State of Emergency

"If a patient is determined to need inpatient admission for an ICU bed, for instance, and you don't have an ICU bed available because they're all full, or you don't have adequate nursing staffing, or if it takes an hour-and-a-half to transfer the patient because of inefficient communication and handoffs—all of those things then start to back up your emergency department flow," says Gross.

These improvements can be surprisingly simple, says Schneider. Getting discharges out by noon frees up a lot of capacity, for instance. "It's not easy to do, but it's low cost. You just have to change everyone's practice," she explains. Smoothing out the OR schedule so elective surgeries don't all fall during the first part of the week can also make a big difference.

One of the top strategies being pushed by ACEP is the "full capacity protocol," which essentially means patients are moved "upstairs" when they no longer belong in the ER. Given inpatient crowding, patients often end up in the hallways of other departments, but that is actually better than lingering in the ED for both the patient and the hospital, says Schneider.

Studies suggest that simply moving patients out of the ED onto the floor can reduce length of stay by about one day, reduce the likelihood that elderly patients will be admitted to a nursing home, and save costs in the long run. "The problem is some of those are hidden costs," says Schneider. "So patients get boarded and length of stay goes up and you don't think that it's because of boarding. But there's data over data over data that shows that boarding is bad for patients, but it also costs more."

Key No. 4: Get the right technology
When the Texas Department of State Health Services issued its first notification about the H1N1 flu virus being identified in the state, White wasn't at his usual post as medical director of Tomball Regional Medical Center. That Saturday morning he was serving as the medical director for an external event—Eeyore's Birthday Party, a day-long festival that takes place every year in Austin—nearly 140 miles away.

Nevertheless, he received notification of the outbreak through a Twitter feed from an epidemiology group and knew some changes had to be made in the ED to respond. Tomball had recently installed an ED information system that allowed White to remotely access and change screening tools triage nurses were using to include H1N1 symptoms and make H1N1 screening and lab testing mandatory for ED staff, effective immediately.