Mitigating the Impact of Nursing Shortages in the Emergency Department

Identifying life threats with speed and accuracy is the core mission of the emergency department and nurses play a critical role. No better example can be found than in the heroic nursing efforts throughout the COVID-19 pandemic. Unfortunately, shortages of qualified nurses have periodically challenged care delivery over the past several decades. The COVID-19 pandemic paired with underlying labor market trends has made this challenge especially acute in 2021. Here we present strategies to mitigate the impact.

 Eight Tactics to Help Manage ED Nurse Shortages

1. Validate orders placed in triage by auditing a sample of records. Do this for orders placed by nursing, APPs, or physicians. Work to minimize add-ons or over-ordering. These are even more toxic to high performance when nursing labor is constrained. Refresh nursing protocols to be sure they are up to date.
2. Consider other sources of labor to reduce nursing workload. Hiring and training phlebotomists can increase nurse productivity. In addition to drawing blood, phlebotomists can perform ECGs. What is the scope of practice for paramedics in your municipality? Paramedics are often able to start IVs and transport monitored patients. Can CT and plain radiography transport patients? Can APPs and physicians discharge their patients without nursing intervention? Can others perform documentation that consumes nursing time?
3. Optimize the clinician schedule to match demand. Many departments have seen substantial shifts in arrival patterns and acuity during the last year. Revisit arrivals by day of the week and by the hour of the day for opportunities to allocate coverage better. Utilize any available tools to help match demand to capacity.
4. Consider a physician in triage. APPs are often placed in triage roles, but physicians can be underutilized when beds are closed due to boarding or constrained nursing labor. Physicians are more likely to render definitive care in triage and can be less likely to order unnecessary testing.
5. Leverage a regular cadence of meetings with support services to optimize performance. Are the ancillary services the emergency department depends upon staffed in a way that matches demand? Are these meetings effective, or does everyone work to defend the status quo? Create minutes and action plans to drive accountability. Set goals and manage performance for testing TAT, hemolysis rates, and other mutually agreed upon key metrics.
6. Sharing performance metrics with team members daily can provide insight into opportunities for improvement and recognize outstanding work under challenging circumstances. This can be as simple as a dry erase board or as sophisticated as an automated email digest.
7. Integration between clinical service lines can create capacity. Can hospital medicine, critical care, or other clinical services help? Can admitting flow for common clinical scenarios be streamlined?
8. Round in the ED with your senior leaders during the hours when nurse staffing challenges are apparent. Hospital administrators are acutely aware of the challenging nursing labor market, but they may not fully understand the impact on emergency department operations.

Experts predict that the shortage of nurses will be persistent and severe in some markets. Constructive partnership and close collaboration will be important as we work together to meet this challenge. If you have other tips for managing nursing shortages in the ED, please share them in the comment section.