Penn Nursing Study Finds Inpatient Staffing Ratios Directly Impact ER Crowding

The solution to overcrowded emergency departments may lie not within the ER itself, but in the staffing levels of general hospital wards. According to research from the University of Pennsylvania’s School of Nursing, increasing the number of nurses on adult medical-surgical units can significantly reduce the time patients spend waiting for a bed.

The study, led by researchers at the Center for Health Outcomes and Policy Research (CHOPR), identifies a direct correlation between “inpatient” staffing and “boarding”—a phenomenon where patients who have already been admitted to the hospital are forced to remain in the emergency department because no beds are available upstairs. This bottleneck prevents new emergency cases from being seen, leading to the long wait times often associated with ER visits.

The Connection Between Ratios and Wait Times

Researchers found that every one-patient increase in a nurse’s average workload on a medical-surgical unit is associated with a 5% to 9% increase in the odds of high emergency department boarding. When nurses on the general “floors” are stretched too thin, the process of discharging current patients and admitting new ones slows down, causing a backup that stretches all the way to the hospital’s front doors.

The data highlights a stark divide between “well-staffed” and “poorly staffed” facilities. Hospitals that maintain an average of 4.8 patients per nurse on their medical-surgical units have 40% lower odds of experiencing high emergency department boarding compared to hospitals where nurses average 6.7 patients.

Hospitals with lower patient-per-nurse ratios showed significantly lower rates of emergency department boarding.

“Emergency department crowding is often a downstream symptom of inadequate staffing on inpatient floors,” said Karen B. Lasater, an associate professor at Penn Nursing and the study’s lead author. When inpatient units lack the staff to handle transfers efficiently, the emergency department effectively becomes a holding ward for the rest of the hospital.

The Financial and Structural Bottleneck

ED boarding occurs when patients who have been admitted to the hospital must wait in the emergency department because no inpatient bed is available. This prevents the ER from functioning as a point of entry and transforms it into a temporary housing unit.

While hospital administrators often argue that mandatory staffing ratios reduce flexibility and increase operating costs, the CHOPR study suggests that safer ratios may actually improve hospital-wide efficiency. By ensuring that medical-surgical floors have enough nurses to facilitate timely patient transfers, hospitals can clear their emergency departments more effectively, increasing their capacity to treat new patients.

While much of the public debate centers on nurse burnout and patient safety at the bedside, this research indicates that staffing levels are also a primary lever for managing hospital-wide patient flow and reducing public wait times for emergency care.

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