Western Journal of Emergency Medicine 104 Volume X, no. 2 : May 2009
Leslie S. Zun, MD, MBA
Analysis of the Literature on Emergency
Rosalind Franklin University of Medicine and Science/Chicago Medical School,
Department of Emergency Medicine
Mount Sinai Hospital, Department of Emergency Medicine, Chicago, Illinois
Supervising Section Editor: Christopher A. Kahn, MD, MPH
Submission history: Submitted March 31, 2008; Revision Received September 15, 2008; Accepted November 24, 2008.
Reprints available through open access at www.westjem.org
Introduction: The purpose of this paper was to review and analyze all the literature concerning ED
patient throughput. The secondary goal was to determine if certain factors would significantly alter
patients’ ED throughput.
Methods: A MEDLINE search was performed from 1966 to 2007 using the terms “turnaround,”
“emergency departments,” “emergency medicine,” “efficiency,” “throughput,” “overcrowding” and
“crowding.” Studies were graded using a scale of one to four based on the ACEP paper quality
criteria. Inclusion criteria were English language and at least a level four or better on the quality scale.
An analysis of successful procedures and techniques was performed.
Results: Literature search using the key terms found 29 articles on turnaround times, 129 on ED
efficiency, 3 on throughput, 64 on overcrowding and 52 on crowding. Twenty-six articles were found
to meet the inclusion criteria. There were three level I studies, thirteen level II studies, five level III
studies and five level IV studies. The studies were categorized into five areas: determinants (7),
laboratories processes (4), triage process (3), academic responsibilities (2), and techniques (10). Few
papers used the same techniques or process to examine or reduce patient throughput precluding a
Conclusions: An analysis of the literature was difficult because of varying study methodologies and
less than ideal quality. EDs with combinations of low inpatient census, in-room registration, point of
care testing and an urgent care area demonstrated increased patient throughput.
Improving efficiency and throughput in the emergency
department (ED) has multiple benefits. Better efficiency
should increase patient satisfaction, enhance revenue and
reduce ambulance diversion. The need to focus on ED
efficiency has become more acute in recent years due to
increasing litigation, including a case where a patient in
Chicago died while waiting for care.1
EDs across the U.S. struggle to provide efficient care
in a timely fashion. Increasing patient volumes, a reduction
in the number of EDs, higher inpatient census and ED staff
reduction all exacerbate the struggle. The purpose of this
paper is to review the literature and summarize strategies used
nationwide to deal with this crisis. Proven techniques could be
used by hospital and ED managers.
We searched MEDLINE from 1966 to March 2007 for
English language articles using the keywords turnaround,
efficiency, throughput, overcrowding and crowding. No other
restrictions in the search fields were used. We also reviewed
references from these articles to ensure that we included all
We required one or more factors related to throughput to
Volume X, no. 2 : May 2009 109 Western Journal of Emergency Medicine
These data could not be tabulated to perform a meta-analysis
because of diverse study designs and the marginal quality
of the papers. In general, the research methodology in these
administrative studies was not as rigorous as other scientific
research. Most were observational or before-and-after studies,
which included potential confounding variables. Additional
factors to explain the problems with this type of research
include lack of external funding, difficulty in isolating specific
techniques to reduce LOS, or difficulty performing randomized
interventions. The analysis of each article was scientifically
based, but there was always the possibility of rater bias. Lastly,
the grouping of study topics was arbitrary but necessary to
determine trends and commonalities.
The world’s ED throughput literature is limited in
applicability from one institution to another; however, there
do appear to be some overarching alterations in behavior that
will serve to speed patients through the ED. Useful strategies
include improvements in triage, urgent care centers, point-of-
care testing and bedside registration.
Address for Correspondence: Leslie S Zun, MD, MBA. Chairman,
Department of Emergency Medicine Mt. Sinai Hospital Medical Center,
15th and California, Chicago, Illinois 60608. Email: firstname.lastname@example.org
Conflicts of Interest: By the WestJEM article submission agreement,
all authors are required to disclose all affiliations, funding sources,
and financial or management relationships that could be perceived
as potential sources of bias. The authors disclosed none.
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Zun Analysis of Literature on ED Throughput