Red flag’ conditions prompt response to surge in volume

These are excerpts from the policy on how the emergency department at the Medical College
of Georgia Medical Center in Augusta responds to surges in patient volume:

Charge nurse role.

Charge nurses will demonstrate a greater degree of ED leadership. This means charge nurses will take an active role in communicating with the physicians regarding patient flow.

They will serve in a "flight controller" capacity. To accomplish this charge nurses will make rounds every three hours with the senior resident and attending. The format of the rounds will be at the discretion of the parties involved.

Patient flow.

Charge nurses will track patient times in the ED. They will maintain a list of all patients who have been in the ED for more than three hours. They will discuss these patients with the responsible physicians and attempt to maximize attention to these patients.


Time benchmarks of five minutes will be established for triage and registration. To accomplish this, the triage nurse will notify the charge nurse if the ED is more than five patients behind. The charge nurse will take any necessary steps to fix the backlog of patients.

The triage nurse will order X-rays and will be encouraged to call attending/residents with questions concerning X-rays.

Staff nurse role.

Staff nurses should make every effort to take ownership of their patients. The staff nurse will push the patients through while the physicians should be pulling. Staff nurses should communicate frequently with residents and attendings. They also should think ahead and set up trays (pelvic, suture, etc.) before the physician gets in the room.

On call-activation and "red flag" conditions.

Red flag conditions exist when there are five patients who have been waiting more than three hours to be seen or when there are 10 or more patients in the waiting area and all beds are full in the ED.

In collaboration with ED attendings, the charge nurse will make the decision on whether to call the on-call physician. The charge nurse will notify the attending physicians present that the ED’s status requires initiation of the on-call process.

The initial call to the attending physician and resident will be made for the purposes of notifying them (a heads-up) that their services may be needed and that a second call will occur in 30 minutes. During that time, the on-call attending physician and resident will prepare to come in if needed. If conditions do not improve during those 30 minutes, the charge nurse/attending will call back the on-call physicians and tell them they are needed. It will also be the on-call physician’s responsibility to call back in 30 minutes to the ED for a status report. This will allow a period of 30 minutes for driving to the ED.

At times, a more acceptable option will be to request that an attending arrive to a shift early or have the attending stay over to continue picking up new patients.

If the attending stays to take patients (not to finish up charts) or if the on-call physician is called in, then it is considered an "on-call activation." If an on-call activation is made, then the resident on call will be called in or residents currently working the ED will be asked to remain on duty to see more patients.

On-call practice.

When the on-call attending and resident arrive, they will immediately begin physician triage. The physician will not write on or sign the triage sheet. Instead, a staff note will be used for the limited history and physical, and a separate order sheet will be used to get orders started.


The clerk will call all directives. The attendings and residents should be filling out information sheets and allowing the clerks to make the call. The attending will be responsible for a timely decision to admit. However, the resident most often will carry out the actual process.

Just as with hotel room reservations, admissions can be called ahead. If a change in plan occurs, the admission always can be canceled.


For more information, contact:

  • Michael Shafé, MD, FACEP, FAAEM, Director of Emergency Services, Medical College of Georgia, 1120 15th St., AF 2054, Augusta, GA 30912. Telephone: (706) 721-3337.
  • Larry B. Mellick, MS, MD, FAAP, FACEP, Vice Chairman for Academic Development and Research, Department of Emergency Medicine, Medical College of Georgia, 1120 15th St., AF 2036, Augusta, GA 30912-2800. Telephone: (706) 721-1083.