As hospitals continue to grapple with long wait times in emergency departments (EDs), some patient advocates have pushed for “safe staffing committees” to deal with the problem, but the idea has proven to be controversial.
Maryland, which has the longest ED wait times in the country, is one state where the idea appears to be gaining momentum.
“While blame for long wait times is sometimes attributed to overuse of the ER [emergency room] by patients, the actual number of ER visits per 1,000 population in Maryland is among the lowest in the U.S.,” Anna Palmisano, PhD, director of Marylanders for Patient Rights, a patient advocacy group, wrote in a July 12 commentary on Maryland Matters, an independent news website. “Meanwhile, under-staffed and overwhelmed ER medical staff try to care for emergency patients as best they can. Sadly, there is no end in sight to lengthy waits and no active attempt to fix this urgent problem in the near term.”
State Legislation
Palmisano’s group has joined with labor unions, MedChi (the Maryland State Medical Society), and others, to support passage of a Safe Staffing Act in Maryland.
“A Safe Staffing Act would bring the knowledge and experience of direct care workers to bear on reducing ER wait time and improving overall quality of care by formation of Safe Staffing Committees at each Maryland hospital,” Palmisano wrote. “These committees would bring frontline, direct care workers together with hospital managers to ensure best practices in hospital staffing.”
The measure would require hospitals to establish a clinical staffing committee made up of employees and management; the committee would develop and implement a safe staffing plan and update it as necessary depending on its effectiveness.
In Maryland, the bill passed the state House of Delegates but has been blocked from moving forward in the state senate by the chair of the relevant committee there, according to Palmisano. Meanwhile, nine other states have passed such laws, she noted in her commentary, adding that she performed a study of ED wait time changes in various states from 2019 to 2024 using data from the Centers for Medicare & Medicaid Services (CMS).
“Maryland ER wait time increased from 194 to 250 minutes, an increase of 28% — almost an hour,” she wrote. “By comparison, ER wait time in states with Safe Staffing Committees increased from average of 141 to 151 minutes, an average change of less than 7% — only 10 minutes. In fact, two states with Safe Staffing Committees, Washington and Nevada, actually decreased their ER wait times during this period.”
But not everyone thinks that the committees will solve the problem. “Understand what they’re requiring,” Peter Viccellio, MD, professor and vice chairman of emergency medicine at the Renaissance School of Medicine at Stony Brook University in New York, told MedPage Today. “They’re requiring you to form a committee. They’re not requiring that you staff safely. They’re just requiring that you have a committee, right? Meet once a month and look at the data and have a memo about the meeting.”
Another Alternative — ‘Surgical Smoothing’
Viccellio was not impressed by the study results. “By having a committee, we went from 141 to 151 minutes. Well, that’s not a very effective committee,” he said. Instead, to solve the problem of ED waits and boarding, Viccellio advocates for a process called “surgical smoothing,” under which hospitals “smooth out” elective surgeries by increasing the number of days on which they are done, thus freeing up inpatient beds for emergency patients who end up being admitted.
“So, if you look at just elective surgery, we’re not talking about going from 5 to 7 days a week,” Viccellio explained last November during a summit on ED boarding hosted by the Agency for Healthcare Research and Quality. “No, it’d be nice if we could go from 3 to 5 days a week, because most of the surgery is done in the first few days.”
In one example of successful smoothing, the Children’s Hospital of Cincinnati decided to build a 100-inpatient-bed tower to solve its boarding problem. They were in the middle of doing the architectural drawings for the tower when they met with an expert who convinced them to first try surgical smoothing.
“That smoothing resulted in canceling the building … and with the same surgeons and the same number of operating rooms, they were able to do $130 million more in business,” Viccellio said during the summit.
As for the safe staffing laws, “the problem with committees for safe staffing is it assumes that somehow the unsafe staffing is a willful act, as opposed to ‘we have a bunch of unfilled [positions],'” he said during the phone interview. “We want the staff, but there are no nurses available.”
Changing the Metric
The American College of Emergency Physicians (ACEP) says a broader look at the problem is needed. “More must be done to clear the inpatient bottlenecks that contribute to the nation’s boarding crisis, and staffing requirements are only one part of a complex conversation,” Laura Wooster, MPH, ACEP’s senior vice president for advocacy and practice affairs, said in an email to MedPage Today. “Systemic solutions are needed to more effectively address boarding in the emergency department.”
ACEP recently helped CMS develop a proposed ED quality metric — another incentive to change the way EDs are staffed. The metric includes four measures:
- Patient wait time exceeding 1 hour
- Whether the patient left the ED without being evaluated
- Boarding time exceeding 4 hours
- Time from ED arrival to physical departure exceeding 8 hours
Achieving safe staffing in EDs is challenging because, unlike other hospital departments, “we can’t simply close our doors or prevent patients from entering if we are beyond our safe ratios,” Brandon Morshedi, MD, an emergency medicine physician and associate medical director of the Metropolitan Emergency Medical Services (EMS) in Little Rock, Arkansas, said in an email. “Because of EMTALA [Emergency Medical Treatment and Active Labor Act] obligations, EDs are required and federally mandated to see and provide medical screening examinations at a minimum to every patient seeking or requesting care, as long as they have the capacity and capability to do so.”
Just using initial wait time to judge whether EDs are staffed safely “may not paint the entire picture, because that just means we are good at ‘clicking the box’ that we completed your medical screening examination in triage and that you were seen by a qualified medical provider (physician or advanced practice provider) in triage,” said Morshedi, who is also a board-certified EMS physician. “You may then go back to the waiting room and continue to wait for several hours until an available room opens up, or until your condition becomes so acute that we have to displace a patient currently in an ED bed to bring you back to a room.”
“Safe staffing ratios only work if all levels at the hospital deploy them, which means that it’s well past time for hospital executives and administrators to financially support the front door of the hospital as well as its back door … the emergency department,” he added.
