Hospitals where more emergency department nurses reported inadequate staffing had longer ED stays and more patients leaving without being seen, a 10-state study of 410 hospitals found.
The study, published Sept. 25 in Medical Care, was led by researchers at Philadelphia-based Penn Nursing’s Center for Health Outcomes and Policy Research. They linked survey responses from 11,705 hospital nurses with ED crowding measures from CMS Hospital Compare and with American Hospital Association data. The nurses were surveyed between December 2023 and March 2024 in California, Florida, Illinois, Louisiana, New Jersey, New Mexico, New York, Oregon, Pennsylvania and Washington.
Staffing shortfalls were common. On average, 61% of ED nurses and 58% of inpatient nurses said their hospital did not have enough staff to get the work done. Additionally, at the average hospital, 68% of ED nurses said their ED boarded patients daily, meaning patients were held in the ED because no inpatient beds were available.
The researchers looked at what happened as the share of ED nurses reporting inadequate staffing rose by one standard deviation. After adjusting for hospital characteristics, that increase was associated with:
- An 8.5-minute increase in ED length of stay for patients without psychiatric or mental health concerns
- An 18.4-minute increase in ED length of stay for patients with psychiatric or mental health concerns
- A 0.4 percentage-point increase in the share of patients who left without being seen
Staffing on inpatient units also showed up in the ED. When more inpatient nurses reported inadequate staffing, patients with psychiatric or mental health concerns stayed 18 minutes longer in the ED. Inpatient staffing was not significantly tied to the other two crowding measures.
“Crowding occurs when hospitals don’t have enough resources to admit patients into a bed, whether in the ED or inpatient units,” first author Jane Muir, PhD, RN, an assistant professor at Penn Nursing, said in a news release about the study. “A hospital bed without a nurse to staff it is not an available bed.”
The average hospital in the study missed two Joint Commission targets:
- Patients leaving unseen: 2.8% left without being seen, against a recommended rate below 2%.
- Psychiatric and mental health patients: They spent an average of 324 minutes in the ED, about 5.4 hours, compared to the recommended stay of less than four hours.
Researchers also projected what better staffing would mean for a typical study hospital, which sees about 64,000 ED patients a year. Reducing ED nurse staffing inadequacy by one standard deviation would shorten stays enough to see 2,939 additional patients a year based on overall length of stay.
Based on psychiatric and mental health length of stay, the gain would be 3,765 patients. About 256 fewer patients a year would leave without being seen.
The authors argued that other crowding fixes, including provider-in-triage models, rapid evaluation areas and hallway beds, are unlikely to work without enough nurses to care for the added patients. They also wrote that the findings contradict fears that minimum nurse staffing requirements, such as those in California and Oregon, would limit access to ED care.
The study was cross-sectional, so it cannot show that understaffing causes crowding. Staffing was measured by what nurses reported, not by FTE counts. The data did not account for seasonal swings in crowding.
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