Coping with a crowded ED: an expanded unique role for midlevel providers.

Crowding in the emergency department (ED) has multiple causes, including space and staffing in both inpatient areas and the ED. Waiting for inpatient beds is the primary issue in our ED. Waiting inpatients require continuing care and attention from emergency-medicine (EM) physicians. As a managerial response, we developed a unique role for midlevel practitioners (MLPs) in which they could provide "back-end" work for patients awaiting inpatient beds. After initial EM physician evaluation, patients without ready inpatient beds were grouped in the ED and their care was transferred to the transition team (TT). The TT consisted of an MLP (nurse practitioner or physician assistant) and a registered nurse or licensed practical nurse, all reporting to ED supervisors. MLPs were readily available from the local medical professional market. The TT provided all patient care until a patient was seen by the admitting inpatient service or until the patient left for an inpatient unit. The major TT objectives were a reduction of EM physician work in caring for inpatients, and improved patient care. We demonstrated that the TT assumed a significant patient load, an indirect measure of reduced EM physician work, but this did not improve patient satisfaction. The TT clinical role is less desirable to MLPs than are other traditional clinical roles. The TT is a potentially available, incremental staffing resource for a crowded ED.