To our knowledge, this study is the first to report on the actual development, implementation, and evaluation of a daily ED surge protocol that utilizes a widely accepted conceptual model of ED flow. Unlike single global measure of ED crowding, our protocol measures frequent surge levels for various Input-Throughput-Output components of the ED, which are tied directly to standardized specific actions to address underlying root causes. Despite continued rise in hospital occupant levels and budgetary restraints, we found a improvement in the number of times the ED actually hit severe surges with the exception of Output, which is expected since this component of the flow model is intimately tied to hospital occupant levels. When severe surges did happen, we were able to deal with them much more effectively and efficiently, resulting in an overall decrease in sustained surges in the ED including the Output component.
Limitations
Similar to other pragmatic quality improvement projects that rely on manual processes, it was difficult to ensure absolute compliance of surge level measurements throughout the study period. As a result, there were occasional missing surge level data at various times of different days. However, we believe these are relatively nonsignificant occurrences that balanced out over the pre- and post-implementation periods. In addition, we did not have the resources to robustly record and confirm completion of specific action items that were activated in response to various surge levels, although we did confirm verbally with frontline workers regularly that those actions were done. Future Plan-Do-Study-Act cycles will focus on explicit measurement of actual completed action items and further refinement of targeted responses to surge. Finally, while we were able to only collect and present data over a relatively short period of evaluation (and thus potentially susceptible to seasonal variations in ED flow), we believe that our data does support the surge protocol’s effectiveness when compared to the robust trend of hospital occupant levels.
Future Directions
This ED surge protocol can be adapted and modified to fit any ED. The specific criteria defining Minor/Moderate/Major surges can be set up as ratios or percentages relative to total number of monitors, beds, etc., available. The principles of linking actions directly to specific triggers within each Input/Throughput/Output category could be translated to fit any-sized organization. Currently in progress is a longer evaluation period and based upon the results as well as individual feedback, necessary adjustments to our definitions, criteria and action items will be considered as part of ongoing quality improvement. The principles of our surge protocol are not limited to the ED, and we will explore its implementation in other hospital departments as well as methods to link them together in alignment with the hospital’s overall corporate strategy in tackling overcrowding.
Conclusion
In summary, implementation of this novel ED surge protocol led to a more effective response and management of high surges, despite significant increase in overall hospital occupancy rates and associated frequency of surges in the Output component of the ED flow model. Our surge measurement tool is capable of identifying within which area of the ED surges are occurring, and our ED surge protocol links specific actions to address those specific root causes. We believe this will lead not only to more accurate assessments of overall ED crowding but also to more timely and effective departmental and institutional responses.