Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions.

The Surge Plan: Improving Emergency Department Overcrowding

12/18/2017 1:31:26 PM | 5 comments

By Babak Khazaeni, MD; John Novales, MD; Jessica Voigt, RN; Gerald Gaffud, RN; Jacqueline Le, MD; Joel Stillings, DO; and Michelle Mouri, DO

Sometimes improving emergency department (ED) throughput requires a hospital-wide effort. Here's how Desert Regional Medical Center in Palm Springs, Calif., mobilized just about every department to help boost ED capacity.
The following is based on a poster presented at CEP America's annual conference.


Desert Regional Medical Center (DRMC) is a 387-bed hospital in southern California's Coachella Valley. Our 27-bed ED is a level II trauma center and a designated STEMI- and stroke-receiving center. Current annual ED volume is 79,400 visits, with 19 percent of our patients admitted to the hospital.
A few years ago, our ED volumes were on the rise, and turnaround times were following suit. Inpatient beds were often full, forcing us to board admitted patients in the ED. At one point, our turnaround time to admission (TAT-A) was as high as 360 minutes (about 6 hours).
Unfortunately, this situation is all too common among America's hospitals. Research shows that the inability to transfer admitted patients into inpatient beds is the most common cause of ED crowding. Consequences of crowding include increased mortality among boarded patients, longer hours on ambulance diversion and higher elopement rates (patients who leave the ED without treatment).
Based on this evidence, the DRMC administration decided to take a "big picture" approach to the problem. They gathered the directors of almost every department in the hospital to form a multidisciplinary Patient Flow Committee. Participants included:
  • Administration
  • House supervisor
  • Emergency department
  • Inpatient departments (critical care, med-surg, telemetry, etc.)
  • Surgery
  • Case management
  • Staffing office
  • Imaging and lab
  • Admitting
  • Environmental services
  • Facilities
  • Cath lab
Our committee met twice a month to discuss operational improvements across the hospital. Since so many patient journeys start in the ED, we decided to focus our early efforts there. To this end, we set a TAT-A goal of 240 minutes and a TAT-D (turnaround time to discharge) goal of 140 minutes.


As in most EDs, our greatest bottlenecks at DRMC occur during surges. These are the time periods when demand for ED and hospital beds exceeds capacity. Surges often necessitate the boarding of patients, which in turn exacerbates ED crowding and lengthens wait times.
Our first project was to create a surge plan that would mobilize the entire hospital to assist in decompressing the ED.
Surge Criteria
The new surge plan was incremental, with surge levels based on our National Emergency Department Overcrowding Scale (NEDOCS) score. NEDOCS is calculated based on key operational variables:
  • Total patients in the ED
  • Total ED beds
  • Number of admits
  • Total hospital beds
  • Number of ventilated patients in the ED
  • Longest boarding time for admitted patient
  • Longest wait in waiting room
Based on our data, we defined the following surge levels:
  • NEDOCS score of 21–60 is labeled “Code Alpha” (green)
  • NEDOCS score of 61–100 is labeled “Code Bravo” (yellow)
  • NEDOCS score of 101–180 is labeled “Code Charlie” (red)
  • NEDOCS score of 181–200 is labeled “Internal Disaster” (maroon)
In-addition to NEDOCS, we added in-house criteria for each level based on our unique needs (e.g., number of psychiatric patients, laboratory turnaround times.) You can find a full explanation of our leveling criteria here.
Surge codes are communicated by hospital-wide email and page. The surge plan also designates communication pathways for hospital leaders (e.g., when Code Charlie is reached, ED staff will notify the ED director and house supervisor.)
Action Plan
The surge plan defines a comprehensive set of interventions for each code level. You can view the complete plan here. In general, they fall into a few broad categories:
  • Inpatient boarding. A designated number of admitted ED patients who are waiting for a bed are moved to the hallway of the inpatient unit.
  • Funneling resources to the ED. The staffing office reallocates available personnel, notifies on-call staff and pulls in additional human resources. Department directors also shift available staff and equipment to the ED.
  • Utilization of overflow areas. Boarded ICU patients are moved to the observation unit and the radiology recovery area to create capacity.
  • Prioritization by ancillary services. Lab, radiology and housekeeping move ED-related tasks to the top of the list. Case management focuses on inpatient discharges and transfers.


The new surge plan went into effect Oct. 1, 2013. Average lengths of stay (LOS) for admitted and discharged patients were tracked before and after this date.
The data demonstrate that the plan was effective in improving turnaround times. Linear trends show overall decreases in LOS for:
  • Discharged patients: 7.6 percent decrease, from 183 to 169 minutes
  • Admitted patients: 14.7 percent decrease, from 345 to 295 minutes (p<0.001)

Improvements continued despite a seasonal upsurge of ED visits in the winter months, most notably in January.


The surge plan was not only successful in improving throughput, it also sparked some positive cultural changes in our hospital.
In particular, boarding of admitted patients on the inpatient floors has decreased dramatically. Unit staff became very proactive at anticipating bed turnover and pulling admitted patients upstairs as soon as possible. They're now so effective that it's actually rare to find an ED patient boarded on any unit.


Since this poster was presented, our throughput times have continued to improve — even as volumes have risen. TAT-A is now down to about 260, an improvement of 100 minutes.
The surge plan was put to the test in summer 2015 when flooding caused the closure of 100 inpatient beds. (Talk about an internal disaster!) Thanks in large part to the surge plan, DRMC was able to remain open and continue serving patients throughout this challenging time.
The Patient Flow Committee continues to meet and tackle new objectives. In 2015, we participated in CEP America's Throughput Collaborative Learning Initiative. We're now working with DRMC's lean consultant to maximize our use of front-end space. We are excited about these changes and committed to tackling the problem of ED crowding from all possible angles.

This post was originally published Dec. 3, 2015, and was updated Dec. 18, 2017.

Our hospital has not adopted placing ED overflow in the inpatient hallways either. So, EVERY stable admitted patient in our ED, including soft telemetry with stable vital signs and attached to a monitor, as they are in the rooms, gets placed in the ED hallway. Those patients have been screened and completely worked up and are stable. We have seen their labs, their EKG's and know their history. They are SAFE to go into our safe as they will be in an ED department. Studies have shown mortality increases the longer admitted patients hang out in the waiting room. ED nurses are not trained to manage full care. Moving on, putting the admitted patients who are just waiting for a bed puts pressure on the CNO/administrators to get patients upstairs. Why? The patients complain and will sometimes call the doctors who will then call the CNO. This also pushes doctors to discharge the patients they have upstairs too. Anyway, admitted patients will receive a survey that reflects inpatient care satisfaction, not ED care.
10/14/2017 12:45:58 PM

Tamra Kelly
How does CDPH approach boarding in IP halls?
1/7/2017 11:02:17 AM

Simone Gold
How do you handle the 4:1 RN ratio? In our hospital the inpatient RNs won't take admitted inpatient hallways if exceeds ratio. I would REALLY appreciate an answer as I need assistance! Ty.
5/17/2016 7:24:30 PM

Rick Newell
Great job Desert team! You clearly have made improvements that have benefited your patients and communities.
12/4/2015 8:48:52 AM

Savoy Brummer
Nice article. We used Nedocs to address some of the same issues at our hospital that sees about the same number of visits. It is highly useful and I think a good action plan is key. Strong work.
12/4/2015 8:35:40 AM