Why is ACEP not pressuring hospital execs to improve staffing levels?

Understaffing leads to emergency department boarding and increased mortality.

The most common cause of emergency department boarding is exit block. Patients wait for emergency care because medical and psychiatric admissions are stuck in the ED for hours to days. In community hospitals, nurse understaffing is the main reason for patient care bottlenecks. 

HCA Mission Hospital is a glaring example of understaffing leading to ED boarding. HCA, the largest for-profit hospital system in the US, has been sued by the state of North Carolina and Buncombe County for degrading the Asheville hospital’s quality and efficiency of patient care. Per the suit, “Long wait times at the hospital’s emergency department are not because of an inadequate number of beds, but because of HCA’s profit-focused choices regarding how to staff the beds it has. HCA does not fully staff its emergency department or certain in-patient units at Mission.”

A recently published study from Wake Forest University by Mark Hall, JD, showed that HCA profited handsomely from understaffing. “HCA sharply reduced Mission’s patient-care costs, dropping those to the bottom of the peer hospital range. That drop in costs was driven substantially by HCA’s reduction in patient-care staffing. Mission’s staffing ratios plummeted from above the peer average to the bottom of the peer hospital range, by cutting the staffing rate from 6.0 full-time equivalent (“FTE”) staff per occupied bed in 2018 to 3.7 in 2021. Over the same time, average staffing at other NC hospitals remained steady at 5.1 FTEs per patient.” 

Graphic from Hall’s April 23, 2024 study of HCA Mission Hospital’s staffing and profits:

Rather than confront hospital executives about understaffing, the American College of Emergency Physicians’ leaders have been deflecting responsibility. 

The 2023 ACEP Summit on Boarding Final Report only mentions staffing three times in its nine pages:

• “Potential solutions: Realignment of Joint Commission focus on boarding and staffing issues.” (Note the focus on the Joint Commission, not hospitals.)

• “Barriers [to addressing boarding]: Staffing ratios and standards.” (Note: this implies that nurse staffing ratios - a solution supported by nearly all nursing organizations - are somehow the barrier to solving boarding rather than a solution. The first time I read this I honestly thought it was a typo.)

• “Joint Commission and QIOs more focus on staffing ratios.” (Note the focus on the Joint Commission, not hospitals. Also, didn't they say that staffing ratios are a barrier to solving boarding?)

ACEP's 2022 letter to the White House about boarding described staffing as a significant problem. For example, "While the causes of ED boarding are multifactorial, unprecedented and rising staffing shortages throughout the health care system have recently brought this issue to a crisis point, further spiraling the stress and burnout driving the current exodus of excellent physicians, nurses and other health care professionals."

However, the boarding document was sent to the White House, not to the hospital executives who make decisions about staffing. ACEP’s framing of staffing shortages as a "public health emergency" (meaning everyone and no one is responsible) takes the pressure off hospital administrators. They, too, can blame "public health" and "nursing shortages" when choosing to boost profits by understaffing nurses in medical and psychiatric units.

Nursing organizations across the country are pushing back on hospitals by lobbying for state legislation mandating minimum nursing staffing levels. For example, the Michigan “Safe Patient Care Act would set safe limits on the number of patients nurses can be assigned to, curb excessive mandatory nurse overtime, and require hospitals to disclose their RN staffing levels.” 

The Michigan College of Emergency Physicians - along with the Michigan Health & Hospital Association - lobbied against the Safe Patient Care Act. 

Contrary to popular belief, the number of active registered nurse (RN) licenses in the US increased by 11.4% between 2021 and 2023. Per a 2023 article in Annals of Emergency Medicine, “In January 2023, researchers from the University of Pennsylvania published the largest survey of registered nurses in the United States. The survey queried 80,000 nurses before and 70,000 nurses during the pandemic and showed relatively constant employment rates before and after the pandemic. The data debunked the idea of a nursing shortage… 

According to the senior author of the survey Linda Aiken, PhD, MN, BSN, ‘The problem is not the supply of nurses, but hospitals are not offering enough jobs to create safe and satisfying work environments that would retain them,’ she said. Others echo these concerns. Jane Muir, PhD, APRN, a researcher at the Center for Health Outcomes and Policy Research at the University of Pennsylvania, explains that hospitals are running on thin staffing ratios. ‘We don’t have a shortage of nurses, we have a shortage of nurses willing to work under these current conditions,’ she says.”

The argument that hospitals do not have enough money to properly staff their medical and psychiatric units rings hollow for health systems like HCA (see stock performance here) or LifePoint Health, which Apollo Global sold to itself in 2021, extracting $1.6 billion from the hospital chain. Per Beckers Hospital Review, “Massachusetts lawmakers say Cerberus Capital Management, a private equity firm that founded Dallas-based Steward Health Care, profited by around $800 million and ‘looted’ the health system when it exited in 2020.”

It’s time for the American College of Emergency Physicians’ leaders to stand up to for-profit hospital executives and administrators about understaffing. 

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