Summary: Hospital capacity is increasingly constrained by outpatient clinic availability, limits on inpatient volume, operative case loads, and rising demand for emergency care. Chronic surge and emergency department (ED) boarding is the new normal. Innovative strategies must meet increased demand and keep hospital-based care, particularly emergency care, available to patients. At Stanford Health Care, an academic medical center and level I trauma center, licensed capacity is just over 600 beds, but regularly the census surges above 800 inpatients. In response, a team designed and implemented a capacity level protocol, streamlining operations and prioritizing safe care. This protocol includes clear thresholds and triggers for escalation, subsequent countermeasures - including an escalation to the emergency surge plan - which maintain continuity and preserve capacity for dynamic patient needs. Protocol development occurred in partnership between the Office of Emergency Management and the Director of Clinical Inpatient Access and Throughput. There was regular stakeholder engagement with leaders from clinical services, including emergency medicine, inpatient medicine, and the interventional platform. It was implemented in 2024 with endorsement from executive and clinical leadership. There are four capacity levels, followed by activation of the emergency surge plan. The levels escalate from routine through categories with increasing risks to patient care, requiring specific actions: targeted provider communication; focused resources for inpatient discharges; limiting intake from the transfer center; prioritizing ED boarders for beds; rescheduling planned admissions and surgical cases. At level three, leaders meet to discuss countermeasures and escalations. Once at capacity level four, those same leaders consider whether to activate the emergency surge plan. This assembles the Hospital Incident Command System (HICS) and requires accountability throughout the platform and the executive level. It reserves countermeasures, including emergency waivers for hallway beds. Since protocol implementation, the emergency surge plan has been activated several times, creating immediate capacity and preserving crucial services.
Masters et al. (Sun,) studied this question.