Optimizing Medical Surge Capacity

Authors: Mary Unanyan, OMS-I
Gregory Jasani, MD; AAEM/RSA Secretary Treasurer

The coronavirus pandemic has caused many to wonder whether our nation’s healthcare system can properly treat all of the projected critically ill patients. Experts worry that the sudden increase in sick patients may overwhelm existing healthcare resources. One way to determine how well hospitals are able to respond to this pandemic is to look at the “surge capacity” of the health system.

Medical surge capacity is a measure of the ability of a health system to manage care for a sudden increased volume of patients beyond the normal operating capacity.1 


Surge capacity involves managing supply and demand—particularly, how to cope with a mismatch in resources and need. Factors that impact surge capacity are often thought of as the “4 S’s.”2 The 4 S’s are:

  1. Staff: Having enough trained personnel to manage an influx of patients

    Personnel would include all staff—physicians (MD/DO), physician assistants, nurses, technicians, administrators, housekeeping, etc. Each member plays a vital role in the ability of a hospital or healthcare system to efficiently operate.

  2. Supplies: Having enough supplies and equipment to properly treat patients

    Supplies include durable equipment, such as cardiac monitors, intravenous (IV) pumps, ventilators, wheelchairs, and beds, as well as consumable supplies, such as medications, intravenous fluids, syringes, sutures, and personal protective equipment.

  3. Structure: Having enough physical space to accommodate these patients

    Hospitals are the most common referred to “structure,” where surge plans can modify traditionally non-medical areas (waiting room, hallways, etc.) into temporary treatment areas. Additionally, there are ideas to create new patient treatment areas outside of hospitals if necessary—for example, utilizing local convention centers, trailers, and/or other public health facilities.3

  4. Systems: Having policies and procedures in place to allow for the rapid expansion in clinical care provided to accommodate the surge

    Well thought-out policies and procedures enable normal systems to translate smoothly into “surge” protocol to ensure an efficient and sustainable clinical response. 

In order to properly respond to an influx of patients, all four factors must be optimized. For example, having adequate supplies in stock would be meaningless without the proper number of trained staff to utilize them. During the coronavirus pandemic, we have seen healthcare systems struggle with all aspects of surge capacity. Lack of adequate personal protective equipment and ventilators is a supply issue. Asking for retired physicians to rejoin the workforce is an attempt to increase staffing numbers.4 Hospitals are converting many spaces into non-traditional intensive care units (ICUs) to try and create more structure.5 Many health systems have also had to make changes to their policies (systems) to accommodate the new realities of providing care during the pandemic.

Surge capacity is an important concept for us as emergency medicine physicians as we are often the first ones to receive these patients. Most emergency departments (EDs) already have disaster plans outlining how they will respond to a sudden influx of critically ill patients. Yet, we must also be cognizant that the surge preparedness of other units will affect the ability of the ED to operate efficiently. If other floors cannot accommodate a surge of critically ill patients, this will trickle down and negatively impact the ED’s operations. For example, if the medicine service cannot accept an additional influx of patients, then those patients will not be able to leave the ED. If those patients cannot leave and remain in the ED beds, then this will cause a backup and decrease the department’s ability to triage and care for the influx of new patients.

As emergency medicine physicians, we must take an active role in preparing our hospitals for a surge in critically ill patients. The coronavirus pandemic will one day be behind us, we must remember the valuable lessons that it taught us about our healthcare system’s room for improvement. One way to improve our response is to optimize surge capacity so that when the next disaster hits, we can provide the best care possible to our patients.


  1. U.S. Department of Health and Human Services. What is medical surge? Updated February 14, 2012. Accessed April 6, 2020.
  2. Phillips, S. Current status of surge research. Acad Emerg Med. 2006;13(11): 1103-1108. doi:10.1197/j.aem.2006.07.007
  3. Hick JL, Hanfling D, Burstein JL, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med. 2004;44(3):253‐261.
  4. Farrell C. COVID-19 draws retired doctors back to work. PBS News Hour website. March 30, 2020. Accessed April 8, 2020.
  5. Condon A, Vaidya A, Paavola A. New York City’s public health system to convert all facilities into ICUs + 20 other updates from the 6 hardest hit states. Becker’s Hospital Review website. April 2, 2020. Accessed April 10, 2020.