Copyright © 2016 The Korean Society of Emergency Medicine
Improving emergency department
Paul Richard Edwin Jarvis
Emergency Department, Calderdale & Huddersfield NHS Foundation Trust, West Yorkshire, UK
Emergency departments (ED) face significant challenges in delivering high quality and timely
patient care on an ever-present background of increasing patient numbers and limited hospital
resources. A mismatch between patient demand and the ED’s capacity to deliver care often leads
to poor patient flow and departmental crowding. These are associated with reduction in the
quality of the care delivered and poor patient outcomes. A literature review was performed to
identify evidence-based strategies to reduce the amount of time patients spend in the ED in or-
der to improve patient flow and reduce crowding in the ED. The use of doctor triage, rapid as-
sessment, streaming and the co-location of a primary care clinician in the ED have all been
shown to improve patient flow. In addition, when used effectively point of care testing has been
shown to reduce patient time in the ED. Patient flow and departmental crowding can be im-
proved by implementing new patterns of working and introducing new technologies such as
point of care testing in the ED.
Keywords Emergency department; Patient flow; Improvement
Clin Exp Emerg Med 2016;3(2):63-68
Received: 15 February 2016
Revised: 2 March 2016
Accepted: 2 March 2016
Paul Richard Edwin Jarvis
Emergency Department, Calderdale
Royal Hospital, Dryclough Lane, Halifax,
West Yorkshire HX3 0PW, UK
How to cite this article:
Jarvis RE. Improving emergency department
patient flow. Clin Exp Emerg Med
This is an Open Access article distributed
under the terms of the Creative Commons
Attribution Non-Commercial License (http://
What is already known
Published literature on improving patient flow in the emergency department is
What is new in the current study
This study identifies those factors that have been shown to improve patient
flow within the emergency department.
Improving emergency department patient flow
Across the world emergency departments (EDs) are facing incre-
asing challenges due to growing patient numbers and an inability
to flex capacity to meet demand. This is on a background of de-
creasing hospital resources. Consequently, ED crowding has be-
come an ubiquitous, international phenomenon. Approximately
half of all EDs report operating near or above maximum capacity.1
Several studies have presented evidence that ED crowding con-
tributes to a reduction in the quality of patient care,2-8 delays in
commencement of treatment9,10 and that adherence with recog-
nised guidelines worsens.11 The link between ED crowding and
mortality is increasingly being recognised.12,13 Another symptom
of overcrowding is patients leaving without their care being com-
pleted. In the United States this accounts for 2% of all ED visits.14
Crowding occurs when demands placed on the ED are greater
than the entire hospitals capacity to ensure timely care in the ED.
The factors that contribute to poor ED performance can be classi-
fied as being either intrinsic or extrinsic to the ED.3 Departmental
layout and staffing levels are examples of intrinsic factors that
influence patient flow, whereas exit block related to the lack of
inpatient bed availability and surges in patient demand are fac-
tors extrinsic to the ED that influence patient flow. The impact
that the wider hospital system has on patient flow in the ED should
not be underestimated. Blom et al.15 showed that the probability
of a patient being admitted from the ED is negatively correlated
to inpatient bed occupancy.
Improving patient flow within the ED is ultimately achieved by
reducing the amount of time patients spend in the ED, thereby
reducing departmental crowding. Shorter patient journey times
are associated with improved patient satisfaction16 and reduc-
tions in mortality and morbidity.17,18
The aim of this article is to review the evidence relating to strat-
egies to reduce the amount of time patients spend in the ED in
order to improve patient throughput in the ED.
Triage is a brief intervention that should occur ideally within 15
minutes of the patient’s arrival in the ED.4,19 The aim of triage is
to risk stratify patient presentations and prioritise them accord-
ingly as a way of allocating limited resources, such as staff and
physical space based on their clinical need.5 Nurse-led triage is
currently the international standard triage model throughout the
world20,21 and there is insufficient evidence of any one triage scale
being more effective than another.6 Utilising the triage nurse to
request investigations, such as blood tests and X-rays, has been
shown to be associated with earlier diagnosis, shorter waiting
times and faster patient throughput in the ED.22-24 For this system
to be effective there has to be a robust training programme, pro-
tocols and a standardised approach to investigation.
Doctor-led triage is often cited as a possible solution to poor
ED flow.5 It is important to differentiate having a doctor embed-
ded in the triage process from other models of ED working such
as ‘see and treat’ (or ‘fast-track’). Triage is the initial assessment
of undifferentiated patients, whereas see and treat identifies pa-
tients without serious illness or injury who are likely to have the
potential for prompt discharge.
Rowe et al.5 evaluated the impact of having a doctor, of any
grade, assisting the triage process. They demonstrated that a phy-
sician in triage is an effective intervention to alleviate the effects
of ED crowding. Triage performed specifically by a senior doctor
has been proposed as a way of accelerating patient flow through
the ED, reducing admissions and improving the time to key deci-
sion making.2 This is done by initiating prompt patient assessment,
appropriate diagnostic testing and initiating treatment earlier in
the patient’s journey. This includes the identification of definite
admissions and expediting swifter and safer discharge of patients
not requiring further investigation or treatment.
A review confirmed that having a senior doctor in triage im-
pacted positively upon many ED metrics and concluded that it
offers a valuable solution to ED crowding.25 Another systematic
review found senior doctors, working individually at the front door
of the ED or as part of a wider triage team is associated with a
reduction in overall ED patient journey time and the length of
time from the patient arriving to them being assessed by a doc-
tor.5 Although it appears, as a model of working, doctor triage is
beneficial to patient flow in the ED, the heterogeneous nature of
the role of the doctor in these studies means it is difficult to de-
termine the most efficient and effective model for senior doctor
RAPID ASSESSMENT MODELS
Rapid assessment is the assessment, investigation, and initial treat-
ment of patients as soon as they arrive in the ED. This model uti-
lises the principle of single piece flow more commonly found in
the automotive manufacturing industry.26 Essentially early assess-
ment and investigation coupled with prompt initiation of treat-
ment aims to reduce the amount of waiting time that occurs be-
tween each of these steps in the traditional model. Typically these
are patients that do not require resuscitation room or high de-
pendency unit treatment.27
A review article demonstrated that utilising a rapid assessment
Clin Exp Emerg Med 2016;3(2):63-68
Paul Richard Edwin Jarvis
model reduces the overall journey time of patients in the ED. This
review article also demonstrated that the length of time it takes
for patients to be seen by a doctor is reduced when a rapid as-
sessment model is utilised.27
The costs of implementing such system is often cited as a bar-
rier to its introduction. However there is evidence that altering
the existing work pattern within the ED and introducing a rapid
assessment model within the confines of existing departmental
resources is associated with improved patient flow.28
Streaming is the process of allocating similar patients (with re-
gards to disease severity or nature of complaint) to a particular
work stream. Typically, patients in each work stream are assessed
by dedicated staff in a specific geographical area within the ED.
For example, ‘see and treat’ is a form of streaming where patients
with less severe illnesses are allocated to a dedicated clinical area
and receive assessment and treatment from a clinical team only
seeing ‘see and treat’ patients. By its nature, triage leads to a build
up of relatively well patients in the ED as critically ill patients are
seen preferentially. However, streaming ensures less urgent pa-
tients continue to be seen in a timely manner. The individual pa-
tient work streams in the ED can be staffed by senior doctors,
nurse practitioners, physician’s assistants or a combination of all
There is little evidence to support the use of streaming patients
according to their triage categories as a means of redirecting pa-
tients from hospital EDs to other clinical settings outside of the
hospital, such as primary care.3
There is evidence that dividing ED patients into work streams
results in reduced waiting times and shorter ED journey times
when compared with a non-streamed ED model.22 The effective-
ness of this strategy is likely to be dependent upon how patients
are signposted towards the different streams within the ED and
whether there is appropriate staffing and physical space to meet
the patient demand of each individual work stream.29
There is limited evidence that dividing patients entirely based
upon whether they are likely to be admitted or not has any bene-
fit on ED patient flow.22
PRIMARY CARE CO-LOCATED IN THE ED
Two reviews have evaluated the effectiveness of utilising primary
care clinicians within the ED setting for patients with less urgent
clinical problems.30,31 There was insufficient evidence comparing
the safety of care provided by general practitioners in the ED com-
pared with emergency physicians. However, there is some evidence
to suggest there is a potential for cost savings as general practi-
tioners tend to order fewer tests and fewer admissions31,32 whilst
patient satisfaction was increased.32 The waiting time for ED pa-
tients in hospitals with a co located general practitioner service
was on average 19% less than patients attending EDs without a
primary care service.33
Point-of-care testing (POCT) provides clinicians with rapid results
for commonly ordered investigations. Moving laboratory standard
testing into the ED could increase the speed of diagnosis. Numer-
ous reports have highlighted a reduction in turnaround times for
investigation results utilising POCT in an emergency setting.22,34-37
A systematic review performed in 2011 showed that the introduc-
tion of POCT in the ED may reduce the total patient journey time
in the ED.22 More recent studies have demonstrated a similar mod-
est reduction in the amount of time a patient spends in the ED
before a disposition decision is reached when POCT is utilised.36,37
Norgaard and Mogensen38 compared laboratory turnaround
times when utilising POCT in the ED with centralised laboratory
testing with an air-tube transport system for the rapid transport
of blood samples. They showed that in this setting POCT yielded
results on average 46 minutes earlier than from the central labo-
A multicentre randomised controlled study performed in the
United Kingdom evaluated the performance of POCT in the ED
examining cardiac biomarkers in patients with suspected myo-
cardial infarction.39 This study demonstrated a discharge rate
which was 20% greater in patients who had blood analysed by
POCT. Interestingly, this study demonstrated a greater effect in
district general hospitals rather when compared with large uni-
versity-affiliated teaching hospitals. This phenomenon has been
demonstrated by other authors.40 Interestingly, recent evidence
suggests that POCT can add value when used in the prehospital
setting and may reduce the number of patients brought to the
Blood sample POCT is most commonly performed by nursing
staff in the ED.44 To ensure quality assurance there needs to be a
robust training programme in place reinforced with regular recer-
tification. This places an additional burden on members of staff
who already have heavy workloads. However, improvements in
patient flow seen within the ED as a result of the introduction of
POCT are likely to reduce staff workload.44
The cost of a single test performed utilising POCT is higher than
the cost of a similar test performed in a centralised laboratory.36
Improving emergency department patient flow
However, Rooney and Schilling44 state that the time saved elimi-
nating steps when POCT is introduced, such as the sample trans-
portation, registration of the sample in the laboratory and time
spent retrieving results, means the cost of utilising POCT seldom
exceeds those of analysis in a centralised laboratory. An Austra-
lian study performed in 2014 concluded that each hour of patient
time saved by utilising POCT costs approximately 120 Australian
dollars (84.69 US dollars).36
Jarvis et al.45 combined POCT with consultant-led rapid assess-
ment in the ED and demonstrated a 40% reduction in disposition
decision time. This would support the idea that the overall effec-
tiveness is dependent upon the processes within the ED.
The actual impact of implementing POCT in a specific ED varies
greatly. Presumably, the overall effect POCT has on patient jour-
ney times is dependent on the effectiveness and productivity in
the rest of the ED. Consequently, ED working patterns may require
substantial modification to maximise the benefits of POCT. When
used effectively, POCT has been shown to reduce delays to the
initiation of treatment, increase patient discharge rates and de-
crease total ED journey time.45
Poor patient flow, and the resulting crowding, represents a signif-
icant restriction on the ED’s ability to deliver high quality emer-
gency and urgent care. Excessive patient waiting, slow investiga-
tion turnaround times and delays in making disposition decisions
are key factors intrinsic to the ED which affect patient flow.
The association between increased ED mortality rates and de-
partmental crowding12,13 suggest that crowding should be treated
as a significant public health concern. It is influenced by factors
in the pre-hospital, wider hospital setting, community and social
care and should not be considered as a problem based entirely in
the ED. Nevertheless, the significance of these extrinsic factors
should not disempower EDs from improving their processes and
work patterns to assist patient flow.
The use of doctor triage, rapid assessment, streaming and the
co-location of a primary care clinician in the ED have all been
shown to improve patient flow. In addition, when used effectively
POCT has been shown to reduce delays in disposition decisions
being made and increase timely patient discharge rates with an
associated reduction in the overall total patient journey time. There
is an elevated cost when compared with laboratory testing on a
test for test basis.36 However, these increased costs may be out-
weighed by improvements in patient flow.44
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was re-
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