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A Systematic Review of Simulation Studies

Investigating Emergency Department


Overcrowding
Sharoda A. Paul
Madhu C. Reddy
College of Information Sciences and Technology,
The Pennsylvania State University,
University Park,
PA 16802-6823,
USA
{spaul,mreddy}@ist.psu.edu

Christopher J. DeFlitch
Department of Emergency Medicine,
Penn State Hershey Medical Center,
500 University Drive,
Hershey, PA 17033-0850,
USA
cdeflitch@hmc.psu.edu

The problem of emergency department (ED) overcrowding has reached crisis proportions in the
last decade. In 2005, the National Academy of Engineering and the Institute of Medicine reported
on the important role of simulation as a systems analysis tool that can have an impact on care
processes at the care-team, organizational, and environmental levels. Simulation has been widely
used to understand causes of ED overcrowding and to test interventions to alleviate its effects. In this
paper, we present a systematic review of ED simulation literature from 1970 to 2006 from healthcare,
systems engineering, operations research and computer science publication venues. The goals of
this review are to highlight the contributions of these simulation studies to our understanding of ED
overcrowding and to discuss how simulation can be better used as a tool to address this problem.
We found that simulation studies provide important insights into ED overcrowding but they also had
major limitations that must be addressed.
Keywords: emergency department simulations, literature review, emergency department, over-
crowding, simulation

1. Introduction a day, 7 days a week. The US Emergency Medical Treat-


ment and Active Labor Act (EMTALA) requires that all
The major role of the emergency department (ED) is to ED patients must be provided with medical screening and
provide care for acutely ill and injured patients 24 hours stabilization of their conditions, irrespective of their abil-
ity to pay [1]. As a result, EDs care not only for acutely ill
patients but also for under-served populations who have
SIMULATION, Vol. 86, Issue 8-9, August-September 2010 559571 no other options for medical care because of socioeco-
c 2010 The Society for Modeling and Simulation International
1
nomic barriers [2]. Thus, the ED is the safety net of the
DOI: 10.1177/0037549710360912 healthcare system due to its role in providing care to unin-
Figure 1 appears in color online: http://sim.sagepub.com sured, indigent and otherwise vulnerable patients [3, 4].

Volume 86, Numbers 8-9 SIMULATION 559


Paul, Reddy, and DeFlitch

One of the main problems facing EDs is overcrowding1 ing [3335]. These simulation studies have proposed sev-
this problem has now reached crisis proportions [2, 58]. eral solutions to alleviate overcrowding. In this paper, we
Between 1993 and 2003, ED visits in the United States present a systematic review of the ED simulation literature
increased by 23.6 million, while at the same time 425 from 1970 to 2006 from the fields of healthcare, systems
EDs closed and total hospital beds declined by 198,000 engineering, operations research, and computer science.
[9]. ED overcrowding manifests itself in many different The goals of this review are to highlight the contributions
ways: an excessive number of patients in the ED, patients that simulation studies make to our understanding of the
being treated in hallways [8], ambulance diversions [10], problem of ED overcrowding, and discuss how simulation
long patient wait times, and patients leaving without treat- can be better used as a tool to address this problem.
ment. ED overcrowding leads to increased medical errors This paper is organized in the following manner. The
[2], poor patient outcomes [11, 12], high levels of stress, next section provides background on the role of simulation
decreased morale among ED staff, and decreased capacity in understanding ED overcrowding. Then, the Section 3
of EDs to respond to mass casualty incidents [9]. Other describes the process we used for selecting studies. Next,
effects of ED overcrowding are patient dissatisfaction, de- we report the findings of the simulation studies in Sec-
creased physician productivity, violence, negative effects tion 4. In Section 5, we present insights gained from these
on teaching missions in academic EDs, and miscommuni- studies, the limitations of current studies, and directions
cation [13]. for future research. We conclude with some final thoughts
Research on addressing the problem of ED overcrowd- of how simulation can be used as a tool to address ED
ing has primarily fallen into three categories: descriptive, overcrowding.
predictive and intervention-oriented. Descriptive studies
have focused on defining overcrowding [14], examining 2. The Role of Simulation in ED Overcrowding
the causes and effects of overcrowding [2, 7, 8, 10] and
proposing models [15] to describe the problem and mea- Several solutions have been proposed to alleviate the ef-
sures to quantify it [1623]. Predictive studies have fo- fects of ED overcrowding including providing patients
cused on measures [20] to predict when an ED will be- with better access to clinics, expanding ED square footage
come overcrowded and development of early warning sys- and beds, improving support by radiology, laboratory, and
tems for impending overcrowding episodes [24, 25]. Such consultant services, and reducing incoming transfers to
predictive models assume that extra resources, such as re- the ED during busy periods [13]. Fatovich and Hirsch [10]
serve personnel and auxiliary treatment bays, will be de- proposed stop-gap measures such as increasing ED ca-
ployed once the ED is alerted to an impending overcrowd- pacity, increasing human and physical resources, and im-
ing episode. However, given the limited availability of re- proving discharge processes to deal with overcrowding.
sources caused by cuts in hospital funding [13], a third Most of these proposed solutions call for increasing ca-
stream of research, intervention-oriented studies, has fo- pacity and resources. However, because of economic con-
cused on interventions to optimize available resources and straints, most hospitals do not have extra resources to de-
processes. These interventions include monitoring code ploy. Therefore, there is a need to focus on optimizing ex-
red hours and patient length of stay (LOS), educating isting resources and processes. Systems analysis tools can
physicians regarding non-ED options for patients [26], play an important role in this process. Systems analysis
and re-designing processes [27] and patient flows [28, 29]. tools are used by engineers to understand how complex
In 2000 and 2001, the Institute of Medicine (IOM) pub- systems operate, how well these systems meet operational
lished two reports, To Err is Human [30] and Crossing the goals, and how they can be improved [32]. Such tools can
Quality Chasm [31], which highlighted the deficiencies be used for enterprise management, financial engineering
in current care processes and urged stakeholders in the and risk analysis, and knowledge discovery.
American healthcare system to take steps to improve qual- Simulation, an important systems analysis tool, pro-
ity and efficiency of care. In response, the National Acad- vides great flexibility in testing scenarios, hypotheses,
emy of Engineering (NAE) collaborated with the IOM to policies, and re-engineering ideas in healthcare settings. It
report on the important role of systems engineering tools can be used as research tool, education device, decision-
in improving and optimizing care processes [32]. This making tool and planning model [36]. Pritsker [37]
report stressed that there is a knowledge/awareness di- defined simulation as the development of a mathemati-
vide separating healthcare professionals from their po- cal/logical model of a system and the experimental ma-
tential partners in the engineering fields and that bridging nipulation of the model on a computer. To study a sys-
this gap is key to increasing the quality and productivity tem, a model, which is a set of mathematical or logical
of healthcare. It emphasized the utility of simulation as a assumptions about the system, is created. The model is
systems analysis tool that can have a positive impact on then either solved via mathematical methods (i.e. an ana-
care processes at the care-team, organizational, and envi- lytic solution) or evaluated numerically using a computer
ronmental levels. (i.e. a simulation) [38].
In the ED, simulation has been has been extensively Simulation has been used in an array of healthcare set-
applied to test what if scenarios to combat overcrowd- tings ranging from hospital sub-systems and outpatient

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A SYSTEMATIC REVIEW OF SIMULATION STUDIES INVESTIGATING EMERGENCY DEPARTMENT OVERCROWDING

Figure 1. Identified simulation studies by year

departments [39] to national healthcare systems [40]. In these 37 documents for additional studies that met our cri-
the late 1970s, England and Roberts [41] reported 21 ar- teria and found 6 additional studies. After this phase, we
eas of application of simulation in healthcare including had a total of 43 simulation studies. Most of these studies
hospitals, ambulatory care, manpower planning and fore- were conducted after 1990 (Figure 1 shows the distribu-
casting, community, regional and national health systems, tion of studies by year).
and education. In hospitals, simulation research has been Of the 43 simulation studies, 24 (56%) studies were
applied to areas such as admission control systems, bed published in computer science venues, 9 (21%) in medical
planning, ambulance and emergency services, labs and ra- and health sciences venues, 5 (12%) in operations research
diology, and surgery. Simulation studies have also focused and management venues, 4 (9%) in industrial engineering
on understanding the care planning process [42], tracing venues, and 1 (2%) in other venues. Of these studies, we
the spread of diseases and epidemics, and virtual reality were able to access 32 via online and print sources. Some
simulations for training [43]. The earliest efforts in sim- of the early studies were not available online and we did
ulating emergency services date back to the mid-1960s not have access to the print versions.
[44]. Starting with Bollings study [45] in 1972, simula-
tion studies of EDs have provided valuable insight into
4. Results
factors and reasons for overcrowding [46].
We analyzed the simulation studies with respect to: (1)
3. Methods their motivation and goals1 (2) the modeling techniques
used1 (3) the data sources and collection methods1 (4)
patient classification and patient flows1 and (5) study
We used a two-phase approach to identify simulation findings.
studies relevant to ED overcrowding. In the first phase,
we searched the databases of Proquest, PubMed, ACM,
IEEE, and the Systems Dynamics Conference from 1970 4.1 Motivation and Goals
to 2006. These databases are the comprehensive sources
of literature in computer science, operations management, Few studies mentioned explicitly that their motivation
healthcare, and engineering fields. We used the search was the desire to create a general model of overcrowd-
phrases emergency department simulation, emergency ing in EDs [47], or to decrease levels of overcrowding
department patient flows and other combinations of these [48]. Instead, the motivations for most studies were re-
phrases (e.g. emergency department flow simulation). lated to costs and competition, efficiency, re-engineering,
We defined relevant documents as those studies that used and quality of service (Table 1). Given the motivations to
simulation to understand the problem of overcrowding, ef- cut costs and increase efficiency, one of the primary goals
fects of overcrowding (e.g. long patient wait times), and/or of these studies were to examine causes of inefficiencies
proposed solutions to the overcrowding problem. We did in processes and resource utilization. Therefore, studies
not include studies that had merely modeled the ED but examined patient flows [49] and bottlenecks in flows [34,
did not perform computer simulations of the model. Us- 50], causes of excessive wait times [49, 51], and patient
ing the various search phrases, we found 37 relevant docu- throughput [35]. A few studies also evaluated the effects
ments. In the second phase, we examined the references of of introducing fast care for low acuity patients [33, 52],

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Table 1. Motivation of the simulation studies


systems dynamics [63], and conceptual [64, 71] and math-
Motivations ematical modeling [68].
Costs and competition A simulation model can be deterministic (if it does not
Rising costs [33, 64]
contain any random variables) or stochastic (if it contains
one or more random variables) [38]. Stochastic processes
Decrease or control costs of operation [6567]
are governed by probabilistic laws and have been applied
High costs of building, equipment, and staffing [62]
to study various aspects of health systems since the early
Reduce staffing levels without decreasing efficiency [68] 1950s [76]. We found that most often the ED was modeled
Rising competition [59, 65] as a stochastic system since the inter-arrival times and ser-
Reduced patient visits [69] vice times of patients are considered random variables.
Increase corporate customer base without decreasing The ED was also primarily modeled as a discrete sys-
quality [54] tem. Discrete event simulation has been used extensively
Efficiency in examining patient flows and allocation of resources in
Inefficiencies [33] healthcare clinics [77] and was the most popular simula-
Increase efficiency [67] tion technique in the studies we reviewed. Queuing mod-
More efficient staff utilization [59] els are discrete-event models used to represent customers
Overloaded ED staff [70] queuing to gain access to limited resources and have been
Staff scheduling to meet unpredictable workload patterns used to simulate unscheduled patient arrivals in EDs, oper-
[60] ating rooms (ORs), intensive care units (ICUs), blood clin-
Doctors had the highest average utilization, were not ap- ics, and X-ray departments. For instance, Liyanage and
propriately assigned and were the bottlenecks of the sys- Gale [74] used queuing theory to develop a simulation to
tem [55] find the optimal number of resources that would minimize
Develop a general tool for evaluating policy changes for im- the mean operating cost of the ED. Some discrete-event
proving productivity and efficiency in the ED [53] models [53, 57, 70] were written in SLAM (Simulation
Re-engineering Language for Alternative Modeling), a process-oriented
Increase in ED size and separation of ambulance patients simulation language developed by Pegden and Pritsker
from outpatients [49] (see [38]). Using SLAM, the ED can be pictorially repre-
Improve the ER process [71] sented as a network of nodes and branches through which
New ED with lab and X-ray facilities [72]. patients flow. Other discrete-event modeling tools include
Quality of service Arena [34, 35, 49, 51, 54, 56, 59, 65, 68], Extend [48, 64],
Excessive patient wait times [34, 50, 51, 56, 63, 66, 70, 73, SIMAN [60, 73], and SIMUL-8 [58].
74] Another modeling technique used was systems dynam-
Long patient wait times for low acuity patients [52, 73] ics [78]. This technique is used to model the complexity in
High LOS of patients [35] large systems and has been successfully applied to busi-
Lack of ED capacity [70, 74] ness modeling [79]. The systems dynamics tool iThink
High withdrawal rates of patients [70]
was used for such models [63]. While discrete-event sim-
ulations can be used to create detailed models of sub-
ED on ambulance diversion status often [35]
systems within healthcare, systems dynamics enables a
Increased patient dissatisfaction [69]
systemic view of the interactions of patient flows and in-
formation. Finally, conceptual modeling was used in some
studies to create process maps and documentation.
not providing care to low acuity patients [53], and re-
designing processes to reduce patient LOS [54]. A second 4.3 Data Sources and Collection Methods
major goal was to optimize resources such as staff and
beds. Several studies examined alternative staff schedules
[5557], assessed the effect of different staff schedules on The simulation studies used a wide variety of data sources
wait times [58, 59], and quality of service [60] in order as inputs to their models. The data collection techniques
to recommend cost-effective schedules. Since beds are an included interviews with care providers and management,
important resource in the ED, studies examined critical observations, historical data from ED databases, patient
bed requirements [61, 62] and the impact of bed availabil- charts, time and motion studies, and using automated date-
ity on wait times of admitted patients [50, 63]. time stamping machines (Table 2).
Hospital databases and information systems, patient
charts and medical records all play an important role in
4.2 Modeling Techniques obtaining data on arrival patterns, time spent on differ-
ent activities by care providers, and inter-arrival times and
The studies utilized a variety of modeling techniques in- LOS distributions. Data obtained about inter-arrival times
cluding discrete-event [4749, 51, 55, 58, 60, 67, 73, 75], and service times [34, 35, 52], volume and mix of patients

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Table 2. Data collection sources for modeling the ED


categories lead to a variety of patient flows across stud-
Data source Data obtained ies. Patient flows were based on patient entry mode [52,
Hospital databases Historical patient data
75], patient acuity [60, 73], number and types of resources
needed [72], and the need for auxiliary services such as
information and systems Arrival patterns of patients and
number in each priority category labs and X-rays [55]. Some flows were based on a combi-
[58] nation of these factors.
Time spent for each activity [58]
Distribution of patients arrival 4.5 Study Findings
times by time of day and day of the
week [59]
The scenarios tested by the simulation studies can be
Determine inter-arrival time and
LOS distributions [61]
broadly categorized as resource-related, process-related,
and environment-related (Table 3).
Medical records Arrival rates and service times
Resources in the ED were human, equipment, and
Observations Shift patterns [73]
space resources. Resource-related scenarios focused on
Patient charts Arrival times, mode of arrival, changing levels of resources, allocation, and reallocation
tests performed, discharge time
[69] of resources. Process-related scenarios focused on chang-
Surveys Identify patient flows and common
ing processes in the ED, including how processes were
CCU configurations [61] performed, as well as when certain processes were done.
ED logs Patient volume and mix data [75] Environment-related scenarios focused on variables exter-
Interviews ED staff activity data [75]
nal to EDs such as demand patterns and characteristics of
hospital units which interface with the ED.
Time studies Registration time of patients [60]
Paid ED staff Times of entry, service, exit etc.
Bed management Data on admissions 4.5.1 Resource-Related Findings

4.5.1.1 Space Space in the ED, defined in terms of beds


or rooms, is an important resource. During periods of
[50], staffing levels [60, 74], and types and duration of overcrowding, patients experience their most significant
treatment [54] were used to determine model inputs and delay waiting for an ED bed [81]. Takakuwa and Shiozaki
outputs. [49] found that 59% of the waiting time in the ED was
for beds. Komashie and Mousavi [51] tested two differ-
ent scenarios regarding beds in the minor treatment area
4.4 Patient Classification and Flows or minors of their ED. In scenario 1, they added an
extra bed to the minors area, but, in scenario 2, they
There was no single approach to classifying patients. Dif- added six extra beds to the area. Surprisingly, they found
ferent studies categorized patients along different dimen- very little improvement in LOS in scenario 2 as com-
sions. The three main dimensions of categorization were pared with scenario 1. They did find that queuing time
mode of arrival, level of acuity, and case type. The mode for beds went down 83% in scenario 21 however, there
of arrival of patients was helicopter, ambulance, or walk- was a significant increase in wait times for nurses and
in. In the emergency care domain, the most common way doctors. Their study highlighted that adding extra beds
to categorize patients according to acuity is emergency, merely shifted the queues from the waiting room to the
urgency, and non-urgency [72]. However, different EDs bed. Samaha et al. [35] also found that adding beds or
used different terms to track levels of acuity including de- square footage to the ED did not shorten LOS. These re-
grees (e.g. first, second), levels [60, 80] (e.g. IV), trauma sults are corroborated by recent findings that increase in
levels (e.g. major, minor), and ESI-5 levels [33]. Simi- ED bed capacity does not decrease ambulance diversions
larly, there was a variety of ways to categorize patients by (an indicator of overcrowding) and might even lead to an
case type, including by chief complaint [69] (e.g. abdomi- increase in LOS [82].
nal pain, laceration), specialty (e.g. internal, surgical), and Studies also examined the effects of re-using space or
even treatment areas [50] (e.g. fast-track patients, observa- rooms in the absence of adequate beds. Kirtland et al. [69]
tion room patients). found that placing patients in the treatment area when beds
Some studies categorized patients by combining these were not available instead of sending them back to waiting
dimensions, such as Clark and Waring [57] who combined area saved 14.1 minutes. McGuire [66] found that having
mode of arrival with level of acuity (e.g. critical walk-in), a separate holding area for admitted patients waiting for
and Sinreich and Marmor [67] who combined mode of test results saved 22 minutes per patient on average, and
arrival with case type (e.g. walk-in surgical). Kirtland et al. [69] found that using an internal waiting
In most studies, different patient flows were modeled room for patients awaiting lab and X-ray results would be
for each category of patients. The wide variety of patient useful when the ED is very busy.

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Paul, Reddy, and DeFlitch

Table 3. Categorization of scenarios tested

Resource-related Space
Varying the number of beds or rooms available [49, 51, 62, 63, 70]
Having a single holding area instead of one room per patient [71]
Using an internal waiting room for patients waiting for lab results [66, 69]
Human resources
Alternative staff scheduling [5560, 68, 71, 75]
Varying the number of ED staff available [34, 35, 69, 70, 80]
Varying resident availability [35, 73]
Varying the number of non-ED staff [49]
Adding a dedicated triage nurse [34]
Addition of a registration clerk during peak hours [66]
Estimating the optimal number of servers that will minimize the mean operating cost of the system [74]
Equipment
Varying the number of implements in the drip room and stretchers [49]
Installing lab and X-ray facilities in ED [72]
Process-related Procedural
Addition of fast-track [35, 52, 69, 71]
Take patient back to open treatment rooms instead of keeping in waiting rooms [69]
Change triage protocols so triage nurse can order certain tests [69, 71]
Allowing nurse to order testing/treatment without participation of physician [71]
Changing criteria used for sending patients to fast-track areas [66]
Priority given to only Category 1 patients, rest treated on a first-come-first-served basis [80]
Not serving Category 5 patients [80]
Triaging patients into different categories [72]
Scheduling non-emergency patients so as to smooth demand [72]
Temporal
Reducing lab turn-around time [64, 66, 69]
Initiate search for admission room earlier [69]
Discharging inpatients earlier [64]
Extend hours of fast-track and pediatric clinic [66]
Environment-related Varying patient demand [54, 63, 70, 72]
Varying percentage of true emergency patients [72]
Adding inpatient beds [64]
Varying number of beds in different locations or units of hospital [34, 50]
Reduce time for bed notifications from Medical Telemetry Unit (MTU) to ED, decrease number of patients
being admitted to MTU [34]
Varying queue discipline [73]

4.5.1.2 Human and Equipment Resources Simula- Michalis [58] compared different shift patterns via sim-
tion studies focused on two major resources other than ulation and found that the doctor shift pattern that best
beds: human and equipment resources. One cause of in- matched the patient arrival pattern gave the shortest wait
efficiency in EDs is that due to the sporadic demand, times.
the staff are idle at times and overworked at other times Queuing analysis techniques were used to match
[72]. Hence, several simulation studies were interested staffing patterns to ED demand [83]. Tan et al. [55] used
in examining the effects of alternative staff schedules on preliminary queuing analysis to develop an alternative
waiting times and LOS [5560, 68, 71, 75]. Rossetti et doctor schedule and compared it with the current schedule
al. [59] simulated 18 attending staff schedules and iden- via simulation. The results identified the doctors station
tified a schedule that decreased average patient time in as the bottleneck. The new schedule increased the capac-
the ED by 14.5 minutes/patient. Based on the simula- ity of the bottleneck and hence reduced patient time in
tion, they found that this schedule also decreased physi- the system. Clark and Waring [57] tested whether doctor
cian utilization and percentage of long visits. Coats and and nurse scheduling would affect the time spent waiting

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to see a doctor, the total time in the system, the utiliza- order tests and X-rays saved 3.6 minutes [69]. Pallin and
tion rate of doctors, and the utilization rate of nurses. They Kittell [71] tested a protocol to allow nurses to order test-
found that scheduling of physicians will have a significant ing/treatment without participation of physician but did
effect on waiting times. However, the nurses schedule did not mention the results of simulating this scenario. Labo-
not have the same impact. Evans et al. [56] tested alterna- ratory turnaround times add to waiting times in the ED and
tive schedules containing different numbers of nurses and can be decreased significantly with point-of-care lab test-
technicians but the same number of doctors as the actual ing [86]. McGuire [66] found that reducing lab turnaround
system and found only a 5-minute reduction in average time decreased LOS. Kirtland et al. [69] found that using
LOS. These finding, which seem to indicate that nurse I-stat machines in the ED for point-of-care testing saved
scheduling does not significantly impact waiting times, 8.4 minutes.
are interesting given the large amount of research focus-
ing on optimizing nursing allocation in various parts of the
hospital [76]. 4.5.3 Environment-Related Findings
Although equipment is an important resource, only a
few studies examined the effects of adding equipment to Many simulation studies also focused on the effects of
the ED. Hannan et al. [72] found that installation of lab factors external to EDs that can cause overcrowding. A
and X-rays in the ED had the same effect as hiring an ad- major cause of overcrowding is the unavailability of in-
ditional nurse and physician. Takakuwa and Shiozaki [49] patient beds and inpatient bed occupancy has been found
looked at the effects of varying the number of stretchers to be strongly correlated with ED LOS [87]. Miller et
and implements in the drip room. al. [64] found that adding 30 inpatients beds would cut
Some studies aimed at determining the optimal re- LOS by half. Gonzalez et al. [70] found that increasing
sources required to minimize the mean operating cost of the number of beds to which ED patients can be admit-
the system [74] and successfully support the patient de- ted would maximize profits and minimize waiting time.
mand [70]. Takakuwa and Shiozaki [49] adjusted the num- Lane et al. [63] examined how reductions in bed capacity
ber of rooms, internists, surgeons, pediatricians, imple- in the hospital wards affected patient waiting times in the
ments in the drip room, stretchers, etc., and found that ED. They examined the ED as part of the larger hospital-
there was no optimal configuration of these resources wide system and considered emergency patients and elec-
which can lead to the lowest waiting time. tive treatment patients. They found that removing hospi-
tal beds did not increase ED waiting time, but did cause
more cancellations of elective procedures. Elbeyli and Kr-
4.5.2 Process-Related Findings ishnan [50] found that adding beds to step-down units and
other specialized units decreased the average time of pa-
The simulation studies examined several procedural tients waiting to be admitted from the ED. Blasak et al.
changes to alleviate the effects of ED overcrowding. Most [34] investigated how the interface between the ED and
studies found that establishing a fast-track path for low the Medical Telemetry Unit (MTU) affected wait times in
acuity patients was effective in decreasing wait times the ED. They found that they needed to reduce the time
without negatively impacting quality of care [84]. Samaha for bed notifications from MTU to ED, decrease num-
et al. [35] simulated all routine patients being directed ber of non-ED patients being admitted to MTU and de-
to fast-track and found a considerable reduction in LOS. crease LOS in MTU [34] to reduce waiting times for ED
Similarly, Kirtland et al. [69] found that fast-track saved patients.
15.5 minutes in the ED. Pallin and Kittell [71] simulated Two of the primary uncontrollable external features of
fast-tracking by eliminating return visits and found a 50% the ED environment are patient demand and mix of patient
reduction in staff and resources due to the fast-tracking. types. Studies have examined the effects of changes in pa-
Garcia et al. [52] found that taking one nurse and bed from tient demand on wait times. Hannan et al. [72] tested the
the ED and using them in a fast-track would significantly effects of increased demand and increased percentage of
lower flow time for low acuity patients. McGuire [66] also true emergency patients. They also examined scheduling
found that extending the hours of the fast-track led to a 16- non-emergency patients to reduce demand. They found
minute decrease in LOS. However, they found that waiting that when demand increased above 20%, the waiting times
time was not affected by initiating search for admission for emergency patients did not change much, but the non-
rooms earlier in the process. Samaha et al. [35] found that emergency patients had to wait longer. Baesler et al. [54]
bedside registration would not reduce LOS and would be used their simulation to find the maximum demand that
costly to implement1 but, a recent empirical study found the ED would be able to handle without the average pa-
that including bedside registration in the process did de- tient time exceeding 100 minutes. They found that this
crease LOS [85]. would happen when the demand increased by 130%. To
Some procedural scenarios looked at changing stan- handle this increase in demand and keep the wait time un-
dard protocols in the ED to reduce wait-times. Studies der 100 minutes, the ED would need four full-time doctors
found that changing triage protocols so triage nurses could and one half-time doctor.

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5. Discussion consensus on the specific process changes that can be ap-


plied across all EDs. Rather, each ED must identify its
After analyzing the simulation studies, we found that they own unique characteristics and processes when trying to
provided useful insights into the problems of ED over- deal with the problem of overcrowding.
crowding. However, at the same time, we found major Third, the ED is part of a larger and more complex
limitations to the studies that must be addressed if they hospital system and is affected by many external factors.
are to help us to better understand and alleviate ED over- As the recent IOM report on ED overcrowding states [9],
crowding. overcrowding is a system-wide issue that must be ad-
dressed across multiple hospital units and care settings.
Hence, it is important to understand the relationships of
5.1 Insights from Simulation Studies the ED with other units of the hospital. Environment-
related changes, such as variable patient demand, are out-
The simulation studies highlighted a number of important side the control of EDs. However, simulation of vari-
issues that we must consider as we try to address ED over- ous demand patterns can help EDs predict resource lev-
crowding. els needed to meet those demands. In the simulation stud-
First, the conventional solution to ED overcrowding is ies, adding beds to units that interfaced with the ED in-
increasing available ED space (e.g. increase the number variably led to decrease in LOS for ED patients waiting
of ED beds). However, the simulation studies have clearly to be admitted to those units. Reducing time for bed no-
shown that while increasing ED space may provide short- tifications from other units to the ED also improved wait
term relief by allowing more patients to be admitted to the times. These results indicate that there is a strong inter-
ED, this would not necessarily reduce patient wait times. connectedness between the ED and the rest of the hospital.
The patient queues would merely shift from the waiting Lane et al.s study [63] revealed that the effects of changes
rooms to the bedside. Therefore, although beds are an im- in the ED may not be reflected within the ED but in other
portant resource, a more critical resource are the physi- parts of the hospital. For instance, they found that reduc-
cians because they are often the bottleneck of the system tions in hospital beds did not have an impact on ED wait
and the most utilized resource [55]. Most improvements times but resulted in cancellations of elective procedures.
in waiting times and LOS resulted from more effective They concluded that policy changes must be based on an
scheduling of doctors [55, 57, 59], eliminating non-patient understanding of how EDs connected to pre-hospital ser-
care duties from doctors duties [73] and using doctors in vices, to the rest of the hospital, and the surrounding com-
the fast-track. Blake and Carter [73] came to an interest- munity.
ing but counter-intuitive finding that while most processes
with service problems are improved by adding manpower,
the performance of the ED is negatively affected by the ad- 5.2 Limitations of Simulation Studies
dition of residents since the time spent by attending physi-
cians in resident education as opposed to direct patient Although the simulation studies provided important in-
care decreases the benefits of adding more manpower. sights into the problem of ED overcrowding, they had lim-
Second, many studies found that the problems in the itations that affected their usefulness in helping deal with
ED were process-related [35]. Improvements in processes, the problem.
such as fast-tracking and reducing lab turn-around times, First, patient flows were viewed in these studies in an
reduced wait times. Changing procedures and protocols overly simplistic manner. There are two aspects of patient
in the ED such as placing patients in separate areas when flows in healthcare: clinical and operational [88]. From a
they are waiting for test results, and having the triage nurse clinical perspective, a patient flow is the progression of a
order tests and X-rays, also saved time. However, although patients health status1 from an operational perspective, a
a few processes such as fast-tracking provided positive re- patient flow is the movement of a patient through various
sults across studies, most process improvements were ED- locations or stations in a hospital. In the ED, the clini-
specific. For instance, Kirtland et al. [69] found no sig- cal and operational aspects of flows are often intertwined
nificant time saving for using an internal waiting room for since the patients health status (case type and level of acu-
patients waiting for lab and X-ray results except when the ity) typically determines which treatment stations they
ED was very busy but McGuire [66] found that having a visit. This leads to a large variety of patient flows in the
separate holding area for admitted patients waiting for test ED. For instance, Takakuwa and Shiozaki [49] found 70
results saved 22 minutes per patient. Similarly, Blasak et patterns of patient flows for 9 patient categories in a sin-
al. [34] found that adding a dedicated triage nurse would gle ED. The process of modeling this variety of patient
create a bottleneck but Gonzalez et al. [70] recommended flows is difficult and time-consuming. Therefore, for the
the addition of a nurse to perform administrative work sake of simplicity, most flows were modeled as linear, that
such as following up room availability. Therefore, while is, patients moved in a sequential manner from station to
there is consensus that process-related issues are critical station. However, in reality patients might undergo several
to an EDs ability to handle overcrowding, there is little care processes at the same time. The overlaps and interde-

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A SYSTEMATIC REVIEW OF SIMULATION STUDIES INVESTIGATING EMERGENCY DEPARTMENT OVERCROWDING

pendencies between components of patient flows were not erations that a patient goes through or which a member
modeled in the simulation studies. of the staff performs, from five hospitals1 it took 1,350
Second, many studies did not incorporate informa- man-hours to conduct time and motion studies to mea-
tion flows when modeling patient flows. The health- sure service times for all elements. A simulation model is
care process can be viewed as a series of information- only as accurate as the data used to build it. Therefore, the
processing steps starting from the initial collection of difficulty in capturing reliable data can lead to inaccurate
data about the patients condition to forming a hypothe- simulation results.
sis and testing it by collection of more data [32]. Given
the variety of information required at each step of the 5.3 Future Research Directions
patient flow, and the multitude of information and com-
munication technologies used in modern EDs [32], infor- We have three suggestions for future research directions
mation flows are closely linked to patient flows. These for simulation studies. First, simulation models need to
information flows are a crucial aspect of the modeling capture human behavior. In 1975, Valinsky [36] noted that
in an ED but have not been addressed by the simula- there had been little work on modeling the human ele-
tion literature. Also, simulation studies have not consid- ments of the healthcare system, such as the patient, med-
ered the role of information and communication technolo- ical staff, and administrators within the health field. More
gies (ICTs) within EDs. ICTs such as electronic medical than 30 years later, this is still the case. The simulation
record (EMR) systems, electronic dashboards, radio fre- models we reviewed have not examined the physiologi-
quency identification (RFID), wireless registration, and cal, psychological, and social aspects of patient care in
mobile computing devices are being used in EDs to help EDs. Providers and patients behavior is directed by be-
with clinical documentation, decision-support, informa- liefs, attitudes, and expectations. Therefore, an important
tion management, and coordination of patient flows [9]. question to answer is how these beliefs and attitudes can
These ICTs have the potential to significantly impact ED be modeled or if this is an aspect of patient care that is ir-
overcrowding. By not incorporating ICTs into the simula- relevant to simulation modeling. To incorporate elements
tions, the studies have failed to capture an important re- of human behavior in healthcare simulations, simulation
source. research can draw on the fields of humancomputer in-
Third, the lack of standardization of workflow, care teraction (HCI) and computer-supported cooperative work
practices, patient categories, and patient flows across EDs (CSCW) which have studied the cognitive and social as-
makes it hard to design a generic model of an ED for pects of human behavior, such as emotion [89], commu-
use in a simulation. Sinreich and Marmor [67] developed nication [90], collaboration [91, 92], and the social orga-
a generic tool flexible enough to model any ED. They nization of work [93] in healthcare settings. Simulation
classified EDs into four basic types based on two factors: researchers can apply findings from these fields about the
ED physician type, i.e. whether the ED physician spe- behavior of patients and healthcare providers to model hu-
cialized in emergency medicine or other areas, and pa- man interactions as part of the ED.
tients condition, i.e. how the ED processed acute and Second, we need to study the ED as part of a larger
ambulatory patients. However, given the wide variety of system. In simulation modeling, the choice of system
processes, this classification may not be sufficient. As a depends on the objectives of the study [38]. In most stud-
result, most simulation studies had to create ED-specific ies, the objective was to improve efficiency and cut costs
models, which in turn lead to ED-specific solutions that of operation and the ED was studied as an isolated unit.
could not be generalized to other EDs. The interactions/interfaces between ED and other services
Fourth, the purpose of data acquisition is to estimate such as EMS, labs, and the rest of the hospital were not
the parameters of the system and to validate the model. modeled in most studies. However, factors external to the
The time, cost, and difficulty associated with obtaining ED, such as hospital bed occupancy, strongly affect ED
empirical data for simulation models has been a challenge length of stay [87]. Research has also shown that interven-
[36]. Although arrival patterns and patient volume/mix tions aimed at factors external to the ED have been most
data can usually be obtained from information systems successful in reducing ED overcrowding [26]. Therefore,
and medical charts, service times can only be obtained simulation studies need to focus more on the role of the
through observation and time/motion studies. However, ED with the context of the larger hospital system. This can
placing researchers in overcrowded EDs is often difficult be done by incorporating other hospital units that interface
due to the fast-paced nature of the environment and pa- with the ED as part of the model. Simulation studies can
tient privacy issues. One approach is to pay ED staff for draw on research from fields such as CSCW which have
data collection [72] or to use self-reported work sampling examined the effects of patient flows between the ED and
techniques to gather data [59]. However, the success of other hospital units [94].
these techniques depends on the busy care-giver to col- Incorporating external factors might lead to complex
lect the data. The difficulty of collecting this type of data models and certain types of simulation are better suited
was highlighted in the following study. Rossetti et al. [59] for such models. Discrete-event simulation, the most pop-
obtained a list of 16,250 standardized elements, i.e. op- ular technique in the reviewed studies, is not well suited

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Paul, Reddy, and DeFlitch

to studying complex integrated systems in healthcare be- ED overcrowding. Simulation is a powerful tool that re-
cause of the high level of complexity and data require- searchers can deploy to confront the problem of ED
ments of such simulations, as well as the time and cost as- overcrowding.
sociated [77]. However, it provides excellent micro-level
analysis of the ED. Systems dynamics techniques can be
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[77] Jun, J.B., S.H. Jacobson and J.R. Swisher. 1999. Application of
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[78] Forrester, J.W. 1961. Industrial Dynamics. New York: John Wiley
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[79] Sterman, J.D. 2000. Business Dynamics: Systems Thinking and Sharoda A. Paul is a final year PhD candidate at the College of
Modeling for a Complex World. New York: Irwin/McGraw-Hill. Information Sciences and Technology at The Pennsylvania State
[80] Badri, M.A. and J. Hollingsworth. 1993. A simulation model for University. Her dissertation examined collaborative information
scheduling in the emergency room. International Journal of Op- seeking and sensemaking activities of healthcare providers in
eration and Production Management, 13(3): 1324. a hospital emergency department. Her research interests are
[81] Liu, S., C. Hobgood and J.H. Brice. 2003. Impact of critical bed in the fields of computer-supported cooperative work, human
status on emergency department patient flow and overcrowding. computer interaction, healthcare informatics, and collaborative
Academic Emergency Medicine, 10(4): 382385. and social Web search.

570 SIMULATION Volume 86, Numbers 8-9


A SYSTEMATIC REVIEW OF SIMULATION STUDIES INVESTIGATING EMERGENCY DEPARTMENT OVERCROWDING

Madhu Reddy, PhD, is an Assistant Professor in the College Christopher DeFlitch, MD, is the Chief Medical Information
of Information Sciences and Technology at The Pennsylvania Officer and Vice Chair for Emergency Medicine at The Penn-
State University. His primary research interests are in the ar- sylvania State University Milton S. Hershey Medical Center.
eas of medical informatics and computer-supported cooperative His research interests are in transforming the delivery of health
work. He is especially interested in the design, implementation care through health information technology and process re-
and adoption of collaborative healthcare technologies such as engineering. He is particularly interested in approaches to re-
electronic patient records. His current research is focused on designing emergency departments to be more effective through
how these and other technologies can support information be- the use of health IT and patient flow engineering.
havior in multidisciplinary patient-care teams.

Volume 86, Numbers 8-9 SIMULATION 571