At this very minute in emergency departments across the country, physicians and nurses are working hard, trying to manage patient loads and workloads that are both unsafe and unsustainable. How patients are assigned to providers and how workloads of clinicians are managed has implications in terms of worker satisfaction, patient safety, efficiency, and flow. Yet, most departments do not have a clearly articulated strategy for making equitable assignments and particularly for determining when an individual provider is overloaded.
A few goals should be articulated for designing the best model for patient assignments and managing the workload within a department:
- Models that utilize teams are superior because they enhance communication and improve workflow; in turn, this improves efficiency.1
- Models that utilize geographic zones are superior because they also enhance communication, teamwork, and efficiency.2
- Models that empower providers with regard to workload are preferred.3
- A patient flow coordinator overseeing patient flow for the department is an integral role and part of a patient assignment system. The traditional charge nurse role has morphed into an effective coordinator, policing the department and each zone for inefficiencies, backlogs, delays, and workloads.4
- Patient segmentation, grouping patients according to resources needed and anticipated length of stay, is an innovative new concept and part of the best patient assignment models.5
- The move toward objective measures of workloads for physicians and nurses will continue and aid in patient assignments.6
- Load leveling, balancing the workloads of clinicians, is an important concept in ED workflow for both physicians and nurses.
Patient Staffing/Assignment Models
An informal telephone survey of members of the Emergency Department Benchmarking Alliance (EDBA), a nonprofit organization with more than 1,000 ED members, identified the following models of patient assignments. It quickly becomes clear that the vocabulary and language don’t fully exist to even discuss the topic, and you will likely hear terms that are entirely unfamiliar. A department may use combination strategies.
Primary Care Nursing: One nurse cares for the patient.
Assembly Line Nursing: One nurse performs one task.
Zone Nursing: A nurse is assigned to a geographic zone.
Cross-Cover Nursing: A group of nurses covers all rooms/tasks within the department (most often seen in very small departments).
Team Nursing: A nurse is assigned to a physician/team for a shift and cares for that physician’s patients.
Free-Range Staffing: The physician (or nurse) self-assigns to the patient (the most common patient assignment strategy).
By Assignment: Patients are assigned to an area by a designated provider in charge.