Starling’s Curve:

A Way to Conceptualize Emergency

Department Overcrowding

Linda Laskowski-JoAeromedical ServicHospital, Newark,

J Emerg Nurs 2005

0099-1767/$30.00

Copyright n 2005

doi: 10.1016/j.jen.2

G U E S T E D I T O R I A L

June 2005 31:3

Linda Laskowski-Jones, RN, MS, APRN, BC,

CCRN, CEN, Newark, Del

I became the Emergency Department

Editor’s note: We are indebted to Ms Laskowski-Jones and others whocontribute their insights and strategies to deal with ED overcrowding. ENA

Nursing Director of a large suburban Level I trauma cen-

ter emergency department (ED) in 2001 after spending

12 years as a trauma coordinator/trauma program man-

ager. Although I had been an intensive care unit (ICU)

and ED staff nurse in a prior life, I really did not have a

total grasp of all the forces that have an impact on the

function of the department, or the complexities involved,

until I assumed the director role. I spent the first few

months trying to make sense of the volume surges, over-

crowding, long wait times, ambulance diversion, staff dis-

satisfiers, and lack of inpatient bed availability.

One day, I found myself discussing with our hospital

CEO what every other ED nursing director in every other

ED across the nation discussesZpatient satisfaction and

dissatisfaction. In our case, we had had an 8% increase

in patient volume each month compared with the same

period last year. It was f lu season, in-patient bed avail-

ability was strained, and the nursing staff was feeling the

brunt of the pressure to move patients through a con-

gested system. We are very fortunate to have a physician

as our CEO, and I found myself talking in terms of

Starling’s Law.

nes is Director of Trauma, Emergency, andes, Christiana Care Health System]ChristianaDel; E-mail: Ljones@christianacare.org.

;31:229-30.

by the Emergency Nurses Association.

005.05.001

We are all familiar with the concept. As venous return or

preload increases, cardiac output compensates by increasing

up to a certain point, beyond which the myocardial fibers are

stretched too far and further increases in volume lead to a

reduction in cardiac output. Unchecked, heart failure results.

Applying a cardiac model to the ED, it occurred to me

to look at ‘‘cardiac output’’ as a measure of overall ED system

performance as evidenced by metrics that define patient

throughput (eg, length of stay, ambulance diversion hours,

number of patients who leave without being registered,

number of patients admitted without inpatient beds), pa-

tient satisfaction, staff satisfaction, staff turnover rate, va-

cancy rate, patient and staff safety, and quality of clinical

care. ‘‘Heart rate’’ is the speed at which staff work and is

directly related to the number of staff members available to

work, their motivation level, work ethic, knowledge base,

experience, and ability to be efficient within the work

environment. ‘‘Stroke volume’’ is actual amount of total

productive work performed by the ED staff during a given

period of time. The determinants of stroke volumeZpreload, afterload and contractilityZsignificantly affect sys-

tem performance. ‘‘Preload’’ can be seen as the ED patient

census volume or demand for services (especially when acuity is

considered) at a particular time. ‘‘Afterload’’ is resistance to

has identified three top clinical issues: overcrowding, the nursing shortage,and funding for nursing education. Overcrowding, as one ENA boardmember put it, is something that emergency nurses and their representativeassociation ‘‘own’’ the most, something that is unique to them. It is nurseswho are on the front lines of the war on overcrowding, dealing with not justED issues but with huge hospital and community system issues. It is EDdirectors of nursing who accept the responsibility and often create thestrategies to improve the care of ED patients. The Journal will disseminatethese strategies as we receive them. Please keep the Journal in mind, ande-mail us at glenehan@comcast.net.

JOURNAL OF EMERGENCY NURSING 229

G U E S T E D I T O R I A L / L a s k o w s k i - J o n e s

ED outf lowZin other words, the delays in inpatient bed

availability, dysfunctional physician admitting practices,

and delays in laboratory and diagnostic turnaround times, as

well as impairment in other services that facilitate ED

patient disposition. Finally, ‘‘contractility’’ is the ability of

the ED staff to be f lexible and to readily accommodate to

rapidly changing working conditions. Factors that affect

staff contractility include their physical and emotional well-

being, their job satisfaction, and their sense of perceived

support from their coworkers and leadership team.

When I apply this model to the dynamics of an ED

environment, I can clearly visualize the factors that can both

facilitate system performance or lead to system failure. For

example, a sufficient number of staff with a solid work ethic,

knowledge, and experience level enable the system to step up

the pace when necessary (‘‘heart rate’’), especially with the

‘‘adrenalin rush’’ of high acuity or a volume surge from a

multicasualty incident. Even inexperienced staff can func-

tion well in this setting as long as seasoned nurses are

available for guidance and support. Insufficient staffing or

inadequately prepared nurses to meet the challenges of the

ED environment spells trouble. At the same time, an ED

environment fraught with inefficiencies such as poorly de-

signed processes for patient f low, stocking, and documen-

tation can definitely slow the ‘‘heart rate.’’ Our ED patients

accumulate as our pace slows. If the pace is too slow, we

have system failure. A sufficient ‘‘preload’’ is necessary for

optimal system function: staff gain or maintain their clini-

cal skills, and revenues derived from the ED visits have a

positive impact on the hospital’s bottom line. But as patient

volume decreases below some mysterious level, the human

tendency among staff members to become nonproductive or

engage in petty behaviors toward each other also seems to

increase. However, a sustained increase in preload (patient

volume), a volume surge beyond the failure limits, or a high

preload in the presence of elevated afterload that resists

patient f low also predisposes to system failure. Preload is the

most difficult variable to predict and control. Methods to

reduce preload, such as ambulance diversion, jeopardize the

ED’s role as the community safety net and should be avoided

whenever possible. Surge capacity planning is essential.

Although afterload reduction is what we typically seek

in EDs to facilitate throughput, a certain amount of

resistance to f low is needed to ensure we work up ED

patients appropriately and admit only those who really need

inpatient resources. Generally, more problems occur with

230 J

high afterload. To combat the afterload, the right number of

inpatient beds must be made available through quick and

efficient bed management systems. ‘‘ED afterload reduc-

tion’’ must be owned by the entire organization. Strategies to

decompress the ED rapidly, such as placing admitted ED

patients without bed assignments in inpatient hallways and

using nontraditional care areas for overf low, are important

aspects of surge capacity planning. Express admission units

and effective care management/discharge planning processes

are other solutions. Perhaps one of the most important

components of system performance is staff ‘‘contractility.’’

Optimizing contractility means hiring good people and

keeping them through effective leadership, professional de-

velopment opportunities, peer support, and providing the

necessary tools to do the job. Efforts at maintaining work-

life balance to avoid burnout under stressful conditions

are critically important. Just as we see in the cardiopulmo-

nary model, staff who become tired after constantly being

pulled in all directions lose their ability to contract ef-

fectively. They may not be able to readily change their pace,

their attitude, or their approach to situations, especially un-

der duress. Having a number of such ‘‘scarred’’ staff mem-

bers increases the likelihood of poor system performance,

even with relatively minor increases in ED volume or re-

sistance to outf low. System ‘‘ischemia’’ develops and leads

to burnout or compassion fatigue.

All the components of this model are dependent on each

other for optimum system performance. The next time you

find yourself needing to explain why certain measures of

ED system performance have changed, consider analyzing

the problem as you would a patient with congestive heart

failure. Decide whether your system needs an inotrope, a

chronotrope, a vasodilator, or even a diuretic! We have used

vasodilators such as instituting an Express Admission Unit

that rapidly decompresses the ED and taking over a physical

therapy gym as a fast track for a couple weeks, at the peak of

the flu season. The biggest inotrope or even chronotrope is

probably support and recognition of the staff for their heroic

efforts during stressful times. Finally, keep reassessingZthe

system is a living, dynamic entity, and requires constant sur-

veillance and adjustments to keep it healthy! At my hospital,

we set the bar very high and have enjoyed many successes.

I’m most proud of our low ED nursing turnover rateZonly

5.6%, with no vacancies, but we never underestimate the

daunting challenges of maintaining peak performance. Just as

in the ICU, we’re constantly titrating all those drips.

OURNAL OF EMERGENCY NURSING 31:3 June 2005