It’s not business as usual: You can fight patient surges with an aggressive plan

Find triggers right for your ED, have a contingency plan you can activate

It’s been such a slow morning in your emergency department that you’ve actually been able to catch up on paperwork. Then three new patients arrive within minutes of each other. Then another six patients come in, one right after the other. Before you can finish triaging them, three more trudge in the door.

In a flash, your ED is swamped and you’re far, far behind. Do you just proceed with business as usual and accept that some patients will wait a long time for treatment, or do you activate the plans you put in place for this situation? You do have a plan — don’t you?

At the Medical College of Georgia (MCG) in Augusta, that kind of morning would trigger the ED’s "surge protection" plan, says Larry Mellick, MS, MD, FAAP, FACEP, vice chairman for academic development and research in the department of emergency medicine. Just slogging through without changing
your game plan is a big mistake, he says.

"When patient surges occur, it is very important to have the capacity to think outside the lines," Mellick says. "For example, one needs the ability to juggle patients in and out of rooms and the creation of novel temporary patient care space."

Michael Shafé, MD, FACEP, FAAEM, director of emergency services at MCG, says the plan is designed for sudden increases in the volume of routine patients, unlike a mass casualty plan involving multiple victims from the same incident. The exact time and nature of the surges can’t be predicted, but Shafé says he can count on them happening regularly.

"This is a daily issue for us, and we have this plan in place every day," he says.

A full-blown unanticipated surge occurs about one out of every three days, Shafé says. "We can handle a surge of about 15 patients routinely with these mechanisms in place," he says. "Without it, we’d get way behind, and it could take us all day to recover from that."

The MCG plan, in place for one year, involves increased communication among ED staff and with other departments, plus pulling in nurses from other areas to help with triage and assessment. On-call physicians may be called in from home, and other physicians may have to stay after their shifts are over. The intent is to boost the ED’s resources quickly and to make moving ED patients through the system a top priority until the surge is over, Shafé says.

As the nurses in triage are overwhelmed, they pull in nurses from the back to help, and they let physicians know, he says. "The physicians know they have to move faster and open some beds," he adds.

MCG recently had 15 patients arrive in 10 minutes. "We had the float nurse come out to help," Shafé says. "You have to make sure you provide the charge nurse the authority to redistribute the ED’s resources, and make sure that’s a high priority."

MCG started by first analyzing the ED’s volume. Managers plotted out the average number of patients arriving every hour of the day for several years. The data helped the ED determine its usual busy times and ensure that the department was staffed adequately for those times.

MCG identified that between 10 a.m. and 1 p.m., they saw a huge rise in the volume of patients entering the ED. "So we adjusted our staffing to make sure that we were adequately staffed for those times that we knew we would have a large volume," Shafé says.

Most EDs are not dealing with this issue, he says. "If a surge hits you in your busy time, and you don’t already have enough staff, that really puts you behind the eight ball," Shafé says. "You’re already in a bad situation before the surge happens."

The costs of the surge protection plan were hiring extra physicians to meet expected and known volume growth, expanding double attending coverage to 24 hours, and going to triple attending staffing during the busiest eight hours of the day, Mellick says.

From there, the hospital developed policies and procedures that come into play when certain triggers occur in the ED. (For more on how the ED’s surge protection system works, see related article, p. 123.) If there are more than four patients waiting to be triaged, the float nurse is moved to a triage position out front. If there are five patients waiting three hours in the waiting room or a total of 10 patients in the waiting room with all ED beds full, the ED declares a "red flag" condition and may call in its on-call physicians and nurses to help.

That’s not an easy decision, Mellick says. It can be costly to call in that help, and they may not be happy when they show up. It must be an option for serious surges in volume, but summoning those on call can be kept to a minimum if you staff the ED correctly in the first place, he says.

Shafé notes that the triggers for such a plan will vary from one ED to the next. ED managers must study their own patient volume and resources to determine what wait times are acceptable and what should trigger a response, he says.

Another mechanism is triggered when all the ED rooms are filled and there are 15 patients waiting. One of the physicians is sent to the waiting area to do physician triage and assess whether lab or radiographic studies need to be initiated.

Shafé notes that it is important to send a nurse, phlebotomist, or tech with the triage physician so that blood and urine samples can be obtained and X-ray requests can be sent. Based on that assessment, the triage physician may redirect some patients to the ED’s express care service or elevate their care levels for faster treatment in the ED.

Mellick says physician triage can have a tremendous effect in clearing the waiting room. It also can result in some dramatic saves. "In our setting, this process has allowed early discovery of a patient inappropriately triaged to the waiting room with atypical sounding chest pain and later found to have EKG changes consistent with an inferior myocardial infarction," he says.

The result has been a dramatic reduction in patients who left without being seen (LWBS), Shafé says.

To demonstrate, consider that between January and March 2003, when the physician triage system was in place, the average monthly number of LWBS patients was 69. Between April and July 2003, when the physician triage system wasn’t in place due to physician illnesses, the average monthly number of LWBS patients was 144.

"That’s a better measure of satisfaction [than surveys]: if they don’t leave," Shafé says.

During a surge, staff also have to work harder to turn over beds fast. Thus, the physicians do what they call "quick disposition rounds." They look at all patients in the department and decide who can wait in the waiting room for results and who cannot.

"If the patient is taking up room that we need to make assessment of a patient in a gown, just waiting on result of urine analysis, we move [him or her] out to the waiting room to wait on that lab test or we move [the patient] out into the hall so we can use that exam room," he says. "It’s almost like we’re creating a secondary waiting area for those patients to use the rooms more efficiently."

In addition, staff satisfaction has increased, Mellick says. "When I work 11-7, many times people will say, you’ve emptied the waiting room three times, and despite the fact that we’ve had a huge volume of patients, it’s still fairly effortless.’"

When patients come back to the exam rooms, they already have their lab test results ready, he points out. "You almost just have to walk in the room and discharge them," he says.

The physicians also try to move patients out of the ED faster during a surge. For patients they expect to admit, the physicians will start calling the doctors they will admit to and let them know the ED is in a rush situation. The patient will be sent up early, before the lab results come back, so the other physician is reminded to check on those results after the transfer.

Mellick cautions that such a surge plan will work only if you coordinate it with other departments and win their cooperation. Otherwise, you can be hit with delays that thwart all your other efforts.

If your laboratory or X-ray departments are slow, all your best-laid plans may unravel, he says.

"Patients begin to stack up as necessary laboratory tests for patient disposition slowly trickle back down to the emergency department," Mellick says.

"Point-of-care testing may have a valuable role and put laboratory testing in the hands of those who feel the pain and pressure of overwhelming patient volumes," he adds.

The ED staff generally welcomed the surge plan, but Shafé says they didn’t fully get on board until they saw how well it worked and how much it improved the ED’s reputation in the hospital.

"ED staff are not usually willing to work harder just for the sake of working harder; but when you explain the political currency it brings from administration, the revenue it generates for the department, and how it makes the department successful, they buy into it," he says.

ED managers convinced the administration to give them all the things they needed such as stat lab reports, bedside registration, laptops, and a quick turnaround time from the laboratory and radiology department, Shafé says. "The staff see that and realize that the work is worthwhile," he says.

Although MCG is a large facility that handles 75,000-80,000 patients a year in its ED, a surge protection plan could be implemented at a smaller facility, Mellick maintains. "They could call in the on-call physician, and he or she could manage physician triage," he says. "Or they could simply have the NP or PA, who doesn’t cost as much, do physician’ triage and help manage surges."

The results of a well-executed surge plan can be impressive to witness, Mellick says. He compares it to watching an outnumbered army rally to victory.

"It is very tempting to lose heart and listen to those who point out the hopelessness of catching up or ever getting ahead when you encounter a surge in volume," he says "But it is possible to plan ahead for and manage the challenge of patient surges in real time."

[Editor’s note: ED Management readers always are on the lookout for solutions to overcrowding in the ED. Do you have a strategy that worked for you? If so, contact Greg Freeman, editor of EDM, by e-mail at or by phone at (770) 998-8455.]