum of patients in the preceding 24 hours, divided by the total sum of beds in the hospital. Foster previously used the method, which helps record the actual use of inpatient beds during 24 hours.

The study determined the impact of the emergency room nursing period on throughout metrics using the analysis of hospital occupancy and admission rate, covariance and controlled for total daily emergency room volume. Daily hours of nursing were compared along with quartiles as a fixed factor. The study adopted daily door to admit the length of stay, the total sum of patients who left without being seen, and door to discharge length of stay as the dependent variables in every model. SPSS Univariate GLM procedure was used to produce results.

Results

The daily mean number of visits was 293, with 126-453. The nursing hours ranged from 330 - 586 per day, and a median of 463.9. The mean number of lengths of stay per day for the discharged patients was 247.7 minutes, while the range was 154-387. The mean number of lengths of stay per day for the admitted patients was 443.5 minutes, while the range was 258-797. The emergency room admission rate was 16.9, with 9.8% - 22.7%. The mean number of patients left without being seen per day was 18.5 and summed to 6486 with 1-56 patients per day. The mean number for the hospital occupancy per day was 69.6% -117.8%.

The emergency room door to discharge length of stay (LOS) and the decrease significantly impacted the sum of patients who left without being seen in daily nursing hours independent of hospital occupancy, emergency room daily volume, and admission rate. The Lowest quartile days of nursing hours had 29.1 minutes increase for every patient’s indoor to discharge length of stay compared to the highest quartile days of nursing hours. Along with these same quartiles, the lowest quartile days of nursing hours had a rise of ten patients that left without being seen every day. Both differences were statistically significant. However, the Door to admit the length of stay was not significantly impacted by nursing hours. Otherwise, for door to discharge length of stay and the sum of patients that left without being seen, a comparison of adjacent quartiles failed to always result in any difference of statistical significance. There existed a clear data trend along with the quartiles that exhibited correlation.

Discussion

Usually, the emergency room performance metrics are equated to emergency room throughput metrics. As a result, there is a continuous attempt to understand factors that affect a facility’s performance (Lambe et al., 2003). One of such factors in this study was the effect of nurse staffing. Suboptimal nurse staffing can affect several nursing tasks like medication administration, discharge education, vital signs, triage, and phlebotomy (Ramsey et al. 2018). Due to increased nursing delays, there is a proportionate increase in wait times; thus, more patients are left without being seen (Schull et al., 2003). The increased wait time due to staffing shortage agrees with this study’s first hypothesis that Short-staffed nursing in emergency rooms increases patients’ wait times. Also, increased patient indoor to discharge length signifies that treatment time has also significantly increased, thus, agreeing with the second hypothesis that short-staffed nursing prolongs the patient treatment times in emergency rooms.

Consequently, the increased number of patients who left without being seen due to increased waiting time translates to dissatisfaction. Hence, it disagrees with the third hypothesis that suggests that increased wait times due to nurse shortage do not lower patient satisfaction (Ramsey et al. 2018). Patients who stay in emergency rooms for long hours without being seen are highly dissatisfied because they need prompt services.

Besides, it is possible that the level of nurse staffing impacts all the essential processes in a patient’s path through the room and has initially been indicated to affect patient safety. Moreover, the global shortage of nursing practitioners continues to be a challenge (Lambe et al., 2003). Lengthy and tedious hiring processes, high nursing turnover, and changes in overtime rules, among other parameters, contributed to the global nursing shortage and decreased nursing hours within emergency rooms (Ramsey et al. 2018). This study also contributes to the evidence body that nurse staffing deficiency directly and significantly contributes to the sum of patients who left without being seen and increased emergency room length of stay, which is also indicated to reduce patient satisfaction.