title: Patient flow in the emergency department: a classification and analysis of admission process policies.
abstract: OBJECTIVE
  We investigate the effect of admission process policies on patient flow in the emergency department (ED).
  
  
  METHODS
  We surveyed an advisory panel group to determine approaches to admission process policies and classified them as admission decision is made by the team of providers (attending physicians, residents, physician extenders) (type 1) or attending physicians (type 2) on the admitting service, team of providers (type 3), or attending physicians (type 4) in the ED. We developed discrete-event simulation models of patient flow to evaluate the potential effect of the 4 basic policy types and 2 hybrid types, referred to as triage attending physician consultation and remote collaborative consultation on key performance measures.
  
  
  RESULTS
  Compared with the current admission process policy (type 1), the alternatives were all effective in reducing the length of stay of admitted patients by 14% to 26%. In other words, patients may spend 1.4 to 2.5 hours fewer on average in the ED before being admitted to internal medicine under a new admission process policy. The improved flow of admitted patients decreased both the ED length of stay of discharged patients and the overall length of stay by up to 5% and 6.4%, respectively. These results are framed in context of teaching mission and physician experience.
  
  
  CONCLUSIONS
  An efficient admission process can reduce waiting times for both admitted and discharged ED patients. This study contributed to demonstrating the potential value of leveraging admission process policies and developing a framework for pursuing these policies.
authors.affiliation: Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA; Penn State Hershey Medical Center, and the Penn State University Center for Integrated Healthcare Delivery Systems, Pennsylvania State University, University Park, PA.
authors.forename: Hyojung
authors.initials: H
authors.lastname: Kang
authors.affiliation: Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA; Penn State Hershey Medical Center, and the Penn State University Center for Integrated Healthcare Delivery Systems, Pennsylvania State University, University Park, PA. Electronic address: hbn2@psu.edu.
authors.forename: Harriet Black
authors.initials: HB
authors.lastname: Nembhard
authors.affiliation: Department of Internal Medicine, Pennsylvania State University, University Park, PA; Penn State Hershey Medical Center, and the Penn State University Center for Integrated Healthcare Delivery Systems, Pennsylvania State University, University Park, PA.
authors.forename: Colleen
authors.initials: C
authors.lastname: Rafferty
authors.affiliation: Department of Emergency Medicine, Pennsylvania State University, University Park, PA; Penn State Hershey Medical Center, and the Penn State University Center for Integrated Healthcare Delivery Systems, Pennsylvania State University, University Park, PA.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: DeFlitch
mesh_terms: D000046:Academic Medical Centers / Q000458:organization & administration; D004635:Emergency Medicine / Q000458:organization & administration; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D007388:Internal Medicine / Q000458:organization & administration*; D007902:Length of Stay; D017146:Models, Organizational; D019982:Organizational Case Studies; D016134:Organizational Policy; D010343:Patient Admission; D010414:Pennsylvania; D014218:Triage; D057188:Workflow