12 March 2007

Things that give *me* chest pain

Our facility is quite old. We see over 100,000 patients per year in an ED environment which includes:

  • 1 trauma resuscitation bay
  • 4 medical resuscitation beds
  • 32 "regular" telemetry beds
  • 6 fast track beds cannibalized to be regular tele beds
  • 4 observation beds also so cannibalized
  • 3 "real" fast track beds
For a total of 50 beds. There are also anywhere from 8-10 euphemistically named "Hallway beds" (basically spots to park a gurney which are now "official beds" with monitors and a dedicated chart slot since their occupancy rate is essentially 100%) and when the feces has truly hit the fan we will occasionally park a half dozen chairs in the hallways for the "quick & easy" patients who would otherwise never get a "real" bed.

And the physical plant is essentially the only rate-limiting factor in our ability to move patients through. The docs are well-staffed (overstaffed, some might say), and the nursing staffing could be better but is adequate, and the hospital is great when it comes to admissions (we never board patients in the ED more than 2-3 hours). There just isn't enough physical space to put any more patients (I have suggested bunk beds, but administration doesn't like the idea). And I get the feeling that the business would be there for us if we could build the capacity.

So we are building a new shop. I just got back from a planning meeting. It is going to be absolutely gargantuan, costing in the range of half a billion dollars, with an ED only slightly small than one in the Death Star. The footprint of the ED will be over a football field on each side, over 100,000 square feet, sporting 90 beds.


That's planned out as 4 "pods" of 20 beds each, and one ten-bed Fast Track. For comparison purposes, the median ED in the US is probably about 20 beds. It boggles the mind and scares the crap out of me.

You see, I have to run this joint. Not alone, of course, and thank god for that. But how on earth am I going to staff that place? I have a couple of years to get ready, fortunately, but consider the imponderables:
  • How many patients will there be? Will our volume jump 10% the first year? 15%? 20%?
  • How many docs will have to be on shift during peak hours?
  • How many during off hours?
  • What time of day will I flex up and down?
  • How many shifts will I need to schedule?
  • How many doctors will I need to employ to fill those shifts?
  • Should we get specialized peds ER docs? etc etc etc.
Oh dear lord. There are so many unknowables, and I need to recruit a year or two in advance to get staffed up for the expected surge in volumes. What if I hire too many? What if I hire too few? And that leaves aside the whole operational issues -- patient distribution and tracking, communication, etc. I joked that we'll need roller blades or segways just to get around. And if someone gets put in room 71 and the tech puts him in "Room 17" in the computer, we will never find him.

So, exciting, but I get palpitations and chest tightness just thinking about the challenge. Hey, and I'm a little sweaty and my left hand is sort of tingling . . . .


  1. I don't know what they pay you folks........but it ain't enough.

    I was in the ER a few months ago for a sliced up finger and the nurses there had to put up with all kinds of crap from the folks waiting to get looked at.

    My best friend is a trauma nurse and I get to hear all his stories....you folks are underpaid.

  2. I agree with george, you are definitely under paid. Good luck with the new facility.


    We had a medium sized, sleepy ED with a 36k yearly census for years and years. I was happy that all the bad cases and nasty stuffs went over to the county trauma center. Then someone complained that our ED was way too small, so they all, except for me, demanded that the facility needed to be expanded. I, of course, objected to a bigger facility and vehemently argued against it. But unfortunately I was an unpersuasive, lone voice against a mob. A bigger, fancier, more expensive ED was then built doubling our beds. Our census immediately jumped up to 62,000 over 3 years. Now everyone complains how damn busy it is. We're working harder but aren't being paid anymore than what we had been getting before the new ED was built. Recruitment has been hard both on the physician side as well as the nursing side. I can't do cross word puzzles or surf the web while on duty anymore. That just sucks!

  4. Wow.

    Surely there are other hospitals in the U.S. who have been through something similar? Perhaps you could pay them a visit and hear what they encountered and how they dealt with it.

    You also might want to start some intensive data tracking now, to get a sense of your peak times and what kinds of dx's you're seeing.

    Been there, done that. Doing your homework is critical.

    It's pretty daunting though. I mean, where do you even begin? Seriously, I highly recommend talking to ED folks at other hospitals that have done this; they'll probably come up with stuff you never even thought of.

    Good luck! I hope you'll continue to blog about how this unfolds!

  5. Yowch.

    Well, ahem, I have 3.5 years experience as an ED tech in a Level 1 academic center (we see about 85k a year, I think), and I start PA school in May. So long about 2009 or so, I'll be looking for work.

    Sure, I'd like to come "home" for a bit, but the magic 8-ball says midlevels are going to be a part of your solution...

  6. Thanks for the well wishes. Yes, we do have "professionals" helping us through the process, and yes we are actively visiting other sites. Eventually, we will be ready -- it'll be another year before the first shovel touches the ground. It just scares the bejeezus out of me, and is just *so* daunting a prospect. And anon 2:16, we too are in a way victims of our own success. Our hospital has tried and succeeded in becoming the 'big dog' in our county, and we just are having trouble keeping up. I can't remember the last time I actually had down time on the shift. But I find that (within reason) the more our volume goes up, the more my pay goes up, which assuages my grief a bit. Bigger is better, right?


  7. Patients are like a gas -- they expand and fill up any available space (beds). Or the extra beds become "extra" holding areas by default awaiting admission. That is what happened at our place.

    Financially, we (physicians) did better before we expanded because the waiting room was always full and the space for physician staffing was finite. Now we are often overstaffed (physicians) when daily census fluctuations are lower or nurses don't show up for work.

    I would love to move back the the Pacific NW where I grew up and help you out in a couple years, but right now my wife won't let me!

  8. I am a student and a volunteer at my local hospital, formerly a county hospital but now a public hospital with a board of directors, CEO, and a President. The old ER was an open, cramped space with curtains for walls and around 35 beds. This new ER is 90 beds with a locked behavioral emergency department, peds, trauma with 4 seperate bays, women's center, major care, urgent care (aka fast track), and chest pain center. Here are some links to some sites on it and maybe this will give you some thoughts on your new facility.


  9. 90 beds? Holy hell, glad I'm not the charge nurse there! Our administration had developed new programs to increase our census, which has duly increased. Unfortunately there are not enough open inpatient beds or floor nurses or ER space and ER nurses to handle the increased volume. The stress of trying to cope with this has caused about 30% of the experienced staff to beat feet which adds a further stress causing us to constantly work short staffed. Uggh

  10. Just reading this post, I know where you work at. Soo... rumor has it that when the new facility gets up and running, the ED at the old campus across town'll be shut down. That's going to eat up a big chunk of those extra beds. After a year or two, you'll be wishing it'd been built to 180 beds. How wide are the hallways going to be?


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