Focus on what is doable instead of what can’t be done.
I’m really worried about how bad the winter is going to be. My ER is overwhelmed with volume and acuity and we’re losing nurses. I feel like I should wave the white flag and surrender as medical director. I’m considering leaving medicine or early retirement. What can I do?
In a recent article by Kelen et al. in the NEJM, the authors referred to ED crowding as the “canary in the coal mine” of healthcare. ED crowding creates safety issues and moral harm to the ED staff, and the authors argue that many factors related to flow are outside the control of the ED.
It’s hard to believe that just over a year ago, our volumes had bottomed out and we were wondering if and when they would return to normal. We were reducing hours, worried about pay and trying to be creative with the staffing we had to avoid layoffs.
Volume certainly returned. As did acuity. These factors have exacerbated the preexisting flow issues that most hospitals experienced before the pandemic. Adding more stress to the system is the national shortage of nurses.
Essentially, everyone I talk to is in the same boat trying to balance volume and acuity with reduced staffing and more boarder hours. While some EDs appear to be in worse shape than others, I can’t recall any conversations I’ve had with colleagues who aren’t feeling the strain and stress to their system. Like your shop, my docs will joke about becoming emergency “waiting room” specialists.
So, if misery loves company, there’s plenty of it to go around. It also tells me that a better job is likely not just around the corner. Therefore, we should be focusing on doing everything we can to improve our current situation.
Understanding the problem
In order to find the solution, we must better understand the problem by answering the following questions: Why is it so bad? How did it get so bad? Where are we currently? How do we fix it?
First, I try to answer these questions myself. I do my best philosophical thinking when I’m out walking the dog. When I start to get some answers, I put them on paper and try to build on them. We can’t solve this within our own physician silo. Next, you’ll need to get your nursing leadership team involved and work through these questions together.
If you’re like me, you’re seeing volume and acuity leading to increases in wait time. As Kelen et al. point out, “there is inconvertible evidence that ED crowding leads to significant patient harm.” On the human side, staff are exhausted, and many have left the ED/ICU settings. There is a nursing shortage, and everything combined further leads to retention problems.
Eating a whale starts with one bite
Although the questions are easy, answering them and successfully implementing improvements is not. As I’ve written about before, we must look to control what we can control. As my wife likes to ask her team of engineers, “tell me what you can do, not what you can’t do.”
This ranges from our commitment and plan to see patients in the waiting room to how we commit to key points in the wrap up conversations with patients. Nursing can control their efforts to get patients undressed for x-ray or the prioritization for obtaining urine. When volume and acuity are up, all the little things that extend length of stay seem to get exaggerated. On the other hand, small improvements add up as well.
We generally control physician staffing. Many people reduced hours a year ago. With volume and acuity increases, you may be adding staff back on a regular basis. For the most part, I’d say I’ve been adding hours back to the schedule every one to two months throughout the year and have more weekly hours on the schedule now than pre-pandemic.
While the goal should not be to increase our staffing to make up for nursing shortages, we should be adjusting for shifts in arrival patterns and acuity. Part of the fix on the nursing side of the equation should also include looking at staffing. A quick fix should include looking at pay adjustments and agency use, but we need long term solutions as well.
After we evaluate things we can control, we need to look at opportunities where our influence can positively impact the ED. One area on the nursing side could allow nursing leadership to get creative. This may include the use of paramedics, LPNs, medical assistants and techs.
A colleague told me they just added medics in his ED, which has turned out to be a giant time saver for nurses. We may need to lobby the hospital CNO to entertain this idea and speak to the benefits seen in EDs around the country who are increasing staff in what may be considered non-traditional ways. Nursing may need to change or create job descriptions and possibly work within/ around state regulations.
We also need to use our influence outside of the department. If you haven’t had those tough conversations yet with delays in consultants calling back, radiology turnaround time, hospitalists regularly refusing patients, etc. …this is the time.
They don’t have to be aggressive conversations, but we need to be comfortable breaking down barriers and working outside of our silo to make positive change among the departments that interact with the ED. Afterall, the ED needs to be available to provide care for all who need it.
Recruitment and retention
Pay is a recurrent issue right now. I have nurses showing me job opportunities in other states with super high rates. It’s very clear that the supply of experienced ED/critical care nurses is far exceeded by the demand.
Although I think it’s important for hospital nursing and HR to understand the pay dynamics of the local market and adjust accordingly, it’s also critical to create a good work environment. One of the staffing goals should be to have enough staff so that each employee is working to the highest level of their license. This is where offloading nursing work to techs or medics can make a real difference.
It’s also important to make staff feel valued. Although I love pizza, this goes way beyond pizza delivery. After all, how can you eat pizza when you don’t have time to eat? There’s a lot of info online about building an employee recognition program. It does start with pay, but also includes communication, professional development and celebrating achievement.
Rounding on staff and thanking them for their work, or the great case you had with them (or heard about) is a good start. Public praise for good cases via email and meetings is great as well.
The docs should be one of the reasons that nurses want to stay in our department, and we should be looking to tighten our relationships with the nursing team. Our formal and informal ED social events have taken a hit with COVID, but hopefully we’ll be able to start getting out and about with our teams on a more regular basis.
Another option is nurse education or case reviews at nursing staff meetings to pull back the curtain and explain our thought processes to the case as it’s unfolding. Of course, spending the extra minute or two to teach in real time during a shift is also usually appreciated by the nursing team. Programs to further develop nursing skills, such as teaching ultrasound guided IVs to nurses, can be a win for everyone.
It’s also important to get involvement from those in the trenches. As a leader, we need to listen more than we talk and make sure everyone can voice their ideas and concerns. We’re much better when we use a team approach to solve our problems regarding things like flow, transport and boarding.
My wife has worked for NASA and the Department of Defense. Her missions took years, but everyone could rally around a project that results in a rocket launch to space. Our mission is just as critical as we literally save lives every day and are the safety net of the healthcare system.
However, we’re usually focused on the next patient to be seen, the number of patients in the waiting room, or the patient who is yelling at us and we often lose sight of our mission. My hospital recently had a trauma survivors’ day, and a patient came to speak to us with his family.
Although my job was to show up and say a few words, I found the speeches from the patient and his family warmed my heart. If I needed motivation to jump in and take care of sick people, this was it. Now I know you can’t just pull one of these things together overnight, but while you’re working with the hospital to develop something like this whether it’s for trauma, cardiac, or stroke survivors or something else, there are a couple of easy wins we can implement.
Share the positive comments from your patient satisfaction surveys. You also likely receive at least a few complimentary letters a week from patients and these should be shared as well. Maybe highlight a “save of the month” or “interesting case of the month” at your department meeting (and the nurses meeting).
Finally, while there’s lots of reasons to do patient follow-up phone calls, one of the reasons I love doing them is the appreciation from the patients and the fulfillment that comes from knowing they’re better and my care was appropriate (and the chance to redirect them for further healthcare if they need it).
A friend texted me for my birthday wishing me a month on an island with free drinks when the pandemic is over, and I thought to myself that a month might not be enough. Retention strategies and valuing our staff must include taking care of our staff and making sure that each person is taking care of themselves.
Some on our team may benefit from formal counseling through an Employee Assistance Program. Others just may need their schedule or vacation requests to be honored so they can put a little more life in their work-life balance. But we must check on them and be aware if they’re feeling really burned out. Planning a fun event, celebrating successes, and making sure that everyone gets some time off will go a long way.
Part of our influence must extend to conversations we have with the C-suite. I have always tried to have a positive spin on ED issues when I’m talking to the CEO, but right now, I think we have to be prepared to have some unpleasant conversations.
This doesn’t mean report that we’re trying to hold up a house of cards during a windstorm. It requires an honest conversation about the biggest issues that emergency departments around the country are facing, such as the nursing shortage, the importance of staff to take care of patients and what you’re seeing from other emergency departments around the area.
As tempting as it is to ask the CEO to put a hold on metrics, I think we need to be realistic in our requests if we’re going to maintain credibility. Early in the pandemic, most hospitals were okay with not focusing on metrics.
After all, we were wondering about keeping staff safe and figuring out a new disease. With that said, 18 months in, C-suites are generally back to focusing on metrics, expecting us to have navigated any obstacles since the vaccines rolled out.
We have made a lot of effective interventions because of COVID, including big advancements in telemedicine (including triage) and ED follow up. We need to continue to build on these initiatives and innovations and remind the C-suite of our adaptability and our ability to improve performance in difficult circumstances.
Strength in Numbers
There are opportunities to collaborate with others to get help. First, if you’re part of a multi-hospital system, you should be talking to the other ED leaders in your system to make sure you’re presenting a unified message and/or options to hospital and system leadership. It’s also a good group of people to share current strategies on practice management, particularly if everyone is experiencing similar nurse staffing issues.
On a broader scale, you can work with your state ACEP chapter, which can advocate for legislative issues that include issues related to nursing licensure and regulations like early graduations to add nurses to the work force and allowing non nurses (medics) to do nursing roles (push medications).
Governors have signed a variety of executive orders throughout the pandemic and state chapters of ACEP have generally been working to support their Emergency Nurses Association colleagues.
The work we do is critical to the healthcare of the nation. Although I recognize it’s been a really rough go of it for more than 18 months, we are needed to do what we do best now more than ever. It gets bad every winter. And just when we think we can’t do it anymore, flu season ends, and we can breathe.
Although I don’t know when COVID is going to end, I do know that we will come up for air. I do not have all the answers, but with an organized team approach and some direct conversations, we can each make our work environment better.
Kelen et al. NEJM. Emergency Department Crowding: The Canary in the Healthcare System