The Effect of Mandatory Nurse Ratios on Patient Care in an Emergency Department

Background: In 2004, California enacted mandatory nurse-to-patient ratios in an effort to improve patient care. Objectives: The aim of the study was to look at the association between nursing ratios and quality of care in an urban teaching Emergency Department (ED). Methods: This was an observational study, looking at indicators of quality care before and after the introduction of nursing ratios in an urban California ED serving a mainly indigent population. Indicators examined included wait times; patients who left without being seen (LWBS); medication errors; acute coronary syndrome (ACS) patients receiving aspirin; and time to antibiotics in pneumonia patients. Means and proportions were analyzed using t-tests and chi-squared, as appropriate. Results: All measured wait times increased significantly in 2004 compared to 2003, including room time (from 79 to 123 min, p = 0.0001), throughput time (from 365 to 397 min, p = 0.001), and admission time (from 447 to 552 min, p = 0.0001). Patients who LWBS decreased (from 11.9 % to 11.2%, p = 0.0002). Time to antibiotics in pneumonia patients decreased (from 103 to 62 min, p = 0.002). There were no statistically significant differences in medication errors or administration of aspirin in ACS patients. Conclusions: All wait times increased after implementation of mandatory nursing ratios. Some indicators of quality care improved, whereas others showed no measurable differences. Further research is needed to further define the effect of nursing ratios on quality of patient care.