One of the unforeseen changes to emergency medicine in the peri-pandemic era is the extreme variation in volume and acuity. Prior to the COVID-19 pandemic, it was not unusual to observe up to 15 percent variation in volume between the busiest and slowest days of the week. For instance, an emergency department might see 98 patients on Saturday and 113 patients on Monday. Acuity as measured by admission rate and Emergency Severity Index (ESI) distribution showed a similar degree of variation. Innovative department leaders understood these data and used them to optimize operations. By knowing the arrivals by day of the week and by hour of the day, stratified by the acuity of the patients presenting, medical directors can craft good baseline operational strategies. In particular, these data should inform the opening and closing of specific zones within an emergency department and optimize staffing patterns. For instance, many departments staff down on weekends and up on Mondays. Zone opening and closing times may vary by day of the week. Some emergency departments close the fast track on weekends for lack of patients to populate it. Communities with seasonal variation in population, such as emergency departments near vacation destinations, should also look at data by month.

Since the pandemic, this variation has become extreme for many emergency departments. Some now report variation in daily volume of more than 40 percent, and the weekly patterns are now more difficult to identify. An emergency department such as the example mentioned above might now see 88 on the slowest day of the week and 127 on the busiest day. Even more confounding, the old weekend-to-Monday pattern may no longer apply. Many departments are seeing swings in the ESI distribution, such as steep drop-offs in volumes of low-acuity patients and upticks in high-acuity patient volume when COVID surges are prevalent in the community.

Factoring in the escalating phenomenon of staff callouts, this daily variability becomes even more problematic. Staff nurses have higher rates of callouts (absenteeism) than many other types of workers.¹ Particularly in unionized workforces (where the “sick day” is viewed as a right and is protected), callouts are common. But COVID had impacted absenteeism even more, and now physicians and advanced practice professionals (APPs) are affected as well.² Hospital leaders and managers are struggling to find remedies for an entire workforce that is burnt out, sick, or anxious about getting sick and so chooses to call out for a shift. Even physician groups are having to plan for doctors who call out. Nurse leaders and managers may spend the first part of a workday addressing callouts and trying to fill holes in the schedule.

What are some of the options for ED leaders trying to function with so much daily variation?