September 9, 2009, 12:34 pm

Census and Sensibility

helpThat nurse better watch her back!


Baaaad body mechanics here.

I can’t figure out this little tableau; is she pulling him out of the ditch? Why is there a book on the edge of the fox hole?

I can sure appreciate the sentiment, though.

I’ve been hit with a virtual tsunami of activity now that school has started and could use a little “Help!”

But wait….

There is hope….


This could “Help!”

My son ordered the new Beatles Boxed Set (Stereo) for me! I’m….speechless….and thrilled!!!!

And right now I am listening to local radio station KFRC play the entire Beatles catalog in chronological order.

It’s like having an audio SSRI!

For 46 years the Beatles have been a huge part of my life. When this set comes, I’ll be incommunicado for at least two days. Just me and a set of Bose headphones.


In the spirit of collaboration, Change of Shift is occasionally hosted by our non-nursing colleagues and the next edition gets the EMS treatment! Medic 999 is doing the honors and he has proposed a theme! Information at Change of Shift Comes Visiting. Posts can be sent to “mglencorse at yahoo dot co dot uk”. Mark also hosted Grand Rounds this week and the latest edition of The Handover (the EMS carnival)! Wow!

About the only carnival Mark did not host is Patients for a Moment, and you can find that over at Leslie’s blog Getting Closer to Myself.


Emergency has something in common with Labor & Delivery.

Neither department has control over their census.

Medical/surgical, telemetry units and ICUs have a finite number of beds. When they are full, they are full; they cannot physically expand to more beds.

ED patients and laboring women are never turned away no matter how full the department may be. Oh, the ED may triage and L&D may send a patient in early labor home, but in both cases, eventually, all will be seen.

Labor and delivery has one advantage over the ED.

They can have someone on call.

I’ve never worked in an ED that has had an “on-call” nurse.


I will never understand the logic behind staffing an ED based on the previous 24 hour census.

If the ED does not meet a pre-determined number of patients on one day, the break nurse for the next day is canceled and there is much wailing and gnashing of teeth as the department goes over budget.

Never mind that the acuity level of the patients who were seen was through the roof. Or that 50% of them were admitted. Or that the next day, acuity again sky high, the nurses go without meals/breaks and the department is required to give penalty pay. Again, there is much wailing and gnashing of teeth for having to pay this penalty, a penalty that would never have been required had the break nurse not been canceled.


Now if the ED is slow, staff can always go home early. But not too early, because you never know what is coming in through the doors. So maybe an hour, 90 minutes early, knowing that the remaining staff can handle whatever they need to handle until the next shift comes in.

But what happens when the patients overwhelm the staff, both in acuity and numbers?  Ambulance diversion doesn’t stop the walk-in critical patients. The MIs and the possible CVAs. The GI bleeders. The potentially septic. Trying to get patients out of the department and up to the floor doesn’t work when the floor won’t take the patient for four hours because it would put them “out of ratio”.

This is a huge issue on the night shift. When there is only one unit clerk/registrar, two nurses and an ED tech after 0300.

Of course, at night it is feast or famine.

Either the feces hits the proverbial fan or…it doesn’t.

Which is exactly why we need a nurse on-call.

The ED needs flexible staffing that accounts for those times when the acuity level/census is overwhelming. Not canceling the extra break nurse is one way of doing that on days and evenings; using the on-call system is another way that could be utilized at night. If it can be done in L&D, why can’t it be done in the ED? Surely the money saved in penalty pay for missed breaks and meals would make it budget neutral.

All I know is that trying to drop staff in an ED based on what happened the previous 24 hours makes zero sense.

(And don’t even get me started on why nurse-patient ratios are treated like unbreakable rules on the floors, but it’s okay for the ED to be waaaaay out of ratio and nobody blinks….that’s another whole post!)


  • Medic999

    September 9, 2009 at 12:45 pm

    Right then, patients for a moment it is then!!

    I hope I do CoS justice for you, I’m getting some great posts already!

  • Ken O

    September 10, 2009 at 2:09 am

    You are so right Kim, but you’ll never convince the bean counters of that.

    Oh and never say the “Q word”; it’s one to avoid in my line of work as well!

  • maha

    September 10, 2009 at 4:29 pm

    Agreed! I was working the fast track area in which several patients became rather sick and needed to be admitted – not only did I have to take care of all the new people that kept walking in, but I also had to get admission orders started for the sick patients. All in all, I was juggling 11-12 patients at all times throughout my shift with a 20 minute bathroom/food break sometime in the middle.

  • Reality Rounds

    September 11, 2009 at 8:38 am

    Yes, I have always compared the ER and OB. OB may have one on-call nurse a shift, but we can also not go on bypass like the ER can. Whatever comes in the door in OB, we have to deal with. I do think the ER should have an on-call system though.

  • ERablaze

    September 12, 2009 at 8:31 pm

    RealityRounds, bypass is not what it used to be a few years back. At least in my city, bypass will buy you at most two hours without rescue in your ambulance bay. But we still have to take waiting room patients. And if you know the ER, one or two hours will fly by. We have a time limit now from administration. No more than 2 hours at most. Too bad if we have holdovers. But I agree that on-call is needed. I worked PACU for a brief 2 weeks before running back to the ER and they were required to do 100 on-call hours in a 6 week period.

  • dcac

    September 17, 2009 at 5:34 pm

    Nurse-patient ratios are not treated like unbreakable rules on the floors. They are determined by census at one point in time during the day (usually midnight) and that number of staff stays despite increases in the census of the unit. Staff may be sent home early if the census drops but if the unit gets 10 admissions they usually do not get more staff to cover those admissions. Let’s face it nursing is not easy anywhere and the grass is not greener. Having worked and continuing to work both ED and on a unit in a large hospital I find the work different, but no easier either place.

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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