Operational Countermeasures Help EDs Navigate Staffing Challenges

By Dorothy Brooks

While the nursing shortage has made life more difficult for the rank and file left to pick up the slack, it also has affected all the other types of personnel who take care of patients in the ED. “You can’t really talk about one group without considering the impact on the other groups, or in the context of the other groups,” explains Jody Crane, MD, FACEP, chief medical officer for TeamHealth, a large physician practice based in Knoxville, TN.

For instance, Crane observes when there are not enough nurses to staff inpatient beds, that forces hospitals to close those beds or expand nurse-patient ratios, which makes flow less efficient. “What that has done, obviously, is driven boarding in the ED, making it more difficult to get patients up into the hospital,” Crane says.

In turn, this has affected physicians and advanced practice clinicians (APC) who are left idle in the back of the ED because there are no open treatment spaces and no nurses to provide care. “We have these resources that we can’t operationalize,” Crane laments.

When this happens, it can leave physicians and APCs with “moral injury,” the sense that they cannot provide the best care for patients. “Plus, they are getting frustrated and burned out; they are resigning, and they are leaving,” Crane says.

Clinicians do not want to work a job they cannot do well. Crane believes it all comes down to proper support. But he also notes you cannot blame it all on the nursing shortage. “This is a multifactorial thing. It is the economy, it is COVID, it’s the workplace experience, and it is the financial stressors that have been placed on us by federal funding and managed care,” Crane says. “People are finding it undesirable to work in the ED.”

While long-term solutions will require action from high-level policymakers, there are some operational countermeasures that can help EDs manage through such difficulties. For instance, Crane notes TeamHealth has been doing whatever it can to support the nursing staff. “Whenever we can substitute other resources ... that can help offload the nurses from the tasks they need to do, we’re doing that,” Crane says. “An example would be adding a phlebotomist so that the nurses aren’t having to run around and draw blood.”

Another example is adding transporters to run patients to and from radiology, or dedicating paramedics to provide the same types of medicines they provide in the field. “That can offload nurses from those lower-acuity patients who can then be cared for with or by a paramedic,” Crane says.

Where the nurse shortage is particularly dire, TeamHealth has staffed some traditional nursing jobs, such as triage, with nurse practitioners. “You might think that would be a pretty expensive [solution] for nurse triage, but my response would be where else would you absolutely need to have a person to make sure patients are safe when they walk through the door?” Crane asks.

Although this could frustrate nurse practitioners, Crane reports that when deploying this tactic, patients receive excellent care. “The nurse practitioner, in some cases, could discharge the patients home and they didn’t need a separate nurse resource,” he says. “It was just what we had to do to get by.”

Another way to help EDs manage capacity involves moving care to the front end of the visit. “Depending on the size of your ED and the acuity level, this might [include] having a physician or an APC out front, supported by a nurse, a tech, a phlebotomist, and a transporter,” Crane explains.

The goal of this approach is to ensure patients receive everything they would need if they were able to be in a room.

“[We put] the patient in front of a clinician so if they’ve got a potentially dangerous problem, we can find some treatment space in the back for them,” Crane says. “If they don’t, we can order the right things. If something comes back, such as an elevated potassium level or an elevated troponin level, indicating a more severe condition, at least we are aware of it, and the patients aren’t in the waiting room waiting for nothing.”

Many EDs might find it challenging to staff upfront this way, but Crane believes it should be a priority. “Make sure those teams are able to get every patient seen. It could be a matter of life or death out there in the waiting room,” he says. “It also shortens the length of stay.”

Crane admits this is not an ideal solution. “It is dissatisfying for patients and also dissatisfying for clinicians,” he says.

However, Crane believes virtually all patients would rather be evaluated in the waiting room than wait until a bed is open. “It is just about properly communicating with the patient about what is going on,” he says.

During the COVID-19 pandemic, TeamHealth struggled with the repeated cycles of patient surges that required peak staffing, followed by steep declines in ED volume. “We have found it incredibly difficult to ramp up and ramp down with these cycles,” Crane says. “We were never quite at the best staffing level, but we always tried to err on the side of having more staff rather than less.”

Nonetheless, the wear and tear on clinicians has taken a toll. “Most clinicians who work in EDs have had the worst work experiences of their lives in the last couple of years,” Crane observes. “It is going to take some time for them to heal.”