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The emergency department (ED) “product” is a satisfied patient, appropriately evaluated and safely treated according to evidence-based principles. The term satisfied patient implies in turn timeliness, ED staff relationship and communication competence, physical plant cleanliness, patient privacy, and a host of other customer service competencies as well. The term safely treated implies appropriate staff education provided continuously, quality assurance, risk management, and other capabilities. However, consistently delivering a high-quality ED product is a much more complex challenge than it may initially appear to be.

The 6 key elements of a high-functioning ED must work together harmoniously. They comprise

  • ED providers (physicians and physician extenders)
  • Nursing and nursing extender staff
  • Ancillary services (lab, radiology, etc)
  • Administrative leaders supporting the department (physical plant, registration, unit clerk, etc)
  • Consulting and admitting medical staff
  • ED and hospital culture and their impact on the efficiency of the other 5 elements

The provider group may be among the best but if just one of the other elements of the product is deficient, the product will be deficient as well.


The ED is almost never ideally staffed with providers, with patient demand varying from moment to moment and typically alternating between being overstaffed or understaffed. Nurse staffing is much the same with the added wrinkle that most ED nursing staffs do not cover sick call-in shifts. It is rare indeed for a provider shift to go unfilled but it is all too common on the nursing side to “work short.” Gaps in nursing staffing occur because most EDs do not maintain an on-call nurse schedule to fill a last minute shift opening due to nurse illness, etc. Reassigning a floor nurse who is unfamiliar with the ED and emergency medicine (EM) is generally more aggravation than it's worth.

In addition to provider and nursing demand variation, there is variation in ancillary services response times. In smaller hospitals, the same technician supporting the ED may also be responsible for supplying lab and radiology services to inpatients. Key individuals with responsibilities to several units introduce additional systemic variation when the need is the greatest, that is, when several units are busy.

Physical plant suitability and the level of clerical support also influences ED staffing needs as does the availability of inpatient beds and the responsiveness of the consulting/admitting medical staff.

Finally, how all of these disparate elements work together is highly variable as well. A deficiency in any one of these areas can be overcome to some extent by increasing the resources in the others. However, the goal is to establish and maintain the optimum level for each of these resources and then successfully manage their variation.

Unfortunately, almost everything in the EM literature is focused on studying one of these elements in isolation. This narrow focus, without regard to the other elements, often leads to erroneous ...

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