Editor's Forum

Unsafe Nursing Ratios Incapacitate EDs, Endanger Patients

It’s the evening surge at a busy ED where all beds are occupied. Several admitted patients – including 2 critically ill – are waiting for rooms upstairs. A quick glance reveals a full waiting room with multiple potentially sick patients. Then, 2 new patients arrive via EMS. Each will require immediate stabilizing interventions. If nursing resources were not already overwhelmed, they now will be.

In the blink of an eye, this setup has created one of the most high-risk practice environments in emergency medicine. Yet, few emergency physicians would recognize it as such or even think twice about it. After all, it’s just another day.

But consider this: Decreasing the nurse-to-patient ratio immediately increases the frequency of medication errors and all-cause mortality for all patients in the ED — not only the critically ill ones who just arrived.1-4

In fact, there is strong evidence to suggest that protected emergency nursing ratios are key not only for patient safety, but also for departmental efficiency.5,6 So, why is it controversial to ask that EDs provide adequate nursing staffing?

Staffing issues have been front and center to nursing legislative efforts for quite some time. In fact, campaigns to establish standardized nurse-to-patient ratios have been underway by nursing professional societies since the early 1990s.7 The American Nurses Association currently advocates for state-based regulations that require hospitals to create staffing plans individualized to each nursing unit. This effort is endorsed by the Emergency Nurses Association, the largest professional society representing emergency nurses. Both organizations stop short of supporting mandated nurse-to-patient ratios.7-9

The major adversaries to standardized nurse-to-patient ratios have historically been hospital associations and nurse executives, who argue that fixed ratios leave minimal flexibility in scheduling around variation in patient volume and acuity. Simply stated, standardized nurse-to-patient ratios cost more.7

To date, 14 states have passed legislation regarding nurse staffing.

The regulatory language trends toward ambiguity, leaving much to the discretion of hospital administrators. Only 7 states require that hospitals internally monitor any nurse staffing metrics at all, let alone nurse-to-patient ratios.

Minnesota law avoids the concept of self-monitoring altogether and simply mandates that each hospital’s Chief Nursing Officer develops a staffing plan “with input from others.” As previously mentioned, nurse executives are the largest opponents to standardized staffing ratios.

Massachusetts law requires ICUs to be staffed with nurses at a ratio of either 1:1 or 1:2, depending on the stability of the patient. However, there is no specific mention of critically ill patients in the ED or patients admitted to the ICU who are boarding in the ED. The regulation does not mention nurse-to-patient ratios in any other specialties.

California remains the only state with a legally defined minimum nurse-to-patient ratio for all nurses. Per the regulation, there is always a mandatory 1:4 ratio in the ED. For critically ill patients in the ED and those admitted to the ICU, the maximum ratio is 1:2. Since passing this legislation in 2004, evidence shows the trends seen with dangerous nurse staffing levels are indeed reversible with mandatory staffing ratios.6 It should be noted that the California Nurses Association separated from the ANA over philosophical differences in the late 1990s, with nurse staffing policy being one of the primary issues.7 

While most states have yet to pass legislation regarding nurse staffing, external accrediting organizations have weighed in on the issue to various degrees. Although the Joint Commission is not a government agency, most states require its approval before a health care organization may qualify to receive reimbursements from Medicare and Medicaid. 

The Joint Commission does not explicitly require reporting of nurse-to-patient staffing ratios, though this metric could satisfy a portion of the qualification assessment should the data be presented. In the category of nurse staffing standards, the Joint Commission requires reporting on a minimum of 4 metrics from a list focused on patient outcomes. Of the 4 metrics, 2 must involve “human resource indicators” such as overtime use. The other 2 must involve “clinical or service indicators” such as patient falls.10 

So, who exactly is keeping track of nursing ratios? Outside of a small minority of states, the answer is simple — no one.

ACEP’s current policy on nurse staffing is similar to ENA and ANA policy statements. The American Academy of Emergency Medicine takes it a step further and advocates for a 1:3 maximum nurse-to-patient ratio with protected triage and charge nurse roles for higher acuity departments.11,12

As a young specialty, emergency medicine has the unique ability to rapidly adopt evidence-based practices and make changes to better care for our patients. In this, emergency physicians must stand by our nurse colleagues and advocate for safe staffing ratios. Although hospital associations and nurse executives control the budgets, everyone must work together on this issue to keep patients safe.

So, the next time the ED is staffing nurses at an unsafe ratio, consider documenting it and reporting this patient safety deficiency through the local incident reporting system. After all, a quick post-shift email isn’t going to increase patient mortality.

But dangerous staffing practices?

The evidence suggests that it might.

To learn more about the ongoing national advocacy efforts for safe nurse-to-patient staffing ratios, visit the National Nurses United website at www.nationalnursesunited.org/ratios.

1. Lee A, Cheung YSL, Joynt GM, Leung CCH, Wong WT, Gomersall CD. Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study. Ann Intensive Care. 2017;7(1):46.
2. Cho E, Chin DL, Kim S, Hong O. The relationships of nurse staffing level and work environment with patient adverse events. J Nurs Scholarsh. 2016;48(1):74–82.
3. Aiken LH, Clarke SP, Sloan DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987–1993.
4. Aiken LH, Cimiotti JP, Sloane DM, Smith HL, Flynn L, Neff DF. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care. 2011;49(12):1047–1053.
5. Shindul-Rothschild J, Read CY, Stamp KD, Flanagan J. Nurse staffing and hospital characteristics predictive of time to diagnostic evaluation for patients in the emergency department. J Emerg Nurs. 2017;43(2):138–144.
6. Chan TC, Killeen JP, Vilke GM, Marshall JB, Castillo EM. Effect of mandated nurse-patient ratios on patient wait time and care time in the emergency department. Acad Emerg Med. 2010;17(5):545-552.
7. Greene J. Nurse Groups, Administrators Battle Over Mandatory Nursing Ratios: California Law Debated on National Stage. Ann Emerg Med. 2009;54(3):A31-A33.
8. American Nurses Association. Addressing Nurse Fatigue to Promote Safety and Health. Policy Statement. 2014.
9. Emergency Nurses Association. Staffing and Productivity in the Emergency Department. Position Statement. 2018.
10. The Joint Commission. Standards Information for Health Care Staffing Services.
11. ACEP. Emergency Department Nurse Staffing: Policy Statement. 2016.
12. AAEM. Position Statement on Emergency Nurse-to-Patient ED Staffing Ratios. 2001.


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