Memorial Hospital, a large, urban medical center and level I trauma center, has an emergency department (ED) designed to hold 40 acute patients. It is operating well over capacity, with more than 80 patients actively undergoing care, 30 of whom lie on wheeled stretchers in hallways. Of these 80 patients, 24 are waiting to be admitted to inpatient beds; 4 have been waiting 7–10 hours, 1 for 20 hours, and 1 for over 24 hours. The hospital has been on EMS diversion for 5 hours, but with other nearby hospitals also on diversion, it is still receiving a steady stream of patients. Doctors and nurses used to the high stress of emergency care are maintaining relative order, although they have been operating at full tilt for most of the shift. The risk of errors from fatigue, stress, and hurry grows steadily higher. An EMS crew that has been waiting to offload a patient into the busy ED for more than 35 minutes stands by impatiently. The waiting room is crowded with more than 50 people—34 patients, family, and friends—including children, adults, and elderly. Some are in pain, at least one is bleeding, while others appear to have cold or flu symptoms.

A call from the dispatch center notifies the ED that five patients will soon arrive from a car crash on the nearby interstate, with injuries of varying severity. One is coming by helicopter, and the trauma team is mobilized. The ED director does her best to clear
additional space in the ED. More nursing staff are requested, but none are available; the evening supervisor has been trying to call in personnel for the past 4 hours. The level of activity in the ED is growing visibly, and the amount of attention being provided to each patient is minimal. Several patients in the waiting room give up and leave before being seen by a physician, and two patients who are undergoing treatment in the ED sign out against the medical advice of staff.

To make matters worse, a nearby hospital requests transfer of a complex neurological and orthopedic case to Memorial. The patient is stable, but his condition may deteriorate without immediate intervention. Memorial is normally well equipped to handle such patients, but the neurological and orthopedic specialists on call to the hospital are already busy with other cases in the operating room.

As the night wears on, the volume of patients gradually declines. Although the ED has been pushed to the limit at times, a meltdown has been averted by the efforts of the staff. Nonetheless, despite the best efforts of the emergency care professionals—from emergency medical technicians to emergency doctors and nurses and on-call specialists—the quality of health care delivered by the emergency care system on this night was less than it could and should have been.

Hospital-based emergency and trauma care is critically important to the health and well-being of Americans. In 2003, nearly 114 million visits were made to hospital EDs, more than one for every three people in the United States. About one-quarter of those visits were due to unintentional injuries, the leading cause of death for people aged 1 through 44; indeed, traumatic injury has surpassed heart disease as the most expensive category of medical treatment, resulting in $71.6 billion dollars in expenditures per year (AHRQ, 2006). While most Americans encounter the ED only rarely, they count on it to be there when they need it.

Over the last several decades, the role of hospital-based emergency and trauma care has evolved substantially. EDs continue to focus on their traditional mission of providing urgent and lifesaving care, but have taken on additional responsibilities to meet the needs of communities, providers, and patients. EDs have become a key component of the health care safety net, providing a considerable volume of care to uninsured patients and Medicaid beneficiaries who often cannot access health services elsewhere. EDs are also an important public health partner, responsible for alerting public health agencies to possible threats in the community and sometimes counseling patients on prevention or self-care. Moreover, EDs play a central role in preparing their communities for disasters, and have become an important adjunct to community physicians’ practices. While the demands on emergency and trauma care have grown dramatically, however, the capacity of the system has not kept pace. Balancing these roles in the face of increasing patient volume and limited resources has become increasingly challenging.

Describe 2–3 capacity management issues facing the ED in this scenario, and identify likely causes for them.

Discuss two specific kinds of forecasts or other methods involving capacity planning that managers at Memorial Hospital’s ED might have conducted to help avert the problems it faced in this scenario. What are possible implications for managers and staff from these kinds of forecasts or capacity planning?