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New Research by Boston College Professors Directly Links Nurse Staffing to Massachusetts Emergency Department Patient Delays

BOSTON, Mass – A groundbreaking study published in the latest edition of the Journal of Emergency Nursing shows that the number of patients emergency department (ED) nurses care for is directly related to how long patients wait for treatment.

It is the first time an academic study has drawn a direct line between nurse staffing and how long it takes an ED patient to undergo diagnostic evaluation, according to lead author Boston College Associate Professor Judith Shindul-Rothschild, PhD, MSN, RN, who wrote the study with three other BC nursing professors. Before receiving that diagnostic evaluation from a qualified health care professional, a patient is not receiving any treatment. 

“We already know that Massachusetts emergency departments are overcrowded and patients are struggling with excessive wait times,” Shindul-Rothschild said. “The single best way to significantly lower patient wait times is to adequately staff our EDs with registered nurses.”

The study reports that delay in evaluation time has been associated with an increased risk of poor patient outcomes and significant delays in receiving pain medication, according to research published in the Annals of Emergency Medicine and the Journal of Emergency Nursing.

“Excessive emergency department wait times impacts patients when they are at their most vulnerable,” Massachusetts Nurses Association President Donna Kelly-Williams said. “Patients are waiting far too long in physical and psychological pain for treatment. Nurses in emergency departments across the state see patients suffering. Nurses know that safe patient limits are the best solution we have for solving this problem.”

The Patient Safety Act would dramatically improve patient safety by setting a safe limit on the number of patients assigned to a nurse at one time in all hospital units, while providing the flexibility to adjust staffing based on patients’ needs. Decades of research shows that inadequate nurse staffing leads to increased patient harm, including higher rates of medical errors, hospital-acquired infections, preventable re-admissions and even death.

Key Findings of New Study:

  • Wait times in trauma EDs for diagnostic evaluation double for every three additional patients an emergency nurse cares for in 24 hours, according to the study’s analysis of 15 Massachusetts hospital trauma EDs.
  • For example, if an emergency nurse in a trauma ED has 11 patients in a 24-hour period, the average wait time for patients will be 30 minutes. Patients will wait more than an hour if that nurse adds just three patients in 24 hours.
  • Three patients added to a non-trauma ED nurse’s assignments means an extra 15 minutes waiting for evaluation.
  • Massachusetts hospital characteristics including teaching status, disproportionate share, profit or loss, health referral regional, intensity of hospital services, ED visits, ED inpatient admissions, ED observation admissions and the percentage of hospital beds occupied DID NOT explain the variation in diagnostic evaluation in this study.
  • Lowering the number of ED patients cared for by emergency nurses is the single best solution to improve patient flow and minimize ED overcrowding.

Many hospitals in Massachusetts are struggling with providing timely and effective emergency department care. An influx of patients with behavioral health problems into Massachusetts EDs in recent years has been clashing against an ED system in which patients are already waiting too long for care and hospitals are refusing to provide safe patient limits for nurses.

Data released last year by the Health Policy Commission (HPC) showed that Massachusetts EDs saw a 24 percent increase in mental health and substance abuse patients from 2010 to 2014. In some areas of the state, the increase has been even higher, leading to EDs where nurses are scrambling to provide safe and effective care while treating patients with multiple, high-risk complications.

In testimony by Shindul-Rothschild before the Joint Committee on Public Health, published last year, she described the existing ED wait-time problem in Massachusetts hospitals. Her analysis showed that some Massachusetts hospitals have EDs that far exceed the number of patients a nurse can care for safely. Patients at UMass Marlborough Hospital on average waited more than two hours to be evaluated in the ED, according to Shindul’s research. Patients at these hospitals are waiting too long for treatment in the same regions where the HPC’s newly released data shows spikes in behavioral health visits.

Behavioral health ED visits increased by 40 percent in the Merrimack Valley, according to HPC, where Shindul’s research shows that Lawrence General Hospital, a Level 3 trauma center, has one of the highest per-shift average patient assignments in the state at nine patients per ED nurse. Morton Hospital in Taunton averages eight or more patients per nurse in the ED, in a region where the HPC showed a 33 percent spike in behavioral health visits.

HPC’s data also showed that behavioral health ED visits in the Attleboro region went up by 33 percent from 2010 to 2014. Shindul’s research showed it took an hour and a half for a patient to be given pain medication for a long bone fracture at Sturdy Memorial Hospital in Attleboro and Boston Medical Center. Central Massachusetts saw a 35 percent increase in behavioral health visits over the past five years.

This kind of data provides the public “with a meaningful, evidence-based context within which we can appreciate the human suffering that is extended, unnecessarily, due to insufficient RNs in Massachusetts’ EDs,” Shindul-Rothschild testified at a State House hearing last year.

Hospitals are obliged to demonstrate efficient patient flow management in the emergency department as part of their accreditation with the Joint Commission. Hospitals must also report measures of timely and effective ED care to the Centers for Medicare & Medicaid Services, which rewards or penalizes hospitals financially based on wait times.

The study captured how much time elapses in minutes from when a patient arrives in the emergency department until the patient has a direct diagnostic evaluation with a qualified medical/health care professional, which includes emergency department nurses under the supervision of physicians, nurse practitioners, certified nurse specialists, certified registered nurse anesthetists, certified nurse midwives or physicians assistants.