title: Meeting the four-hour deadline in an A&E department.
abstract: OBJECTIVE
  Accident and emergency (A&E) departments experience a secondary peak in patient length of stay (LoS) at around four hours, caused by the coping strategies used to meet the operational standards imposed by government. The aim of this paper is to build a discrete-event simulation model that captures the coping strategies and more accurately reflects the processes that occur within an A&E department.
  
  
  METHODS
  A discrete-event simulation (DES) model was used to capture the A&E process at a UK hospital and record the LoS for each patient. Input data on 4,150 arrivals over three one-week periods and staffing levels was obtained from hospital records, while output data were compared with the corresponding records. Expert opinion was used to generate the pathways and model the decision-making processes.
  
  
  RESULTS
  The authors were able to replicate accurately the LoS distribution for the hospital. The model was then applied to a second configuration that had been trialled there; again, the results also reflected the experiences of the hospital.
  
  
  CONCLUSIONS
  This demonstrates that the coping strategies, such as re-prioritising patients based on current length of time in the department, employed in A&E departments have an impact on LoS of patients and therefore need to be considered when building predictive models if confidence in the results is to be justified.
  
  
  CONCLUSIONS
  As far as the authors are aware this is the first time that these coping strategies have been included within a simulation model, and therefore the first time that the peak around the four hours has been analysed so accurately using a model.
authors.affiliation: Department of Information Systems, Computing and Mathematics, Brunel University, Uxbridge, UK. Julie.Eatock@brunel.ac.uk
authors.forename: Julie
authors.initials: J
authors.lastname: Eatock
authors.forename: Malcolm
authors.initials: M
authors.lastname: Clarke
authors.forename: Claire
authors.initials: C
authors.lastname: Picton
authors.forename: Terry
authors.initials: T
authors.lastname: Young
mesh_terms: D001509:Bed Occupancy; D003198:Computer Simulation; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008131:London; D017146:Models, Organizational; D009874:Operations Research; D013222:State Medicine; D013996:Time and Motion Studies