A Crowded ED Comes With Risks
Emergency department (ED) overcrowding is a significant problem nationwide — and its effects ripple through the entire healthcare system. Beyond the United States, it impacts hospitals around the world, pushing capacities to their limits and causing boarding times to climb. What’s more, it can be especially harmful to older adults, who are more likely to suffer from negative health outcomes the longer they wait for admission.
When ED volumes surge, it’s vital to have a well-considered plan. This article outlines practical ways to respond to surges in the ED — all while supporting a coordinated, hospital-wide response that improves overall patient flow and reduces risk to older adults.
What Is a Surge?
Surges happen when there is a sudden spike in ED demand. During a surge, it becomes even more challenging to provide timely care. The result is overcrowding, which makes it more difficult for teams to triage, communicate, and execute critical tasks. This exacerbates ED boarding, which is associated with higher mortality among frail older adults. It also increases time spent on ambulance diversion — and the number of patients leaving without treatment. Surges happen during cold and flu season, when there are staffing shortages, when there are delays in diagnostic care, or bottlenecks in inpatient discharges. And of course, in 2020, we saw surge volumes spike due to the global COVID-19 pandemic.
How Hospitals Can Cope
While every ED faces unique challenges, there are pragmatic steps you can take to prepare for a surge. First and foremost, context is critical. Assessing factors such as population growth, ED visit volumes, wait times, staffing needs, and the availability of external care options can help decision-makers understand the pressures contributing to ED overcrowding.
Building an ED Surge Plan
The threshold for triggering a surge plan will depend on your ED and the resources available to you. With this in mind, consider the following to establish a surge plan.
Set a Threshold: Define the conditions that must be met for a “surge” to be declared. Be clear about what qualifies — and what does not.
Streamline Communication: Create clear pathways for alerting staff when a surge occurs. Use real-time data to update teams on wait times, admissions, and available beds. Keep other care sites and regional partners informed to enable a system-wide response.
Have Staffing Protocols: When surge conditions are met, what comes next? Are physicians or nurses on call? Can staff be reallocated from other units? Establish how to deploy human resources ahead of time, so the hospital can adapt quickly when ED volumes peak.
Prioritize Discharge: Establish protocols that support timely discharge. Consider transferring those awaiting transportation to a designated discharge lounge or waiting area where basic supports are provided.
Convert Available Space: See if reallocated staff can help turn over available inpatient beds. Additionally, determine whether unconventional spaces — such as hallways, patient lounges, or offices — can be converted into temporary treatment areas. If so, set hospital-wide protocols to ensure these conversions happen efficiently and safely.
Surge Planning in Action
Addressing a surge is about more than optimizing a single unit. It’s about mobilizing the entire hospital. In 2018, Vituity, a physician-owned leader in healthcare innovation, published a case study demonstrating how Desert Regional Medical Center (DRMC) in Southern California alleviated ED crowding driven by limited inpatient beds. Here is a brief overview of the actions they took:
Interested in the Full Case Study? Review it in detail here.
- Established a multidisciplinary committee to meet regularly and discuss hospital-wide optimization with ED surges in mind.
- Created an incremental surge plan informed by the National Emergency Department Overcrowding Scale (NEDOCS).
- Defined clear pathways for alerting staff to surge conditions — and communication protocols for hospital leaders.
- Freed ED space by moving boarded patients to inpatient hallways and overflow areas.
- Redirected staff and resources to ED during surge periods.
- Transferred boarded ICU patients to the observation unit and radiology recovery area, for safe monitoring away from crowded ED spaces.
- Coordinated with supporting departments (lab, radiology, housekeeping, case management) to prioritize ED tasks where possible and accelerate bed availability.
A Hospital-Wide Effort
When it comes to ED overcrowding driven by surge volumes, having a clear plan in place can help reduce boarding and ED length of stay. This lowers risk for frail older adults and other vulnerable patients — and helps mitigate staff burnout.
If you’re preparing to build a surge plan in your facility, remember that success depends on working in lockstep across the entire hospital. With shared ownership and coordinated action, your team can respond effectively when volumes spike — helping maintain safer, more sustainable care for everyone.