March 30, 2015

Managing the Surge…

By Jeff Wiswell, M.D.



In residency, we always talked about “real life,” as if we were learning emergency medicine on this academic island surround by a sea of other types of practice.  We said things like, “only at _______ would you see something like ______.”

After 3 years of residency and 1 year of fellowship, it turns out that you still see generally the same type of things in the community and you still often deal with the same degree of complexity.  As emergency department acuity rises nationally, it’s rare to see the isolated “classic” presentation of an illness in an otherwise healthy patient.

The most notable difference from working in a community department compared to a larger academic center is the “Surge.”  At larger (often academic) centers, we frequently take it as a given that patients will have to wait.  They wait for all the built-in inefficiencies that come with training the next generation of attendings--consults, second opinions, thorough workups, residents away for lecture, etc.

To a certain extent, there’s some built-in comfort with the wait that develops in these types of environments, in the sense that the waiting room is just a number that only occasionally dwindles down to zero in the early hours of the morning.

In contrast, most graduates will take a job in the community, where patients are often brought directly back to the room--bypassing the waiting room entirely.  Additionally, we’re now entering an era where salary is tied to things like length of stay, patient satisfaction, and left without being seen metrics.

One area that isn’t well taught at most residencies is how to deal with a surge of patients registering in triage for a single coverage shop.  Seeing 1.5-2 patients per hour seems doable until you realize that 14 of those people just happened to present within 45 minutes of each other during a shift.  This kind of surge is a predictably unpredictable part of the job.

This brings up the question of how can an emergency physician digest this and still give quality care?

Everyone practices somewhat differently, but my anecdotal solutions have been the following:

  1. Stop trying to multi-task and recognize that good physicians have mastered rapid task switching and task prioritization (1).  Instead of juggling multiple complex tasks at once, focus on one at a time and then move on.  For example, rather than interviewing 4-5 patients in succession and then heading back to the computer, interview one patient and then put in orders before going to the next one.  This way your nurses can get things started and you can focus on getting orders right and preventing errors in the order entry process.
  2. Accept that at some point the bleeding will stop.  Eventually, registrations will level out and you will be able to catch up.  On the off chance this doesn’t happen, at least your shift will be over at some point
  3. Prioritize documentation.  Try to see a patient and then get most of the note done so that you’re always caught up.  Being behind 2-3 notes can easily turn into 7-8 if a few people all come in at once.  If need be, write down a few key details so you can make sense of them later on.
  4. Apologize for the wait to patients--generally people are understanding when you tell them that the ED is unexpectedly busy.
  5. Do procedures when you have time and create a culture where other staff members help you in setting up.  It’s much easier to repair a laceration when the wound has been washed out by one of the techs and the suture cart is sitting outside the door.
  6. Transfers can be a pain--if you know that you’re going to need to transfer a patient, get started on the process early and keep up-to-date with your documentation so it’s ready to go with the patient.
  7. In residency, try to “drink from the firehose”--as a senior resident, get used to picking up 3-5 patients at a time while the off-service residents signs up for one.  Embrace this chance to learn priority management skills.


1. Clyne, B. (2012), Multitasking in Emergency Medicine. Academic Emergency Medicine, 19: 230–231. doi: 10.1111/j.1553-2712.2011.01265.x 

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I refer you to:

Davidson SJ, Koenig KL and Cone DC: Daily Patient Flow Is Not Surge: “Management Is Prediction” Academic Emergency Medicine. 13(11)1095-6. November 2006.

It is incumbent on every one of us as physicians to do our best to serve our patients and I appreciate your post and the discussion it has provoked among colleagues locally pointing to the behaviors central to fulfilling that responsibility. It’s my view that personal responsibility is both necessary, but insufficient to the challenge emergency medicine practice currently confronts.

As has been noted by many others before me, the distinguishing technology of the specialty of emergency medicine is the system of care. The system of care is a responsibility of all of us, but particularly is a responsibility for those who lead we (in W. Edwards Demings’ words) “willing workers.” All of you, the nurses, technical and support staff who labor alongside you are surely “willing workers.” Our department has been fortunate for leadership cognizant of and driven by system principles as has yours.

Still, though personal responsibility is essential and the advice from your blog post is central to fulfilling that responsibility well, perhaps you will reflect on how we in emergency medicine deliver health care and how that system might change.

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