Emergency Department Nursing Staffing Has Significant Financial Consequences for Patients, Hospitals, and Clinicians

ABSTRACT

Background: Emergency departments (EDs) have experienced increases in patient boarding, which has resulted in significant challenges to providing quality care. The COVID pandemic has exacerbated ED crowding despite reduced ED volumes nationally, which is in part due to national ED nursing shortages. Nursing-specific operational inefficiencies can have detrimental financial consequences for the ED and hospitals. Study Objectives: There were two primary objectives: 1) To quantify the amount of ED beds unavailable due to nurse-staffing challenges 2) To estimate the financial impact of this reduced capacity on the ED. Method(s) A retrospective, cohort review of all ED encounters from January 1, 2021 - December 31, 2021, was identified at our large, academic, safety-net trauma center. Performance metrics were retrieved from a novel, interactive, digital data dashboard at the Zuckerberg San Francisco General Hospital (ZSFGH). Average daily staffed nursing beds were obtained during two key time points daily 11am and 7pm from Q4- 2021 (October 1, 2021 - December 31, 2021) and extrapolated for the calendar year. Total unavailable ED bed minutes were determined based on nursing staffing as were total potential missed encounters due to unavailable ED beds. These were estimated using the average LOS for ED encounters. Average institutional ED charges and realized payments were then used to determine a financial estimate of the impact of the nursing shortage during Q4-2021 and annualized for 2021. We assume, based on pre-pandemic census data, that there is sufficient ED demand and volume to occupy all available ED beds. Result(s) The ZSFGH is a 59-bed ED that when maximally staffed has a weighted average of 56.25 beds daily, accounting for nighttime closures. During the review period, the average daily nursing-staffed beds during Q4-2021 were 47.7 (84.7%). From January 1, 2021 - December 31, 2021, there were 57,888 encounters of which 53,012 (91.6%) were included and 4,876 (8.4%) were excluded due to alternative dispositions such as Absent Without Leave (AWOL), Left Without Being Seen (LWBS), Left Without Being Triaged (LWBT) and Nursing Referrals (RN Referrals). The total unstaffed ED bed minutes was an estimated 4,511,400. The average LOS excluding AWOL, LWBS, LWBT, RN Referrals, and Against Medical Advice (AMA) during this time period was 411 minutes resulting in an estimated 10,977 potential missed encounters, an estimated $8.56M in lost potential charges, and $1.97M in potential lost revenue [Figure 1]. During the pre-pandemic period with available data (August 1, 2019 - February 29, 2020) when boarding and nursing staffing weren't as limited, the daily census was 184.1 patients, excluding LWBS, LWBT, and RN Referrals with an average LOS of 407 minutes for a total daily bedtime of 74,929 minutes for a utilization of 92.5%. During this period, the total daily census with LWBS, LWBT, and RN Referrals was 210.1 patients. These additional patients would account for another 10,582 bed minutes for a total bed utilization of 85,511 mins (105.6%). Conclusion(s) The COVID pandemic has resulted in increasing challenges for already strained EDs. Increasing national nursing shortages reduce operational performance and result in a significant financial loss to EDs. Greater attention to the financial consequences of nursing shortages on EDs may allow for improved resource allocation, capacity recovery, and financial performance. [Formula presented] Yes, authors have interests to disclose Disclosure FujiFilm-SonoSite Consultant/Advisor FujiFilm-SonoSite Disclosure Inflammatix Consultant/Advisor Inflammatix Copyright © 2022