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Logo of emermedjEmergency Medical JournalCurrent TOCInstructions to authors
Emerg Med J. Mar 2003; 20(2): 143–148.
PMCID: PMC1726061

Analysis of patient flow in the emergency department and the effect of an extensive reorganisation


Objectives: To evaluate the different internal factors influencing patient flow, effectiveness, and overcrowding in the emergency department (ED), as well as the effects of ED reorganisation on these indicators.

Methods: The study compared measurements at regular intervals of three hours of patient arrivals and patient flow between two comparable periods (from 10 February to 2 March) of 1999 and 2000. In between, a structural and staff reorganisation of ED was undertaken. The main reason for each patient remaining in ED was recorded and allocated to one of four groups: (1) factors related to ED itself ; (2) factors related to ED-hospital interrelation; (3) factors related to hospital itself; and (4) factors related to neither ED nor hospital. The study measured the number of patients waiting to be seen and the waiting time to be seen as effectiveness markers, as well as the percentage of time that ED was overcrowded, as judged by numerical and functional criteria.

Results: Effectiveness of ED was closely related with some ED related and hospital related factors. After the reorganisation, patients who remained in ED because of hospital related or non-ED-non-hospital related factors decreased. ED reorganisation reduced the number of patients waiting to be seen from 5.8 to 2.5 (p<0.001) and waiting time from 87 to 24 minutes (p<0.001). Before the reorganisation, 31% and 48% of the time was considered to be overcrowded in numerical and functional terms respectively. After the reorganisation, these figures were reduced to 8% and 15% respectively (p<0.001 for both).

Conclusions: ED effectiveness and overcrowding are not only determined by external pressure, but also by internal factors. Measurement of patient flow across ED has proved useful in detecting these factors and in being used to plan an ED reorganisation.

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Selected References

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  • McMillan JR, Younger MS, DeWine LC. Satisfaction with hospital emergency department as a function of patient triage. Health Care Manage Rev. 1986 Summer;11(3):21–27. [PubMed]
  • Hansagi H, Carlsson B, Brismar B. The urgency of care need and patient satisfaction at a hospital emergency department. Health Care Manage Rev. 1992 Spring;17(2):71–75. [PubMed]
  • Miró O, Sánchez M, Ortega MM, Esteban MJ, Millá J. More data about patients who leave emergency department without being seen by a doctor in European hospitals. Eur J Emerg Med. 2000 Mar;7(1):79–80. [PubMed]
  • Miró O, Sánchez M, Millá J. Hospital mortality and staff workload. Lancet. 2000 Oct 14;356(9238):1356–1357. [PubMed]
  • Bindman AB, Grumbach K, Keane D, Rauch L, Luce JM. Consequences of queuing for care at a public hospital emergency department. JAMA. 1991 Aug 28;266(8):1091–1096. [PubMed]
  • Delfino RJ, Murphy-Moulton AM, Burnett RT, Brook JR, Becklake MR. Effects of air pollution on emergency room visits for respiratory illnesses in Montreal, Quebec. Am J Respir Crit Care Med. 1997 Feb;155(2):568–576. [PubMed]
  • Yamamoto LG, Iwamoto LM, Yamamoto KS, Worthley RG. Effect of environmental conditions on emergency department use by wheezing children. Ann Emerg Med. 1993 Mar;22(3):523–529. [PubMed]
  • Oderda GM, Klein-Schwartz W. Lunar cycle and poison center calls. J Toxicol Clin Toxicol. 1983 Jul;20(5):487–495. [PubMed]
  • Miró O, Sánchez M, Borrás A, Millá J. Fútbol, televisión y servicios de urgencias. Med Clin (Barc) 2000 Apr 15;114(14):538–539. [PubMed]
  • Shaw KN, Lavelle JM. VESAS: a solution to seasonal fluctuations in emergency department census. Ann Emerg Med. 1998 Dec;32(6):698–702. [PubMed]
  • Fineberg DA, Stewart MM. Analysis of patient flow in the emergency room. Mt Sinai J Med. 1977 Jul-Aug;44(4):551–559. [PubMed]
  • Reeder TJ, Garrison HG. When the safety net is unsafe: real-time assessment of the overcrowded emergency department. Acad Emerg Med. 2001 Nov;8(11):1070–1074. [PubMed]
  • Miró O, Sánchez M, Coll-Vinent B, Millá J. Estimación del efecto relativo que ejercen los determinantes externos e internos sobre la eficacia de un servicio de urgencias de medicina. Med Clin (Barc) 2000 Sep 16;115(8):294–296. [PubMed]
  • Hu SC. Computerized monitoring of emergency department patient flow. Am J Emerg Med. 1993 Jan;11(1):8–11. [PubMed]
  • Miró O, de Dios A, Antonio MT, Sánchez M, Borrás A, Millá J. Estudio de la mortalidad en un servicio de urgencias de medicina hospitalario: incidencia, causas y consecuencias. Med Clin (Barc) 1999 May 22;112(18):690–692. [PubMed]
  • Miró O, Jiménez S, Alsina C, Javier Tovillas-Morán F, Sánchez M, Borrás A, Millá J. Revisitas no programadas en un servicio de urgencias de medicina hospitalario: incidencia y factores implicados. Med Clin (Barc) 1999 May 8;112(16):610–615. [PubMed]
  • Hansagi H, Olsson M, Sjöberg S, Tomson Y, Göransson S. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med. 2001 Jun;37(6):561–567. [PubMed]
  • Brunet F. Le Service d'Accueil des Urgences: un nouveau concept pour une réforme. Bull Acad Natl Med. 2000;184(2):379–402. [PubMed]
  • Andersson G, Karlberg I. Lack of integration, and seasonal variations in demand explained performance problems and waiting times for patients at emergency departments: a 3 years evaluation of the shift of responsibility between primary and secondary care by closure of two acute hospitals. Health Policy. 2001 Mar;55(3):187–207. [PubMed]
  • Rogers IR, Evans L, Jelinek GA, Jacobs I, Inkpen C, Mountain D. Using clinical indicators in emergency medicine: documenting performance improvements to justify increased resource allocation. J Accid Emerg Med. 1999 Sep;16(5):319–321. [PMC free article] [PubMed]
  • Booth AJ, Harrison CJ, Gardener GJ, Gray AJ. Waiting times and patient satisfaction in the accident and emergency department. Arch Emerg Med. 1992 Jun;9(2):162–168. [PMC free article] [PubMed]
  • Nerney MP, Chin MH, Jin L, Karrison TG, Walter J, Mulliken R, Miller A, Hayley DC, Friedmann PD. Factors associated with older patients' satisfaction with care in an inner-city emergency department. Ann Emerg Med. 2001 Aug;38(2):140–145. [PubMed]
  • Lau FL, Leung KP. Waiting time in an urban accident and emergency department--a way to improve it. J Accid Emerg Med. 1997 Sep;14(5):299–303. [PMC free article] [PubMed]
  • Thompson DA, Yarnold PR, Adams SL, Spacone AB. How accurate are waiting time perceptions of patients in the emergency department? Ann Emerg Med. 1996 Dec;28(6):652–656. [PubMed]
  • Thompson DA, Yarnold PR, Williams DR, Adams SL. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med. 1996 Dec;28(6):657–665. [PubMed]
  • Liptak GS, Super DM, Baker N, Roghmann KJ. An analysis of waiting times in a pediatric emergency department. Clin Pediatr (Phila) 1985 Apr;24(4):202–209. [PubMed]
  • Allen AB, Barnard BG, Falk W, Higgs ER, McCracken JG. A study of waiting time in an emergency department. Can Med Assoc J. 1973 Sep 1;109(5):373–376. [PMC free article] [PubMed]
  • Longsworth FG. Casualty transit time for 100 adult walk-in patients at the University Hospital of the West Indies. West Indian Med J. 1990 Sep;39(3):166–169. [PubMed]
  • Smeltzer CH, Curtis L. An analysis of emergency department time: laying the groundwork for efficiency standards. QRB Qual Rev Bull. 1987 Jul;13(7):240–242. [PubMed]
  • Pereira S, Oliveira e Silva A, Quintas M, Almeida J, Marujo C, Pizarro M, Angélico V, Fonseca L, Loureiro E, Barroso S, et al. Appropriateness of emergency department visits in a Portuguese university hospital. Ann Emerg Med. 2001 Jun;37(6):580–586. [PubMed]
  • Sempere-Selva T, Peiró S, Sendra-Pina P, Martínez-Espín C, López-Aguilera I. Inappropriate use of an accident and emergency department: magnitude, associated factors, and reasons--an approach with explicit criteria. Ann Emerg Med. 2001 Jun;37(6):568–579. [PubMed]
  • Derlet R, Richards J, Kravitz R. Frequent overcrowding in U.S. emergency departments. Acad Emerg Med. 2001 Feb;8(2):151–155. [PubMed]
  • Miró O, Sánchez M, Coll-Vinent B, Millá J. Indicadores de calidad en urgencias: comportamiento en relación con la presión asistencial. Med Clin (Barc) 2001 Jan 27;116(3):92–97. [PubMed]
  • Schwab RA, DelSorbo SM, Cunningham MR, Craven K, Watson WA. Using statistical process control to demonstrate the effect of operational interventions on quality indicators in the emergency department. J Healthc Qual. 1999 Jul-Aug;21(4):38–41. [PubMed]
  • Johnson DV. An administrative perspective on emergency medicine. Emerg Med Clin North Am. 1987 Feb;5(1):149–153. [PubMed]
  • Jelinek GA, Mountain D, O'Brien D, Rogers IR, Wilkes G, Wenban J, Carr J, O'Keefe S, Martin PJ. Re-engineering an Australian emergency department: can we measure success? J Qual Clin Pract. 1999 Sep;19(3):133–138. [PubMed]
  • Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say? Acad Emerg Med. 2000 Jun;7(6):695–709. [PubMed]

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