Having the right mix of physicians, nurses, midlevel providers, and support staff in the emergency department can help ensure emergency department efficiency, patient satisfaction, cost-effective care, and medical-legal safety. But just how do you know that you are staffing your emergency department appropriately and efficiently?

“When it comes to ED staffing, there are strategic drivers and tactical drivers. The strategic drivers are quality of care, patient safety, and the level of service you want to deliver. The tactical drivers are patient volume, acuity, patient length of stay, admit holds, physician capabilities, and non-physician staffing,” said Kirk B. Jensen, M.D., MBA, who is chief medical officer for BestPractices, Inc. Dr. Jensen also is a faculty member of the Institute for Healthcare Improvement (IHI) in Boston, and chair of IHI’s collaborative on Improving Flow in the Acute Care Setting and Operational and Clinical Improvement in the ED.

Many EDs vary 40% between their slowest and busiest days, so peak load crises are inevitable. but how many are tolerable?

“The ED by its nature is often either overstaffed or understaffed because patient volume is not evenly distributed. Many smaller EDs have as much as a 40% variation between their slowest and busiest days, so peak load crises are inevitable. The real question is how many are tolerable? How far do you bend before you break?” Dr. Jensen said.

What are the best ways to reconfigure staffing models as volume increases, and how do you identify the critical inflection points at which another attending physician is required?

“First and foremost, you’ve got to deal with the fact that there are 8,760 hours in a year and the ED is open every one of those hours,” Dr. Jensen said. “You have to decide what a reasonable workload is for your facility and your physicians, and once you exceed that workload, then you need to add coverage.”

“In the past, the numbers often quoted were 2.3 to 2.8 patients per hour. We are now living the new reality of patient complexity, acuity, customer service expectations, skilled workforce shortages, crowding, boarders, and risk management,” he said. “To the extent that a range can be established, it would be 1.8 to 2.8 patients per provider per hour.”

In matching your staffing capabilities or capacity to demand, you reach an inflection point. “If, on average, your doctors can see 2 patients an hour, and your department is averaging anywhere from 1.5 to 2 patients an hour, you’re fine. But somewhere around 2.1 or 2.2 patients per hour, you reach an inflection point at which you have to beef up staffing,” Dr. Jensen said.