What is the Nurse to Patient ratio in the ER? This is a very frequent question for nursing students and new grads. The answer is a very unsatisfying “it depends.”

Ratios in the emergency room depend on three main things:

• Laws and policies - These are different from one state to another and between hospitals
• Patient acuity - Sicker patients should receive more attention and so lower ratios
• Available staff and patient volumes - as explained below, this trumps everything else

Why are nurse ratios important? It’s been proven that adhering to nursing ratios promotes better patient outcomes and patient safety. Mortality rates and duration of stay improvements are both achieved by maintaining appropriate ratios (Lasater, et al, 2021). It's not exactly cut and dry (some studies have shown a lack of improved outcomes) but there is little doubt that nurses are happier and retention is improved. Plus, in some cases, it is the law. Unfortunately, following nurse-patient ratios in the ED is not a simple task. In the inpatient units, it is possible to turn off the influx of new patients. Administration can say “we will send X number of patients to this unit and no more.” This is impossible in the ED and actually illegal.

The Emergency Medical Treatment And Labor Act (EMTALA) has three aspects: EVERYONE that comes to the ED must receive a medical screening exam, any medical emergency must be stabilized, and patients cannot be transferred without a medical necessity and accepting physician. There is a ton more to this law, but it’s that first part that's relevant to our current topic. It doesn’t matter if there are already 200 patients in your 20 bed ED, you are required to see the next patient that arrives. It also doesn’t matter if the complaint is “I’ve had a cough for 5 years” or “I’ve been walking all day and my feet ache.” How can an emergency room be expected to maintain nursing ratios in this situation? By giving it a good old college try and accepting that it’s not always going to happen.

Law and Policy

As of December 2022 there are two states with laws dictating specific nurse to patient ratios: Massachusetts and California. Beside laws dictating specific numbers, other states have codified how hospitals are expected to develop their own nurse to patient ratio policies.

In Massachusetts, ICU nurses are limited by law to only 1 ICU level patient. They can only be assigned a second if he/she is deemed stable enough based on a standardized tool. The law doesn’t dictate ratios for other departments, like telemetry, psychiatric, etc. The improvements anticipated to follow this law's implementation do not appear to have come true, although it’s hard to say if this is because they haven’t been properly implemented or if ratios this tight were not required.

Nurse ratios in California law are more extensive and detailed. California was actually the first state to pass mandated nurse-patient ratio laws. Note that ratios will be expressed as nurse:patient. 1:2 applies to ICUs, PACU and L&D. Telemetry and pediatric units are 1:4, Medical/surgical are 1:5 and psychiatric are 1:6. Emergency departments get three different levels. Standard ER patient ratios are 1:4, ED ICU are 1:2 and trauma are 1:1. There are rules for other departments, but you get the picture. Hospitals are free to make stricter ratios in their policies, but these are the minimums.

Another common method states use to address ratios (and, spoiler, what I believe to be a much more reasonable method) is to require the hospitals to form committees to determine reasonable staffing ratios. These committees are frequently required to have at least half of their members be current bedside nurses as opposed to managers and administrators, ensuring the ones affected by these policies have the majority of the input. This allows for setting ratios based on individual hospital characteristics; overtaxed hospitals in inner cities can ease their ratios to survive while those that are capable can tighten them up to provide better patient outcomes.

All of these laws came about to address unsafe ratios. Everyone’s heard the stories of nurses having to care for 15+ patients at a time. Obviously there is no way to properly assess patients, do effective patient care or thoroughly review charts in this sort of situation. Going from 1:15 to 1:4-6 is reasonable. This can go too far though, like the conversations I’ve seen about restricting them all the way down to 1:1 for all ICU and 1:3 for all telemetry.

One interesting thing to note is ratios around the world. As far as I can tell, other countries rarely have laws dictating specific ratios. I’ve seen some discussion about setting an absolute minimum of one nurse to eight patients in acute care hospitals in England. The United States sits around one third of the way down the list of countries when listed from most to least nurses per 1000 residents.

The Reality of Ratios in the ED

So, now for some unpopular opinions. It is easy to say “a nurse can care for four patients and no more” when you have five nurses and twenty patients. What happens when you have five nurses and twenty-one patients? What happens when you have five nurses and no control over how many patients arrive? Or when one of those patients turns into a cardiac arrest? That’s the emergency department in a nutshell.

So, what should you expect your ratio to be in the emergency department? My advice to new ED nurses is the following:

If you are in a standard assignment (as in “these beds are your beds”), expect to usually maintain a similar ratio as the inpatient telemetry floors at your hospital. Remember that usually, though. A lot of departments will allow for higher ratios in the case of cohorted psych patients or patients awaiting nursing facility placement.

Things are different in rapid treatment areas. There are several different names for these like fast track, quick fix or super track. They also come in a variety of forms, including cohorting low acuity patients in an area with a bunch of chairs or keeping them in the waiting room and only bringing them back to a bed for treatments before sending them back out. In these areas, ratios don’t exactly apply. You aren’t assigned to specific patients, but work to perform interventions as quickly as you can to get them processed and then most likely discharged. Depending on patient volumes, the availability of urgent care in the community and time of day there could be any number of patients per nurse, usually somewhere between four and eight (but sometimes significantly higher).

It’s the ICU and trauma issue that really throws a wrench in the works. Using my workplace as an example, we can occasionally have a shift in which no code blues come in. We also frequently have six or more come in over a 12 hour period, sometimes two or three at a time. Ideally, you place these in an assignment that would maintain an appropriate ratio. If that's not possible, though, they go wherever there is a bed and you get them whatever help you can manage. Patients also turn out to be much sicker than they initially appear in triage, ending up on vasopressors, requiring intubation, etc. So if you have an ICU level patient you can hope to only have one other patient. In reality, you will frequently have to manage a critical patient for a time while still having to keep the rest of your assignment in mind. In theory, either the ICU patient will be moved out or someone else will assume the rest of the assignment.

Let's take a moment to discuss how patients are assigned to a level of care. In short, it’s dictated by hospital policy and physician orders. Most of the time these policies are fairly standard, though. Medical/surgical patients are those that do not require cardiac monitoring, but do need to be admitted for one reason or another. Telemetry patients are those that have been deemed to require continuous cardiac monitoring for one reason or another. Med/surg patients are typically younger, have fewer chronic medical conditions and don’t have a significant risk for hypoxia, cardiac dysrhythmias or electrolyte imbalances. ICU patients usually require vasoactive drips, endotracheal intubation, continuous insulin infusions or frequent detailed assessments.

Aside from patient acuity and volumes, the main obstacle to maintaining nursing ratios is staffing. I can say from experience, while it’s easy to blame staffing problems on management, hiring enough competent nurses can be a tall order. In an emergency department, an incompetent nurse can be worse than not having the nurse at all. Emergency departments in particularly high acuity and high volume areas get hit the hardest, as they often face both a shortage of acceptable applicants and a high turnover rate. This can frequently result in a feedback loop, poor staffing hurting working conditions increasing turnover making staffing worse, that is hard to come out of.

Conclusion

In summary:

• Few states have legalized nursing ratios, but the hospital will have it’s own policies in other states.
• Because of the variety of patient types, ERs will have more than one ratio depending on patient acuity
• The nurse to patient ratio in a standard assignment is likely to be the same as on the telemetry floors.
• ICU and trauma patients will require tighter ratios, usually one or two patients per nurse.
• “Non-medical” patients like psychiatric and those awaiting placement will have a higher patient per nurse ratio.
• Rapid treatment areas frequently will not have a set ratio

The bottom line is that any decent department/charge nurse will attempt to maintain appropriate ratios, but as an ER nurse you should plan on being out of ratio from time to time. One last note, it would be wise to know your organization's policies for documenting when safe nursing ratios are violated and take advantage of them.

Please, take a moment to share your own experiences with nurse to patient ratios in the comments!

Source

Lasater KB, Aiken LH, Sloane D, French R, Martin B, Alexander M, McHugh MD. Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study. BMJ Open. 2021 Dec 8;11(12):e052899. doi: 10.1136/bmjopen-2021-052899. PMID: 34880022; PMCID: PMC8655582.