At this very minute in emergency departments across the country, physicians and nurses are working hard, trying to manage patient loads and workloads that are both unsafe and unsustainable. How patients are assigned to providers and how workloads of clinicians are managed has implications in terms of worker satisfaction, patient safety, efficiency, and flow. Yet, most departments do not have a clearly articulated strategy for making equitable assignments and particularly for determining when an individual provider is overloaded.

A few goals should be articulated for designing the best model for patient assignments and managing the workload within a department:

1. Models that utilize teams are superior because they enhance communication and improve workflow; in turn, this improves efficiency.¹
2. Models that utilize geographic zones are superior because they also enhance communication, teamwork, and efficiency.²
3. Models that empower providers with regard to workload are preferred.³
4. A patient flow coordinator overseeing patient flow for the department is an integral role and part of a patient assignment system. The traditional charge nurse role has morphed into an effective coordinator, policing the department and each zone for inefficiencies, backlogs, delays, and workloads.⁴
5. Patient segmentation, grouping patients according to resources needed and anticipated length of stay, is an innovative new concept and part of the best patient assignment models.⁵
6. The move toward objective measures of workloads for physicians and nurses will continue and aid in patient assignments.⁶
7. Load leveling, balancing the workloads of clinicians, is an important concept in ED workflow for both physicians and nurses.

Patient Staffing/Assignment Models

An informal telephone survey of members of the Emergency Department Benchmarking Alliance (EDBA), a nonprofit organization with more than 1,000 ED members, identified the following models of patient assignments. It quickly becomes clear that the vocabulary and language don’t fully exist to even discuss the topic, and you will likely hear terms that are entirely unfamiliar. A department may use combination strategies.

For Nurses

Primary Care Nursing: One nurse cares for the patient.

Assembly Line Nursing: One nurse performs one task.

Zone Nursing: A nurse is assigned to a geographic zone.

Cross-Cover Nursing: A group of nurses covers all rooms/tasks within the department (most often seen in very small departments).

Team Nursing: A nurse is assigned to a physician/team for a shift and cares for that physician’s patients.

For Physicians

Free-Range Staffing: The physician (or nurse) self-assigns to the patient (the most common patient assignment strategy).

By Assignment: Patients are assigned to an area by a designated provider in charge.

Rotational: This employs a rotation system with patient assignments made in a planned sequence.

Zone Assignments: Analogous to zone nursing, the physician staffs a zone. Zones can receive distributed patients by rotation, acuity, or chief complaint.

Team Assignments: A team including a physician, nurse(s), tech(s), PAs (in some models), a health unit coordinator, and a scribe inhabits a geographic zone and receives patients into that zone.

Workload Feeding: One of the newest and most innovative systems for patient assignment, this is currently being studied at several sites. It involves sophisticated information technology with a “smart tracker” forecasting the workload and assigning patients accordingly.⁷

Most departments have no real-time mechanisms for identifying when the workload challenging providers is unsafe or for physicians to indicate their work threshold. The system has no means for recognizing and responding to the changing conditions of patients, such as when patients unexpectedly become unstable.

Most departments have no system in place for physicians to indicate their work threshold.

One intriguing solution has been employed by Intermountain Medical Center in Salt Lake City. It developed the ability for providers to communicate on the ED tracking system (by a physician or a nurse) when a zone is “at capacity,” regardless of bed vacancy. An icon on the tracking system suggests to the triage nurse and the patient flow coordinator that the staff in that area feel it would be unsafe to send another patient to their zone or team.

These are the types of technology tools that all physicians will employ in the future. Ultimately, physicians will have the capability to objectively calculate, using Emergency Severity Index scales, chief complaint data, and utilization measures, the work being done in a zone by a team or a provider and manage workloads more effectively. Workloads should never be unsafe or unsustainable!

References

1. Kilner E, Sheppard LA. The role of teamwork and communication in the emergency department: a systematic review. Int Emerg Nurs. 2010;18(3):127-137.
2. Shetty A, Gunja N, Byth K, et al. Senior streaming assessment further evaluation after triage zone; a novel model of care encompassing various emergency department throughput measures. Emerg Med Australasia. 2012;24(4):374-382.
3. Gurses AP Carayon P, Wall M. Impact of performance obstacles on intensive care nurses’ workload, perceived quality and safety of care, and quality of working life. Health Serv Res. 2009;44(2):422-443.
4. D’Amico A, Bazzano N, Butterfield J, et al. Doing an extreme makeover of patient flow: going from condition red to green in one week (or less). Institute for Healthcare Improvement website. Accessed June 3, 2017.
5. Asha SE, Ajami A. Improvement in emergency department length of stay using an early senior medical assessment and streaming model of care: a cohort study. Emerg Med Australas. 2013;25(5):445-451.
6. Jones SS, Allen TL, Flottemesch TJ, et al. An independent evaluation of four quantitative emergency department crowding scales. Acad Emerg Med. 2006;13(11):1204-1211.
7. Jones SS, Thomas A, Evans RS, et al. Forecasting daily patient volumes in the emergency department. Acad Emerg Med. 2008;15(2):159-170.