Consider the following examples of the number of patients per hour (PPH):

• 2 PPH 8,760 hours/year = 17,520 patients per year.
• 2.5 PPH 8,760 hours/year = 21,900 patients per year.
• 3 PPH 8,760 hours/year = 26,280 patients per year.

So, for example, 18,000 visits during the 8,760 hours in a year equals 2.05 patients per hour, which might seem to be within an appropriate volume for a single-coverage emergency department. “However, the typical ED processes 64 percent of the daily ED patient volume from 10 a.m. to 10 p.m. So during that time frame, the typical 18,000-visit ED is actually processing 2.63 PPH, or the functional equivalent of a 23,039-visit ED,” Dr. Jensen noted.

“For a single-coverage ED, consider adding coverage when ED patient volume begins to exceed 18,000 visits per year and when peak load crises and their consequences become more frequent,” he said. Such consequences include the following:

• Elevated patient throughput times.
• An unacceptably high left-without-being-seen rate.
• Unacceptably low patient satisfaction.
• Concerns about emergency department clinician behavior in a stressful environment.
• Low rates of clinician satisfaction and retention.

Maximize the lowest-cost staffing alternatives first. When the inflection point indicates it’s time for double coverage, use the least-expensive resource that can successfully accomplish the mission.

“For an average ED, up to 30% of patients can be seen independently by a physician assistant or nurse practitioner,” Dr. Jensen said. Midlevel providers (MLPs) “are usually significantly more productive in a dedicated fast track than when they are assisting the emergency physician in the core.”

Utilizing MLPs for fast track and uncomplicated pediatric patients helps increase flexibility, independence, and productivity. “The quality of the midlevel provider is the biggest predictor of success,” Dr. Jensen added.

“Consider a team-based patient intake process—a physician sees the patient, an MLP does the processing work, and the physician discharges the patient,” Dr. Jensen suggested. This can be a way to optimize efficiency, service, and quality.

Also consider pediatric emergency physicians and emergency physician residents. “Senior-level residents are a net plus because they can actually help with flow, but first- and second-year residents tend to slow you down,” Dr. Jensen said.

“When setting goals and targets for staffing, it helps to benchmark your ED against other hospitals with similar acuity and volume,” Dr. Jensen said. “There are many sources for benchmarking data, including other EDs in your area.”