Shifting the Mindset for Staff Modeling in Emergency Medicine

The COVID-19 pandemic has brought equal parts disruption and innovation to the emergency medicine community. Since the start of the public health emergency, many emergency departments (EDs) have experienced a significant decline in patient volume (and, therefore, reimbursement). The CDC reported a 42 percent decrease in patient volume during the first few months of the pandemic. Since then, we have seen a slight rise in ED patient volume but not nearly to the expected (or budgeted) levels compared to last year.  

Now, practice leaders are facing new challenges. EDs across the county have had to implement new infectious control policies while also facing resource limitations, such as hospital bed capacity or personal protective equipment (PPE). Many EDs are also seeing fewer and much sicker patients – with up to a 20 percent increase in acuity, based on relative value units (RVUs). 

Staff optimization is a key way to manage costs and improve resource allocation.

"ED groups are in a very difficult position right now," explains Dr. Jason Adler, Vice President of Practice Improvement at Brault Practice Solutions and Assistant Clinical Assistant Professor/Director of Compliance and Reimbursement at the University of Maryland. "Our environment has been turned upside down, and groups that can adapt quickly will be better off in the long-run." 

For most ED practices, staff costs represent more than 80 percent of operating expenses. So, it's critical to have the right number of staffed hours throughout the day. It's also important to align those staffed hours with bed capacity and make frequent adjustments to the staffing levels as patient trends change from week to week. 

"For example, on-call physicians can add flexibility in case of a sudden surge. And, when appropriate, physician-led APP teams can help provide added coverage to support your department," continues Dr. Adler. 

Start by digging deeper into your operational and clinical data.  

Most ED groups take a common approach to developing their staffing matrix. They consider department-level data such as daily arrivals, door-to-bed time, and the average length of stay. Many also look at provider productivity metrics such as RVUs-per-hour, patients-per-hour, and RVUs-per-patient.

"Historically, these models have worked. In fact, ED schedules were commonly published months in advance because these numbers were always so stable," explains Dr. Adler. "But, now we're in a new normal. Volumes and arrivals are becoming harder to predict, historical benchmarks no longer apply, and more data points are required to make these complex decisions."

Dr. Adler explains that intelligent data management can be a real game-changer for ED groups trying to optimize their staffing model. 

"For example, instead of average daily arrivals, you could go a level deeper and trend your data by hour of the day and by day of the week – and look at the actual bedded times, ESI acuity data, and length of stay. Then, you can layer in the nursing and facility staffing levels to ensure that you have real bed capacity and available resources to treat incoming patients efficiently."  

But be mindful of the increasing workload and avoid burning out your ED clinicians. 

Cutting staff hours may be the simplest way to cut costs, but Dr. Adler also cautions ED group leaders about the risks of cutting too many staffed hours.  

"For ED clinicians, our current environment is much different than it was last year," explains Dr. Adler. "Even if you're seeing the same number of patients, the workload feels harder. We are in a marathon and have no idea what mile marker we're approaching." 

Dr. Adler explains that we must acknowledge the added stress, fatigue, and difficulty that have been thrust onto our ED providers – especially as we prepare for a potential new wave of infected patients. 

"Many EDs will need to recalibrate their staffing model, but there must also be an adjustment factor that recognizes the importance of wellness and avoiding burnout. If you cut too much, you will lose much more than save." 

It's time to re-think our approach to cost reduction and resource allocation.

It's time to re-imagine how we look at our data and also the department's overall flow. There should be a constant re-assessment of patient metrics such as: when they're bedded, when they leave, and the time and resources involved during their visit. These are crucial metrics that can help you make smarter decisions about modifying coverage to keep up with the ebb and flow of patient volume. 

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By: Dr. Jason Adler, VP of Practice Improvement at Brault Practice Solutions

About Brault:

Brault is a revenue cycle and practice management organization that partners exclusively with hospitals and acute care physician groups. Their intelligent practice solutions include MIPS optimization, practice analytics, and provider documentation training. Learn more at www.Brault.us