The center is the only reliable clearinghouse. Not closing has proved stressful sometimes when the ED has been extremely busy and the staff feels overburdened. The criteria are that every bed in the ED is filled and that according to admitting there is no foreseeable bed within 30 minutes to an hour. The nursing supervisor in consultation with the attending physician in the emergency department and the administrator on call. If we needed to close down beyond the constraints of a single shift, we would naturally confer with administration and physician leadership, including the chief of staff.
Physicians dictate where patients are sent - given bed availability.
If it's a question of level of care, the supervisor may need to make a quick decision. Rarely does such a decision run counter to the wishes of any physician who takes a moment to understand the decision in context, but it can happen, and we are responsible for providing care smoothly throughout the institution. The most difficult decisions involve moving a patient laterally, say from one surgical unit to another. That's a decision that's usually driven by individual physicians. The role of the supervisor isn't to manage the house, it's to supervise the house, and that's a very critical distinction.