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-

The major role of the emergency department (ED) is to
provide care for acutely ill and injured patients 24 hours
SIMULATION, Vol. 86, Issue 8-9, August-September 2010 559571
c 2010 The Society for Modeling and Simulation International
1
DOI: 10.1177/0037549710360912
Figure 1 appears in color online: http://sim.sagepub.com
ment and Active Labor Act (EMTALA) requires that all
ED patients must be provided with medical screening and
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
no other options for medical care because of socioeco-
nomic barriers [2]. Thus, the ED is the safety net of the
healthcare system due to its role in providing care to unin-
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
this problem has now reached crisis proportions [2, 58].
Between 1993 and 2003, ED visits in the United States
increased by 23.6 million, while at the same time 425
EDs closed and total hospital beds declined by 198,000
[9]. ED overcrowding manifests itself in many different
ways: an excessive number of patients in the ED, patients
being treated in hallways [8], ambulance diversions [10],
long patient wait times, and patients leaving without treat-
ment. ED overcrowding leads to increased medical errors
[2], poor patient outcomes [11, 12], high levels of stress,
decreased morale among ED staff, and decreased capacity
of EDs to respond to mass casualty incidents [9]. Other
effects of ED overcrowding are patient dissatisfaction, de-
creased physician productivity, violence, negative effects
on teaching missions in academic EDs, and miscommuni-
cation [13].
Research on addressing the problem of ED overcrowd-
ing has primarily fallen into three categories: descriptive,
predictive and intervention-oriented. Descriptive studies
have focused on defining overcrowding [14], examining
the causes and effects of overcrowding [2, 7, 8, 10] and
proposing models [15] to describe the problem and mea-
sures to quantify it [1623]. Predictive studies have fo-
cused on measures [20] to predict when an ED will be-
come overcrowded and development of early warning sys-
tems for impending overcrowding episodes [24, 25]. Such
predictive models assume that extra resources, such as re-
serve personnel and auxiliary treatment bays, will be de-
ployed once the ED is alerted to an impending overcrowd-
ing episode. However, given the limited availability of re-
sources caused by cuts in hospital funding [13], a third
stream of research, intervention-oriented studies, has fo-
cused on interventions to optimize available resources and
processes. These interventions include monitoring code
red hours and patient length of stay (LOS), educating
physicians regarding non-ED options for patients [26],
and re-designing processes [27] and patient flows [28, 29].
In 2000 and 2001, the Institute of Medicine (IOM) pub-
lished two reports, To Err is Human [30] and Crossing the
Quality Chasm [31], which highlighted the deficiencies
in current care processes and urged stakeholders in the
American healthcare system to take steps to improve qual-
ity and efficiency of care. In response, the National Acad-
emy of Engineering (NAE) collaborated with the IOM to
report on the important role of systems engineering tools
in improving and optimizing care processes [32]. This
report stressed that there is a knowledge/awareness di-
vide separating healthcare professionals from their po-
tential partners in the engineering fields and that bridging
this gap is key to increasing the quality and productivity
of healthcare. It emphasized the utility of simulation as a
systems analysis tool that can have a positive impact on
care processes at the care-team, organizational, and envi-
ronmental levels.
In the ED, simulation has been has been extensively
applied to test what if scenarios to combat overcrowd-
560 SIMULATION Volume 86, Numbers 8-9
ing [3335]. These simulation studies have proposed sev-
eral solutions to alleviate overcrowding. In this paper, we
present a systematic review of the ED simulation literature
from 1970 to 2006 from the fields of healthcare, systems
engineering, operations research, and computer science.
The goals of this review are to highlight the contributions
that simulation studies make to our understanding of the
problem of ED overcrowding, and discuss how simulation
can be better used as a tool to address this problem.
This paper is organized in the following manner. The
next section provides background on the role of simulation
in understanding ED overcrowding. Then, the Section 3
describes the process we used for selecting studies. Next,
we report the findings of the simulation studies in Sec-
tion 4. In Section 5, we present insights gained from these
studies, the limitations of current studies, and directions
for future research. We conclude with some final thoughts
of how simulation can be used as a tool to address ED
overcrowding.
2. The Role of Simulation in ED Overcrowding
Several solutions have been proposed to alleviate the ef-
fects of ED overcrowding including providing patients
with better access to clinics, expanding ED square footage
and beds, improving support by radiology, laboratory, and
consultant services, and reducing incoming transfers to
the ED during busy periods [13]. Fatovich and Hirsch [10]
proposed stop-gap measures such as increasing ED ca-
pacity, increasing human and physical resources, and im-
proving discharge processes to deal with overcrowding.
Most of these proposed solutions call for increasing ca-
pacity and resources. However, because of economic con-
straints, most hospitals do not have extra resources to de-
ploy. Therefore, there is a need to focus on optimizing ex-
isting resources and processes. Systems analysis tools can
play an important role in this process. Systems analysis
tools are used by engineers to understand how complex
systems operate, how well these systems meet operational
goals, and how they can be improved [32]. Such tools can
be used for enterprise management, financial engineering
and risk analysis, and knowledge discovery.
Simulation, an important systems analysis tool, pro-
vides great flexibility in testing scenarios, hypotheses,
policies, and re-engineering ideas in healthcare settings. It
can be used as research tool, education device, decision-
making tool and planning model [36]. Pritsker [37]
defined simulation as the development of a mathemati-
cal/logical model of a system and the experimental ma-
nipulation of the model on a computer. To study a sys-
tem, a model, which is a set of mathematical or logical
assumptions about the system, is created. The model is
then either solved via mathematical methods (i.e. an ana-
lytic solution) or evaluated numerically using a computer
(i.e. a simulation) [38].
Simulation has been used in an array of healthcare set-
tings ranging from hospital sub-systems and outpatient
 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
the late 1970s, England and Roberts [41] reported 21 ar-
eas of application of simulation in healthcare including
hospitals, ambulatory care, manpower planning and fore-
casting, community, regional and national health systems,
and education. In hospitals, simulation research has been
applied to areas such as admission control systems, bed
planning, ambulance and emergency services, labs and ra-
diology, and surgery. Simulation studies have also focused
on understanding the care planning process [42], tracing
the spread of diseases and epidemics, and virtual reality
simulations for training [43]. The earliest efforts in sim-
ulating emergency services date back to the mid-1960s
[44]. Starting with Bollings study [45] in 1972, simula-
tion studies of EDs have provided valuable insight into
factors and reasons for overcrowding [46].
3. Methods
We used a two-phase approach to identify simulation
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
to 2006. These databases are the comprehensive sources
of literature in computer science, operations management,
healthcare, and engineering fields. We used the search
phrases emergency department simulation, emergency
department patient flows and other combinations of these
phrases (e.g. emergency department flow simulation).
We defined relevant documents as those studies that used
simulation to understand the problem of overcrowding, ef-
fects of overcrowding (e.g. long patient wait times), and/or
proposed solutions to the overcrowding problem. We did
not include studies that had merely modeled the ED but
did not perform computer simulations of the model. Us-
ing the various search phrases, we found 37 relevant docu-
ments. In the second phase, we examined the references of
these 37 documents for additional studies that met our cri-
teria and found 6 additional studies. After this phase, we
had a total of 43 simulation studies. Most of these studies
were conducted after 1990 (Figure 1 shows the distribu-
tion of studies by year).
Of the 43 simulation studies, 24 (56%) studies were
published in computer science venues, 9 (21%) in medical
and health sciences venues, 5 (12%) in operations research
and management venues, 4 (9%) in industrial engineering
venues, and 1 (2%) in other venues. Of these studies, we
were able to access 32 via online and print sources. Some
of the early studies were not available online and we did
not have access to the print versions.
4. Results
We analyzed the simulation studies with respect to: (1)
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
findings.
4.1 Motivation and Goals
Few studies mentioned explicitly that their motivation
was the desire to create a general model of overcrowd-
ing in EDs [47], or to decrease levels of overcrowding
[48]. Instead, the motivations for most studies were re-
lated to costs and competition, efficiency, re-engineering,
and quality of service (Table 1). Given the motivations to
cut costs and increase efficiency, one of the primary goals
of these studies were to examine causes of inefficiencies
in processes and resource utilization. Therefore, studies
examined patient flows [49] and bottlenecks in flows [34,
50], causes of excessive wait times [49, 51], and patient
throughput [35]. A few studies also evaluated the effects
of introducing fast care for low acuity patients [33, 52],
Volume 86, Numbers 8-9 SIMULATION 561
 Paul, Reddy, and DeFlitch
Table 1. Motivation of the simulation studies
Motivations
Costs and competition
Rising costs [33, 64]
Decrease or control costs of operation [6567]
High costs of building, equipment, and staffing [62]
Reduce staffing levels without decreasing efficiency [68]
Rising competition [59, 65]
Reduced patient visits [69]
Increase corporate customer base without decreasing
quality [54]
Efficiency
Inefficiencies [33]
Increase efficiency [67]
More efficient staff utilization [59]
Overloaded ED staff [70]
Staff scheduling to meet unpredictable workload patterns
[60]
Doctors had the highest average utilization, were not ap-
propriately assigned and were the bottlenecks of the sys-
tem [55]
Develop a general tool for evaluating policy changes for im-
proving productivity and efficiency in the ED [53]
Re-engineering
Increase in ED size and separation of ambulance patients
from outpatients [49]
Improve the ER process [71]
New ED with lab and X-ray facilities [72].
Quality of service
Excessive patient wait times [34, 50, 51, 56, 63, 66, 70, 73,
74]
Long patient wait times for low acuity patients [52, 73]
High LOS of patients [35]
Lack of ED capacity [70, 74]
High withdrawal rates of patients [70]
ED on ambulance diversion status often [35]
Increased patient dissatisfaction [69]
not providing care to low acuity patients [53], and re-
designing processes to reduce patient LOS [54]. A second
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
wait times [58, 59], and quality of service [60] in order
to recommend cost-effective schedules. Since beds are an
important resource in the ED, studies examined critical
bed requirements [61, 62] and the impact of bed availabil-
ity on wait times of admitted patients [50, 63].
4.2 Modeling Techniques
The studies utilized a variety of modeling techniques in-
cluding discrete-event [4749, 51, 55, 58, 60, 67, 73, 75],
562 SIMULATION Volume 86, Numbers 8-9
systems dynamics [63], and conceptual [64, 71] and math-
ematical modeling [68].
A simulation model can be deterministic (if it does not
contain any random variables) or stochastic (if it contains
one or more random variables) [38]. Stochastic processes
are governed by probabilistic laws and have been applied
to study various aspects of health systems since the early
1950s [76]. We found that most often the ED was modeled
as a stochastic system since the inter-arrival times and ser-
vice times of patients are considered random variables.
The ED was also primarily modeled as a discrete sys-
tem. Discrete event simulation has been used extensively
in examining patient flows and allocation of resources in
healthcare clinics [77] and was the most popular simula-
tion technique in the studies we reviewed. Queuing mod-
els are discrete-event models used to represent customers
queuing to gain access to limited resources and have been
used to simulate unscheduled patient arrivals in EDs, oper-
ating rooms (ORs), intensive care units (ICUs), blood clin-
ics, and X-ray departments. For instance, Liyanage and
Gale [74] used queuing theory to develop a simulation to
find the optimal number of resources that would minimize
the mean operating cost of the ED. Some discrete-event
models [53, 57, 70] were written in SLAM (Simulation
Language for Alternative Modeling), a process-oriented
simulation language developed by Pegden and Pritsker
(see [38]). Using SLAM, the ED can be pictorially repre-
sented as a network of nodes and branches through which
patients flow. Other discrete-event modeling tools include
Arena [34, 35, 49, 51, 54, 56, 59, 65, 68], Extend [48, 64],
SIMAN [60, 73], and SIMUL-8 [58].
Another modeling technique used was systems dynam-
ics [78]. This technique is used to model the complexity in
large systems and has been successfully applied to busi-
ness modeling [79]. The systems dynamics tool iThink
was used for such models [63]. While discrete-event sim-
ulations can be used to create detailed models of sub-
systems within healthcare, systems dynamics enables a
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.
4.3 Data Sources and Collection Methods
The simulation studies used a wide variety of data sources
as inputs to their models. The data collection techniques
included interviews with care providers and management,
observations, historical data from ED databases, patient
charts, time and motion studies, and using automated date-
time stamping machines (Table 2).
Hospital databases and information systems, patient
charts and medical records all play an important role in
obtaining data on arrival patterns, time spent on differ-
ent activities by care providers, and inter-arrival times and
LOS distributions. Data obtained about inter-arrival times
and service times [34, 35, 52], volume and mix of patients
 A SYSTEMATIC REVIEW OF SIMULATION STUDIES INVESTIGATING EMERGENCY DEPARTMENT OVERCROWDING

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

[50], staffing levels [60, 74], and types and duration of
treatment [54] were used to determine model inputs and
outputs.
4.4 Patient Classification and Flows
There was no single approach to classifying patients. Dif-
ferent studies categorized patients along different dimen-
sions. The three main dimensions of categorization were
mode of arrival, level of acuity, and case type. The mode
of arrival of patients was helicopter, ambulance, or walk-
in. In the emergency care domain, the most common way
to categorize patients according to acuity is emergency,
urgency, and non-urgency [72]. However, different EDs
used different terms to track levels of acuity including de-
grees (e.g. first, second), levels [60, 80] (e.g. IV), trauma
levels (e.g. major, minor), and ESI-5 levels [33]. Simi-
larly, there was a variety of ways to categorize patients by
case type, including by chief complaint [69] (e.g. abdomi-
nal pain, laceration), specialty (e.g. internal, surgical), and
even treatment areas [50] (e.g. fast-track patients, observa-
tion room patients).
Some studies categorized patients by combining these
dimensions, such as Clark and Waring [57] who combined
mode of arrival with level of acuity (e.g. critical walk-in),
and Sinreich and Marmor [67] who combined mode of
arrival with case type (e.g. walk-in surgical).
In most studies, different patient flows were modeled
for each category of patients. The wide variety of patient
or rooms, is an important resource. During periods of
overcrowding, patients experience their most significant
delay waiting for an ED bed [81]. Takakuwa and Shiozaki
[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
or minors of their ED. In scenario 1, they added an
extra bed to the minors area, but, in scenario 2, they
added six extra beds to the area. Surprisingly, they found
very little improvement in LOS in scenario 2 as com-
pared with scenario 1. They did find that queuing time
for beds went down 83% in scenario 21 however, there
was a significant increase in wait times for nurses and
doctors. Their study highlighted that adding extra beds
merely shifted the queues from the waiting room to the
bed. Samaha et al. [35] also found that adding beds or
square footage to the ED did not shorten LOS. These re-
sults are corroborated by recent findings that increase in
ED bed capacity does not decrease ambulance diversions
(an indicator of overcrowding) and might even lead to an
increase in LOS [82].
Studies also examined the effects of re-using space or
rooms in the absence of adequate beds. Kirtland et al. [69]
found that placing patients in the treatment area when beds
were not available instead of sending them back to waiting
area saved 14.1 minutes. McGuire [66] found that having
a separate holding area for admitted patients waiting for
test results saved 22 minutes per patient on average, and
Kirtland et al. [69] found that using an internal waiting
room for patients awaiting lab and X-ray results would be
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-
tion studies focused on two major resources other than
beds: human and equipment resources. One cause of in-
efficiency in EDs is that due to the sporadic demand,
the staff are idle at times and overworked at other times
[72]. Hence, several simulation studies were interested
in examining the effects of alternative staff schedules on
waiting times and LOS [5560, 68, 71, 75]. Rossetti et
al. [59] simulated 18 attending staff schedules and iden-
tified a schedule that decreased average patient time in
the ED by 14.5 minutes/patient. Based on the simula-
tion, they found that this schedule also decreased physi-
cian utilization and percentage of long visits. Coats and
Michalis [58] compared different shift patterns via sim-
ulation and found that the doctor shift pattern that best
matched the patient arrival pattern gave the shortest wait
times.
Queuing analysis techniques were used to match
staffing patterns to ED demand [83]. Tan et al. [55] used
preliminary queuing analysis to develop an alternative
doctor schedule and compared it with the current schedule
via simulation. The results identified the doctors station
as the bottleneck. The new schedule increased the capac-
ity of the bottleneck and hence reduced patient time in
the system. Clark and Waring [57] tested whether doctor
and nurse scheduling would affect the time spent waiting

564 SIMULATION Volume 86, Numbers 8-9

 A SYSTEMATIC REVIEW OF SIMULATION STUDIES INVESTIGATING EMERGENCY DEPARTMENT OVERCROWDING
to see a doctor, the total time in the system, the utiliza-
tion rate of doctors, and the utilization rate of nurses. They
found that scheduling of physicians will have a significant
effect on waiting times. However, the nurses schedule did
not have the same impact. Evans et al. [56] tested alterna-
tive schedules containing different numbers of nurses and
technicians but the same number of doctors as the actual
system and found only a 5-minute reduction in average
LOS. These finding, which seem to indicate that nurse
scheduling does not significantly impact waiting times,
are interesting given the large amount of research focus-
ing on optimizing nursing allocation in various parts of the
hospital [76].
Although equipment is an important resource, only a
few studies examined the effects of adding equipment to
the ED. Hannan et al. [72] found that installation of lab
and X-rays in the ED had the same effect as hiring an ad-
ditional nurse and physician. Takakuwa and Shiozaki [49]
looked at the effects of varying the number of stretchers
and implements in the drip room.
Some studies aimed at determining the optimal re-
sources required to minimize the mean operating cost of
the system [74] and successfully support the patient de-
mand [70]. Takakuwa and Shiozaki [49] adjusted the num-
ber of rooms, internists, surgeons, pediatricians, imple-
ments in the drip room, stretchers, etc., and found that
there was no optimal configuration of these resources
which can lead to the lowest waiting time.
4.5.2 Process-Related Findings
The simulation studies examined several procedural
changes to alleviate the effects of ED overcrowding. Most
studies found that establishing a fast-track path for low
acuity patients was effective in decreasing wait times
without negatively impacting quality of care [84]. Samaha
et al. [35] simulated all routine patients being directed
to fast-track and found a considerable reduction in LOS.
Similarly, Kirtland et al. [69] found that fast-track saved
15.5 minutes in the ED. Pallin and Kittell [71] simulated
fast-tracking by eliminating return visits and found a 50%
reduction in staff and resources due to the fast-tracking.
Garcia et al. [52] found that taking one nurse and bed from
the ED and using them in a fast-track would significantly
lower flow time for low acuity patients. McGuire [66] also
found that extending the hours of the fast-track led to a 16-
minute decrease in LOS. However, they found that waiting
time was not affected by initiating search for admission
rooms earlier in the process. Samaha et al. [35] found that
bedside registration would not reduce LOS and would be
costly to implement1 but, a recent empirical study found
that including bedside registration in the process did de-
crease LOS [85].
Some procedural scenarios looked at changing stan-
dard protocols in the ED to reduce wait-times. Studies
found that changing triage protocols so triage nurses could
order tests and X-rays saved 3.6 minutes [69]. Pallin and
Kittell [71] tested a protocol to allow nurses to order test-
ing/treatment without participation of physician but did
not mention the results of simulating this scenario. Labo-
ratory turnaround times add to waiting times in the ED and
can be decreased significantly with point-of-care lab test-
ing [86]. McGuire [66] found that reducing lab turnaround
time decreased LOS. Kirtland et al. [69] found that using
I-stat machines in the ED for point-of-care testing saved
8.4 minutes.
4.5.3 Environment-Related Findings
Many simulation studies also focused on the effects of
factors external to EDs that can cause overcrowding. A
major cause of overcrowding is the unavailability of in-
patient beds and inpatient bed occupancy has been found
to be strongly correlated with ED LOS [87]. Miller et
al. [64] found that adding 30 inpatients beds would cut
LOS by half. Gonzalez et al. [70] found that increasing
the number of beds to which ED patients can be admit-
ted would maximize profits and minimize waiting time.
Lane et al. [63] examined how reductions in bed capacity
in the hospital wards affected patient waiting times in the
ED. They examined the ED as part of the larger hospital-
wide system and considered emergency patients and elec-
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-
ishnan [50] found that adding beds to step-down units and
other specialized units decreased the average time of pa-
tients waiting to be admitted from the ED. Blasak et al.
[34] investigated how the interface between the ED and
the Medical Telemetry Unit (MTU) affected wait times in
the ED. They found that they needed to reduce the time
for bed notifications from MTU to ED, decrease num-
ber of non-ED patients being admitted to MTU and de-
crease LOS in MTU [34] to reduce waiting times for ED
patients.
Two of the primary uncontrollable external features of
the ED environment are patient demand and mix of patient
types. Studies have examined the effects of changes in pa-
tient demand on wait times. Hannan et al. [72] tested the
effects of increased demand and increased percentage of
true emergency patients. They also examined scheduling
non-emergency patients to reduce demand. They found
that when demand increased above 20%, the waiting times
for emergency patients did not change much, but the non-
emergency patients had to wait longer. Baesler et al. [54]
used their simulation to find the maximum demand that
the ED would be able to handle without the average pa-
tient time exceeding 100 minutes. They found that this
would happen when the demand increased by 130%. To
handle this increase in demand and keep the wait time un-
der 100 minutes, the ED would need four full-time doctors
and one half-time doctor.
Volume 86, Numbers 8-9 SIMULATION 565
 Paul, Reddy, and DeFlitch
5. Discussion
After analyzing the simulation studies, we found that they
provided useful insights into the problems of ED over-
crowding. However, at the same time, we found major
limitations to the studies that must be addressed if they
are to help us to better understand and alleviate ED over-
crowding.
5.1 Insights from Simulation Studies
The simulation studies highlighted a number of important
issues that we must consider as we try to address ED over-
crowding.
First, the conventional solution to ED overcrowding is
increasing available ED space (e.g. increase the number
of ED beds). However, the simulation studies have clearly
shown that while increasing ED space may provide short-
term relief by allowing more patients to be admitted to the
ED, this would not necessarily reduce patient wait times.
The patient queues would merely shift from the waiting
rooms to the bedside. Therefore, although beds are an im-
portant resource, a more critical resource are the physi-
cians because they are often the bottleneck of the system
and the most utilized resource [55]. Most improvements
in waiting times and LOS resulted from more effective
scheduling of doctors [55, 57, 59], eliminating non-patient
care duties from doctors duties [73] and using doctors in
the fast-track. Blake and Carter [73] came to an interest-
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-
dition of residents since the time spent by attending physi-
cians in resident education as opposed to direct patient
care decreases the benefits of adding more manpower.
Second, many studies found that the problems in the
ED were process-related [35]. Improvements in processes,
such as fast-tracking and reducing lab turn-around times,
reduced wait times. Changing procedures and protocols
in the ED such as placing patients in separate areas when
they are waiting for test results, and having the triage nurse
order tests and X-rays, also saved time. However, although
a few processes such as fast-tracking provided positive re-
sults across studies, most process improvements were ED-
specific. For instance, Kirtland et al. [69] found no sig-
nificant time saving for using an internal waiting room for
patients waiting for lab and X-ray results except when the
ED was very busy but McGuire [66] found that having a
separate holding area for admitted patients waiting for test
results saved 22 minutes per patient. Similarly, Blasak et
al. [34] found that adding a dedicated triage nurse would
create a bottleneck but Gonzalez et al. [70] recommended
the addition of a nurse to perform administrative work
such as following up room availability. Therefore, while
there is consensus that process-related issues are critical
to an EDs ability to handle overcrowding, there is little
566 SIMULATION Volume 86, Numbers 8-9
consensus on the specific process changes that can be ap-
plied across all EDs. Rather, each ED must identify its
own unique characteristics and processes when trying to
deal with the problem of overcrowding.
Third, the ED is part of a larger and more complex
hospital system and is affected by many external factors.
As the recent IOM report on ED overcrowding states [9],
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
the ED with other units of the hospital. Environment-
related changes, such as variable patient demand, are out-
side the control of EDs. However, simulation of vari-
ous demand patterns can help EDs predict resource lev-
els needed to meet those demands. In the simulation stud-
ies, adding beds to units that interfaced with the ED in-
variably led to decrease in LOS for ED patients waiting
to be admitted to those units. Reducing time for bed no-
tifications from other units to the ED also improved wait
times. These results indicate that there is a strong inter-
connectedness between the ED and the rest of the hospital.
Lane et al.s study [63] revealed that the effects of changes
in the ED may not be reflected within the ED but in other
parts of the hospital. For instance, they found that reduc-
tions in hospital beds did not have an impact on ED wait
times but resulted in cancellations of elective procedures.
They concluded that policy changes must be based on an
understanding of how EDs connected to pre-hospital ser-
vices, to the rest of the hospital, and the surrounding com-
munity.
5.2 Limitations of Simulation Studies
Although the simulation studies provided important in-
sights into the problem of ED overcrowding, they had lim-
itations that affected their usefulness in helping deal with
the problem.
First, patient flows were viewed in these studies in an
overly simplistic manner. There are two aspects of patient
flows in healthcare: clinical and operational [88]. From a
clinical perspective, a patient flow is the progression of a
patients health status1 from an operational perspective, a
patient flow is the movement of a patient through various
locations or stations in a hospital. In the ED, the clini-
cal and operational aspects of flows are often intertwined
since the patients health status (case type and level of acu-
ity) typically determines which treatment stations they
visit. This leads to a large variety of patient flows in the
ED. For instance, Takakuwa and Shiozaki [49] found 70
patterns of patient flows for 9 patient categories in a sin-
gle ED. The process of modeling this variety of patient
flows is difficult and time-consuming. Therefore, for the
sake of simplicity, most flows were modeled as linear, that
is, patients moved in a sequential manner from station to
station. However, in reality patients might undergo several
care processes at the same time. The overlaps and interde-
 A SYSTEMATIC REVIEW OF SIMULATION STUDIES INVESTIGATING EMERGENCY DEPARTMENT OVERCROWDING
pendencies between components of patient flows were not
modeled in the simulation studies.
Second, many studies did not incorporate informa-
tion flows when modeling patient flows. The health-
care process can be viewed as a series of information-
processing steps starting from the initial collection of
data about the patients condition to forming a hypothe-
sis and testing it by collection of more data [32]. Given
the variety of information required at each step of the
patient flow, and the multitude of information and com-
munication technologies used in modern EDs [32], infor-
mation flows are closely linked to patient flows. These
information flows are a crucial aspect of the modeling
in an ED but have not been addressed by the simula-
tion literature. Also, simulation studies have not consid-
ered the role of information and communication technolo-
gies (ICTs) within EDs. ICTs such as electronic medical
record (EMR) systems, electronic dashboards, radio fre-
quency identification (RFID), wireless registration, and
mobile computing devices are being used in EDs to help
with clinical documentation, decision-support, informa-
tion management, and coordination of patient flows [9].
These ICTs have the potential to significantly impact ED
overcrowding. By not incorporating ICTs into the simula-
tions, the studies have failed to capture an important re-
source.
Third, the lack of standardization of workflow, care
practices, patient categories, and patient flows across EDs
makes it hard to design a generic model of an ED for
use in a simulation. Sinreich and Marmor [67] developed
a generic tool flexible enough to model any ED. They
classified EDs into four basic types based on two factors:
ED physician type, i.e. whether the ED physician spe-
cialized in emergency medicine or other areas, and pa-
tients condition, i.e. how the ED processed acute and
ambulatory patients. However, given the wide variety of
processes, this classification may not be sufficient. As a
result, most simulation studies had to create ED-specific
models, which in turn lead to ED-specific solutions that
could not be generalized to other EDs.
Fourth, the purpose of data acquisition is to estimate
the parameters of the system and to validate the model.
The time, cost, and difficulty associated with obtaining
empirical data for simulation models has been a challenge
[36]. Although arrival patterns and patient volume/mix
data can usually be obtained from information systems
and medical charts, service times can only be obtained
through observation and time/motion studies. However,
placing researchers in overcrowded EDs is often difficult
due to the fast-paced nature of the environment and pa-
tient privacy issues. One approach is to pay ED staff for
data collection [72] or to use self-reported work sampling
techniques to gather data [59]. However, the success of
these techniques depends on the busy care-giver to col-
lect the data. The difficulty of collecting this type of data
was highlighted in the following study. Rossetti et al. [59]
obtained a list of 16,250 standardized elements, i.e. op-
erations that a patient goes through or which a member
of the staff performs, from five hospitals1 it took 1,350
man-hours to conduct time and motion studies to mea-
sure service times for all elements. A simulation model is
only as accurate as the data used to build it. Therefore, the
difficulty in capturing reliable data can lead to inaccurate
simulation results.
5.3 Future Research Directions
We have three suggestions for future research directions
for simulation studies. First, simulation models need to
capture human behavior. In 1975, Valinsky [36] noted that
there had been little work on modeling the human ele-
ments of the healthcare system, such as the patient, med-
ical staff, and administrators within the health field. More
than 30 years later, this is still the case. The simulation
models we reviewed have not examined the physiologi-
cal, psychological, and social aspects of patient care in
EDs. Providers and patients behavior is directed by be-
liefs, attitudes, and expectations. Therefore, an important
question to answer is how these beliefs and attitudes can
be modeled or if this is an aspect of patient care that is ir-
relevant to simulation modeling. To incorporate elements
of human behavior in healthcare simulations, simulation
research can draw on the fields of humancomputer in-
teraction (HCI) and computer-supported cooperative work
(CSCW) which have studied the cognitive and social as-
pects of human behavior, such as emotion [89], commu-
nication [90], collaboration [91, 92], and the social orga-
nization of work [93] in healthcare settings. Simulation
researchers can apply findings from these fields about the
behavior of patients and healthcare providers to model hu-
man interactions as part of the ED.
Second, we need to study the ED as part of a larger
system. In simulation modeling, the choice of system
depends on the objectives of the study [38]. In most stud-
ies, the objective was to improve efficiency and cut costs
of operation and the ED was studied as an isolated unit.
The interactions/interfaces between ED and other services
such as EMS, labs, and the rest of the hospital were not
modeled in most studies. However, factors external to the
ED, such as hospital bed occupancy, strongly affect ED
length of stay [87]. Research has also shown that interven-
tions aimed at factors external to the ED have been most
successful in reducing ED overcrowding [26]. Therefore,
simulation studies need to focus more on the role of the
ED with the context of the larger hospital system. This can
be done by incorporating other hospital units that interface
with the ED as part of the model. Simulation studies can
draw on research from fields such as CSCW which have
examined the effects of patient flows between the ED and
other hospital units [94].
Incorporating external factors might lead to complex
models and certain types of simulation are better suited
for such models. Discrete-event simulation, the most pop-
ular technique in the reviewed studies, is not well suited
Volume 86, Numbers 8-9 SIMULATION 567
 Paul, Reddy, and DeFlitch
to studying complex integrated systems in healthcare be-
cause of the high level of complexity and data require-
ments of such simulations, as well as the time and cost as-
sociated [77]. However, it provides excellent micro-level
analysis of the ED. Systems dynamics techniques can be
used to understand the inter-relations between the ED and
the rest of the healthcare system but do not assist man-
agers in micro-level analysis. Therefore, researchers need
to examine ways to combine different techniques such as
discrete-event and systems dynamics techniques to pro-
vide multi-level views of the problem [95].
Third, we need to focus on the individual level of
care and incorporate the patient perspective. The IOM re-
port [32] states that the ultimate purpose of systems tools
should be to ensure that the system is responsive to pa-
tient needs. However, systems tools have not been widely
applied at the individual level of care because the focus
of these tools has been at the team and organization level.
Therefore, systems tools may need to be combined with
other individual level tools such as quality function de-
ployment, to design processes that meet the level of ser-
vice a patient/customer wants, and human factors engi-
neering to improve the patientprovider interactions. Fur-
thermore, researchers have focused on the problem from
the perspective of the healthcare manager instead of the
patient. In studying ED overcrowding, little attention has
been paid to how overcrowding affects quality of care and
patient outcomes [96]. Therefore, measures of overcrowd-
ing have only been weakly associated with quality of care
[18]. The simulation studies reflected the same bias by fo-
cusing mostly on improving efficiency, cutting costs, and
optimizing processes and resources. Only a few studies
were concerned with the direct impact on patient care or
were motivated by reducing patient wait times, LOS, and
dissatisfaction with care. Therefore, we need to examine
how to incorporate patient care needs into the simulation
models.
6. Conclusions
ED overcrowding is a serious and growing problem threat-
ening the safety net of the healthcare system. Simu-
lation tools provide an important method to investigate
overcrowding issues and explore solutions to this prob-
lem. Through a review of the last 30 years of simu-
lation research focusing on ED overcrowding, we have
identified a variety of features that these studies have in
common. Although simulation has been useful in iden-
tifying critical resources and process improvements that
can alleviate overcrowding, these studies still have se-
vere limitations that must be addressed. Most interven-
tions proposed by the simulation studies have been ED-
specific and are not generalizable. Future simulation ef-
forts must incorporate a patient perspective, the role of
information and communication technologies, and en-
vironmental features in order to develop solutions to
568 SIMULATION Volume 86, Numbers 8-9
ED overcrowding. Simulation is a powerful tool that re-
searchers can deploy to confront the problem of ED
overcrowding.
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Sharoda A. Paul is a final year PhD candidate at the College of
Information Sciences and Technology at The Pennsylvania State
University. Her dissertation examined collaborative information
seeking and sensemaking activities of healthcare providers in
a hospital emergency department. Her research interests are
in the fields of computer-supported cooperative work, human
computer interaction, healthcare informatics, and collaborative
and social Web search.
 A SYSTEMATIC REVIEW OF SIMULATION STUDIES INVESTIGATING EMERGENCY DEPARTMENT OVERCROWDING
Madhu Reddy, PhD, is an Assistant Professor in the College
of Information Sciences and Technology at The Pennsylvania
State University. His primary research interests are in the ar-
eas of medical informatics and computer-supported cooperative
work. He is especially interested in the design, implementation
and adoption of collaborative healthcare technologies such as
electronic patient records. His current research is focused on
how these and other technologies can support information be-
havior in multidisciplinary patient-care teams.
Christopher DeFlitch, MD, is the Chief Medical Information
Officer and Vice Chair for Emergency Medicine at The Penn-
sylvania State University Milton S. Hershey Medical Center.
His research interests are in transforming the delivery of health
care through health information technology and process re-
engineering. He is particularly interested in approaches to re-
designing emergency departments to be more effective through
the use of health IT and patient flow engineering.
Volume 86, Numbers 8-9 SIMULATION 571