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“There is a tide in the affairs of men,

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Which, taken at the flood, leads on to fortune:

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Omitted, all the voyage of their life

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Is bound in shallows and miseries.

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On such a full sea are we now afloat,

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And we must take the current when it serves

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Or lose our ventures.”

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William Shakespeare

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Julius Caesar, Act IV, Scene III, 218-2241

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“Diseases desperate grown

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By desperate appliance are relieved,

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Or not at all.”

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William Shakespeare

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Hamlet, Act IV, Scene III, 9-112

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In one of the earliest episodes of the television program ER, one of the emergency physicians, Dr Mark Greene, finds himself in a situation many, if not all, emergency physicians and nurses have faced. The emergency department's (ED) rooms are all filled, occupied by “hospital boarders”—patients who have been evaluated and treated by the ED staff and have been admitted to the hospital, but for whom there are no inpatient beds currently available. Nor is there any expectation that such beds will become available for many, many hours. The ED is thus in total “gridlock.”

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The ED charge nurse approaches Dr Greene and tells him the waiting room is completely full of patients who are getting increasingly agitated and angry, already having waited several hours for care. After thinking for a moment, he says, “Then come with me and let's go take care of them!” He and the nurse begin making their way from patient to patient, walking through the waiting room, evaluating patients, treating those who need medications, discharging those with minor illnesses and injuries, and staging those who were found to have more serious conditions. This continues throughout the night, until all the patients have been seen and the waiting room is emptied, just as dawn arrives. Another nurse approaches them and says, “Good news, we will be getting some beds in a couple of hours!” Dr Greene and the charge nurse just smile at each other, content in a job well done on behalf of their patients.

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The episode arose from the personal experience of one of the chapter authors (TM), who had just such a night in the ED, and who served as a script consultant to “ER” in its early seasons. From experiences such as these arose a growing ED leadership philosophy to develop and implement systems to “front-load flow” in the ED, particularly during times when patient demand predictably exceeds available capacity.3-4 These demand-capacity mismatches have become both widespread and predictable, particularly in large volume EDs.5 The stressors and pressures on ED personnel, including caring for a high-volume of high-acuity patients in an increasingly capacity-constrained environment with dramatic demand-capacity mismatches surely qualifies, in ...

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