Regulatory Requirements for Staff to Patient Ratio in Emergency Rooms

Setting standards for emergency room staff to patient ratios is largely left to state governments. The federal government is only involved with Medicare enrolled hospitals.

Federal Standards

• Taking on more overtime in short-staffed units is a reality for many emergency room staff.

  The major federal standard on staff to patient ratios affects hospitals enrolled in the Medicare program for patients 65 and older. According to Title 42 from the Code of Federal Regulations, such hospitals must offer "adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed." Such language is too nebulous to offer a valid benchmark, according to the American Nurses Association (ANA).

State Approaches

• As of July 2010, California, New York and Texas were among 15 states with mandatory staffing laws, according to a summary posted on the ANA's website, nursingworld.org. An additional seven states--including Illinois, Ohio, Texas and Washington--required hospitals to appoint committees to handle planning and staffing levels. Illinois, New Jersey, New York, Rhode Island and Vermont also mandated some form of public disclosure of staffing levels, the association indicated.

California's Approach

• California's continuous compliance standard has made its staffing law the nation's most rigid one.

  Passed in 1999, California's law has fueled the sharpest debate, according to healthcarehacks.com. Notable features included a requirement of 1 to 1 nurse-to-patient ratios in the operating room, and 1 to 2 for the critical, intensive and neonatal intensive care units. However, the law also required hospitals to stay in "continuous compliance" with these ratios throughout each shift. This might require a nurse using the restroom to reassign her patients, to avoid flouting the law, according to healthcarehacks.com's analysis.

ENA Suggested Guidelines

• Debate persists on whether California's experience has been positive or negative, since the only staffing level study came out in 2002--two years before the law took effect. The Emergency Nurses Association responded with its own guidelines in 2003. Instead of using an hourly standard, emergency department managers could plug 12 months of activity into a spreadsheet to calculate how many employees might be needed, Jennifer Larson reported in an article for nursezone.com.

Recent Developments

• In July 2010, the Registered Nurse Safe Staffing Act returned for Congressional consideration. Aimed at Medicare-participating hospitals, the bill proposed to appoint committees--with direct care nurses in the majority--to develop staffing plans tailored to each institution's needs. However, the American Hospital Association and the American Organization of Nurse Executives, have presented an alternative plan that focuses on improved monitoring and recruitment to relieve emergency room overcrowding.