CLINICAL ARTICLE
Acuity-based
ED Nurse Staffing: A Successful
5-year Experience
Author: Charlene Fullam, RN, MA, CEN, Wading River, NY
Charlene Fullam, Suffolk County Chapter, is Emergency Patient Care
Director, Southside Hospital, North Shore-Long Island Jewish Health
System, Bay Shore, Long Island, NY.
For reprints, write: Charlene Fullam, RN, MA, CEN, 3 Lyme St,
Wading River, NY 11792; E-mail: naxos1@optonline.net.
J Emerg Nurs 2002;28:138-40.
Copyright © 2002 by the Emergency Nurses Association.
0099-1767/2002 $35.00 + 0 18/1/122219
doi:10.1067/men.2002.122219
138
I
have discovered that staffing an emergency department
with emergency nurses on the basis of patient acuity is
more than a regulatory necessity—it is pivotal to suc-
cessful leadership. The initial setup of this system required
time, effort, data, and collaboration with the Management
Information System (MIS) department. However, since the
data collection format was created, I have been able to
obtain accurate staffing information readily by inserting
updated patient volume statistics into the formulated
worksheet. I have used this staffing method successfully
since 1998, and even with a change of positions, the for-
mula easily adapted to the data I obtained at the second
hospital. This article outlines the steps I took to implement
a staffing acuity system.
Step 1: acuity report
First, I arranged a meeting with MIS administrators to dis-
cuss the possibility of developing an ad hoc report that
would supply me with an acuity level breakdown and the
number of patients registered within each acuity level.
(Note: the ability of MIS to supply such a report varies
among institutions; fortunately, the formula is flexible
enough to accommodate this variance. Some MIS depart-
ments are able to run reports by using 5-level ambulatory
patient classification [APC] data, whereas others, particu-
larly those with an electronic log, might use triage levels.)
Although I knew I could negotiate regarding the type of
acuity data supplied and the number of acuity levels (ie,
3 or 5 triage levels), I knew it was essential to request date
parameters. The date parameter feature allows me to ana-
lyze any period upon demand—a single day, a particularly
JOURNAL OF EMERGENCY NURSING 28:2 April 2002
 CLINICAL ARTICLE/Fullam

busy week, perhaps a seasonal change, or the entire year.

Annual reports are invaluable in validating current staffing TABLE 1
Productive hours per year for 1 FTE
levels and proposing an increase of full-time equivalent
(FTE) positions. Activity No. of hours
Total hours paid 1950
4 Weeks vacation 150
I have used this staffing method suc- 4 Personal days 30
cessfully since 1998, and even with a 8 Holidays 60
9 Sick days 67.5
change of positions, the formula easily 1
⁄2 Break per shift worked 109.5
adapted to the data I obtained at the Total productive hours 1533.00
second hospital.
FTE, Full-time equivalent.

Step 2: calculating emergency nurse hours

My second step quantifies the time it takes for an emer-
gency nurse to care for one patient in each level. With lit-
tle effort, the basic criteria for a 5-level acuity system, as
presented at the 1996 ENA Scientific Assembly, can be
used:1
• Level 1 = 20 minutes
• Level 2 = 40 minutes
• Level 3 = 60 minutes
• Level 4 = 120 minutes
• Level 5 = 180 minutes
Because every institution can have mild variations in
their emergency nurse hours (ENH), I calculate my own
ENH. These variations, caused by processes such as regis-
tration, laboratory, and radiology as well as staffing mix,
scope of practice, environment, and architectural design,
can each affect the number of ENH necessary to care for a
patient. Calculating my own ENH is a valuable exercise
because the effort places the emergency department in per-
spective of the proposed time/level standards and also
stimulates ideas for performance improvement. When
determining my own ENH, I re-evaluate for volume
changes of greater than 25% or for any drastic change to
the ED environment.
I request from MIS the top 3 diagnoses or chief com-
plaints of each acuity level. Then, through direct observa-
tion, I record the amount of time it takes the emergency
nurses to care for that patient from door to disposition
decision. (The time spent caring for admitted patients is
determined by a separate calculation.) I observe a cross sec-
tion among the different shifts because they have their own
variables affecting outcome. In addition, if 2 or 3 nurses are
simultaneously providing care, I double or triple the time,
respectively.
Voilà…the formula calculates that I
need 30.64 emergency nurse FTEs to
adequately staff an emergency depart-
ment treating 30,397 patients accord-
ing to our acuity mix.
For example, 48% of our level I triage diagnoses are
chest pain, congestive heart failure, or shortness of breath.
I prospectively monitor the amount of nursing time pro-
vided to these patients. Observing approximately 5% of the
total volume provides an adequate sample group. I then cal-
culate the mean ENH for each acuity level to be applied to
the formula.
Step 3: productive hours
Productive hours are the number of hours annually that an
employee provides direct patient care; this number will vary
among institutions based on vacation time, personal time,
holiday time, and the amount of break time in each shift.
I give consideration to sick time (which is optional) and
deduct it from the summary to maximize the accuracy of
my productive time results (Table 1).

April 2002 28:2 JOURNAL OF EMERGENCY NURSING 139

 CLINICAL ARTICLE/Fullam

TABLE 2 TABLE 3
FTEs based on acuity Calculating FTEs to care for admitted patients held in
RN care hours Total needed the emergency department
Type No. of patients per patient care hours Average No.
Category 1 5742 1.51 8670.42 ENH/h LOS (h) patients/y Total
Category 2 19,453 0.98 19,063.94 Med/Surg 0.13 2.7 7285 1534.221
Category 3 5202 0.33 1716.66 patients
Triage 1 RN 24 h/d 8760.00 ICU patients 0.66 4.5 1728 3079.296
Charge 1 RN 24 h/d 8760.00 Total ENH 4613.517
Needed RN hours per year 46,971.02 needed to care
for admitted
1 RN FTE productive hours 1533.00
patients
Needed RN FTEs 30.64
Total FTEs (1533 3.01
productive
FTE, Full-time equivalent position; RN, registered nurse. h/FTE)

Step 4: staffing by acuity ENH, Emergency nurse hours; FTE, full-time equivalent; LOS, length of stay.

My data elements are now ready to insert into the work-

additional ENH calculation. I gather the following data:
sheet. With use of computer software that has the ability to
the number of medical/surgical admissions per year, the
handle mathematical formulas, such as Microsoft Excel,
number of ICU admissions per year, and the average length
I set up the data as illustrated in Table 2, using the fourth
of stay (LOS) for these 2 types of patients. My definition of
column for my formulas. The “triage” and “charge” assign-
“admit LOS” is the time from the “decision to admit” to
ments do not provide direct patient care and are not
“transfer to unit.” An admitted medical/surgical patient
included in the “hours per patient care.” I add them to the
requires 0.13 ENH for every hour held in the emergency
formula as a constant. They, of course, can be adjusted
department, whereas an ICU patient requires 0.66 ENH
according to a facility’s practice.
per hour. The data in Table 3 indicate an emergency
department that requires an extra 3.0 FTEs to care for
Having a good grasp of these data is admission holds.
my single most valuable tool with
which to validate staffing levels. Conclusion

Voilà…the formula calculates that I need 30.64 emer-
gency nurse FTEs to adequately staff an emergency depart-
ment treating 30,397 patients according to our acuity mix.
With this information, I can then distribute emergency
nurses over a 24-hour period based on patient flow.
Management of FTE distribution is simplified if the MIS
department provides me with the acuity report by hourly
parameters in addition to the date parameters.
Although the initial calculations may seem time-consum-
ing, I find having a good grasp of these data is my single
most valuable tool with which to validate staffing levels.
REFERENCE
1. Jones C. Staffing standards. In: Zimmermann P. Managers
forum. J Emerg Nurs 1999;25:216-27.

Optional step: staffing for admission holds

Depending on the individual facility, admitted patients

who are held in the emergency department require an

140 JOURNAL OF EMERGENCY NURSING 28:2 April 2002