Question
Asked 22nd Nov, 2013

Thought and opinions on a hospital implementing an "Overcapacity Protocol"/"Full Capacity Protocol"?

Is it a safer option than just 'warehousing' patients in an ED? In comparison, what are some limitations?
When demands for urgent and emergent care continue to mount and no Emergency Department (ED) care spaces are available for these emergent and urgent patients and all usual actions for rapid admissions to inpatient beds have been maximized, the Over Capacity Protocol should be initiated. This protocol is intended to ensure systematic actions are undertaken to ensure admitted patients being cared for in the ED will be appropriately admitted to an inpatient unit. The protocol may be extended to other areas of the hospital, for example critical care, as required. (Fraser Health).

All Answers (2)

26th Nov, 2014
Michael Griffiths
Howard University
The sub-acute care model was used in the 1980's to some success.  There were a number of private companies, one in Maryland that pursued this as a business model.  For a brief time this relived Hospital systems of longer than reasonable time in the hospital for recovery.  As you know this model was replaced by Rehabilitation facilities but to my knowledge this transition is still fraught with challenges.  The system is driven by the re-imbursement system unfortunately and not by patient care or effective needs. 
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5th Dec, 2014
James F. Cox
University of Georgia
I am not an expert in healthcare only an interested researcher in understanding and solving problems in this critical area.  My expertise lies in something called “theory of constraints (TOC)”.  While it sounds horribly complex TOC is quite simple and easily applied.  In TOC we use the five focusing steps to continually improve a system‘s ability to produce goal units (in your case treated patients).  The five focusing steps are one of three processes on ongoing improvement (buffer management, frequently used in healthcare, and the change question sequence are the other two processes.). These five focusing steps are:
1. IDENTIFY the system's constraint(s).
2. Decide how to EXPLOIT the system's constraint(s).
3. SUBORDINATE everything else to the above decision.
4. ELEVATE the system's constraint(s).
5. WARNING!!!! If in the previous steps a constraint has been broken, go back to step 1, but do not allow INERTIA to cause a system's constraint.
I recently coauthored (Cox, Robinson, Maxwell; Sept/Oct 2014) an article in the Journal of Family Practice Management illustrating the application of these steps to an 11-provider practice.  I recommend this article if you want to see how to apply this focusing process in healthcare.  It is a quite simple example; just common sense. 
In your case the market (the patients coming into the emergency room) is the constraint most of the time.  Normally you are able to treat incoming patients in a standard manner.  BUT then you occasionally have overloads where you use up the protective capacity of the emergency department and a backup of untreated patients occurs.  Some of this backup occurs because there is no place to offload treated patients immediately so that the provider can move to the next untreated patient.  This situation might be caused by the hospital’s focusing on minimizing staffing in hospital wards to save money.   The TOC solution would be to add a space buffer behind the constraint (between the emergency department and the specialized wards (the UK system calls this department an assessment ward, a holding area as such).  Treated patients are released to this space buffer where trained staff (maybe some removed from the specialized wards) manage patient care until the treated patients are transferred to the wards.  This approach allows emergency department providers to focus on incoming patients instead of managing already treated patients until they can be transferred to wards thus increase the capacity of the emergency room. In academic terms this space buffer aggregates the statistical fluctuations of the various wards thus having less deviations (reduced standard deviation at the assessment ward than at the sum of the specialized wards).  
Several presentations of the TOC basic concepts and applications of the concepts in various industries are available on the TOCICO (Theory of Constraints International Certification Organization) website for free viewing.  See specifically the healthcare portal web link listed below:
There are seven videos available on this link for free viewing.  An annotated bibliography of healthcare presentations is available on this link also.  
Another related link to TOC in healthcare is provided by Alex Knight (also describes his work on the TOC link above) .  Alex has been implementing TOC in emergency rooms, hospitals and the healthcare supply chain for two decades.  He has been able to move hospitals as measured by responsiveness from the bottom of 500 hospitals to the top 10 in a matter of a few months.  He recently authored a novel (Pride and Joy) describing the application of TOC in hospitals (Similar to Eli Goldratt’s The Goal did in manufacturing in the 1980’s). Alex’s consulting organization provides significant educational materials on TOC in healthcare.  This link below is to articles on applying TOC in healthcare.  On the left of this page below are links to case studies (mostly hospitals) and testimonials.
More generally TOC is a management philosophy that focuses attention on the constraint (the leverage point) in any system and how to increase system throughput.  It is not a cost-cutting approach and provides better responsiveness and healthcare.    
I hope this is helpful.  Jim
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