OK. It’s that Saturday evening we were talking about. You were hosting a romantic dinner party for two when you decided it would be extremely cool to uncork the champagne with a sword. You saw it done. On TV, sure, but it looked like live TV and it worked perfectly well. Just hold the bottle with the top facing away from you, firmly. Then, with the sword in your dominant hand you make one rapid slash at the bottleneck, at the end, where it sticks out a little, et voilà!
Except you don’t have a sword. No problem. That big knife, the one you use to cut through chicken bones, should do the trick. You were hoping tonight would be the night, and you are convinced this bit of derring-do will seal the deal. Bravely, you grasp the bottle in one hand, and the Sabatier chef’s knife with fully forged handle and 10-inch carbon steel blade in the other. You look into your date’s eyes. They are wide. Whether from awe or fear is difficult to tell, but in this moment you decide it’s the former. You place the blade flat against the bottle, then, whoosh!
What happened next is unclear, though the broken glass, spilled wine, and blood suggest something went terribly wrong. You are at once embarrassed and feeling faint. Fortunately your friend is a nurse. She calmly wraps your bleeding hand in a kitchen towel and asks you to sit with your head between your legs. She removes the rack of lamb from the oven, makes sure all burners are shut off, does a rapid assessment of you and decides it is safe to walk you to her car for a ride to the ER.
Once there you are registered, triaged, and sent to the waiting room. It’s busy, you are told. It’s going to be a while. You find two seats back in a corner and settle in. You’ve already apologized for ruining the evening, several times, so it seems a good idea to change the subject.
What’s the deal with crowded emergency rooms? Why can’t they just hire more staff?
ER crowding is a complex problem with several contributing factors. For now we will consider only the manpower issue. The basic workforce in any ER consists of doctors, nurses, EMT’s, clerical staff, and, possibly, scribes. How many of each at any given time depends on the volume of patients seen per hour and the size of the department. We will use an 8-bed emergency room as our model.
In California there are laws mandating one nurse for every four ER beds, plus one nurse dedicated to triage, and, usually, another charge nurse to oversee the entire clinical operation. In addition there will be one clerk to handle the phones and possibly an Emergency Medical Tech, or EMT, to take care of things like splinting, bandaging, crutch training and the like. These people are employees of the hospital, and their salaries and benefits directly affect the hospital’s bottom line. In states without mandated staffing ratios it is common to have fewer employees caring for larger numbers of patients as a means of saving money.
Then there is the doctor. In most cases the doctor is not working for the hospital but rather is contracted to an ER staffing company and operates either as an independent contractor or employee of the contracting company. The money paid to the physician is based on the amount of revenue he or she generates through patient care.
Residency trained, board certified Emergency Medicine specialists are, like most other specialists, in short supply. As such they can pick and choose their work environment. That decision is based on several factors: location of the facility, its size, the availability of specialized back-up services, (about which we will go into more depth in a later installment), and the amount of money they will be paid for their services.
To maximize reimbursement the person doing the hiring needs to make sure the physician will be busy, but not so busy as to be overwhelmed. In our 8-bed ER, seeing 40-50 patients per day, one physician per shift is all that is required. Will there be times when a large number of patients will arrive almost at once, or when a particularly challenging case will monopolize the physicians time causing things to back up? Of course.
At those times would a second physician be helpful? Sure. But these types of situations generally resolve in a few hours. It isn’t practical or economically feasible to have a physician on-call who can expect to be needed for no more than two or three hours.
If, though, the ER is getting backed up on a regular basis, additional staffing becomes necessary. Here the ER director has some options. The first, and least expensive, would be to hire scribes. A scribe can increase a physician’s productivity by up to 35% by freeing him from the non-clinical tasks of data entry.
If the patient volume is such that a single doctor working with a scribe is falling behind, then additional caregivers will need to be put in place. The choices here, in order of cost, are physicians’ assistants, nurse practitioners, and, finally, additional doctors. No matter which choice is made, the underlying logic is to hire just enough of the right type of practitioner to get the patients seen in a timely manner without having extra staff standing around looking for something to do.
This means that no matter what sort of ER you find yourself sitting in, there will be times when you will have to wait a while to be seen. Saturday evening, with a relatively minor hand laceration, is likely to be one of them. But think positively. You were, after all, willing to sacrifice limb, if not quite life, to impress your date. That has to count for something.
A place for everyone, but not everyone is in the right place. Why all ER’s are not created equally and why it matters to know which is which.