Studying the Variability in Patient Inflow and Staffing Trends on Sundays versus Other Days in the Academic Emergency Department

Abstract

Background: Resource limitation, staff deficiency, and variability in patient inflow contribute to emergency department (ED) overcrowding, associated with delayed care, poor care, and poor patient outcomes. This study seeks to describe and analyze patient inflow variability and staffing trends on Sundays versus other days in a tertiary academic ED from South India.

Methods: Patient inflow and staffing data for 2 years were collected from hospital records, cross-checked, and statistically analyzed using Epi Info 7.0.

Results: Significant increase in patient inflow (45.6%) was noted on Sundays compared to other days (155.9 [95% confidence interval (CI): 152.75-159.05] vs. 107.1 [95% CI: 105.98-108.22]; P < 0.001), with higher inflow in the morning shifts (67.4 [95% CI: 65.41-69.45] vs. 32.1 [95% CI: 31.45-32.70]; P < 0.001). All categories of ED staff were deficient across all shifts (2.1 [95% CI: 2.05-2.15] tier-2 physicians, 4.9 [95% CI: 4.86-4.94] nurses, and 1.9 [95% CI: 1.88-1.92] nurse assistants on an average), especially tier-1 physicians (0.3 [95% CI: 0.24-0.36] on Sundays and 0.5 [95% CI: 0.48-0.52] on other days; P < 0.001). Patient-per-hour (PPH)-per-provider based on patient arrival rate was generally high. PPH per tier-1 physician was the highest, being 10.6 (95% CI: 9.95-11.14) versus 5.4 (95% CI: 5.26-5.59; P < 0.001) in the morning and 7.2 (95% CI: 6.95-7.45) versus 6.6 (95% CI: 6.43-6.74; P = 0.08) in the evening shifts on Sundays and other days, respectively.

Conclusions: There were deficiencies in all categories of ED staff on all days, and this was pronounced on Sundays due to significantly higher patient inflow. Inadequate ED staffing, especially due to a significant dearth of tier-1 physicians is a pointer toward quality compromise in developing EDs. Authors recommend adequate staff deployment in developing EDs for optimum quality care. This should be implemented such that staffing is based on expected patient inflow so that a PPH-per-provider goal of 2.5 is targeted across all shifts.

Keywords: Emergency department overcrowding; Indian emergency department; Sundays; emergency department staffing; emergency department workload; patient inflow; patient-per-hour.

Figure 1

Monthly variation of patient inflow in emergency department during 1^st and 2^nd years of study