Operations Research Forum (2022) 3: 2

https://doi.org/10.1007/s43069-021-00114-8

ORIGINAL RESEARCH

Queueing Problems in Emergency Departments: A Review

of Practical Approaches and Research Methodologies

Amir Elalouf1 · Guy Wachtel2

Received: 21 May 2020 / Accepted: 8 December 2021 / Published online: 30 December 2021
© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2021

Abstract
Problems related to patient scheduling and queueing in emergency departments
are gaining increasing attention in theory, in the fields of operations research and
emergency and healthcare services, and in practice. This paper aims to provide an
extensive review of studies addressing queueing-related problems explicitly related
to emergency departments. We have reviewed 229 articles and books spanning
seven decades and have sought to organize the information they contain in a manner
that is accessible and useful to researchers seeking to gain knowledge on specific
aspects of such problems. We begin by presenting a historical overview of applica-
tions of queueing theory to healthcare-related problems. We subsequently elaborate
on managerial approaches used to enhance efficiency in emergency departments.
These approaches include bed management, fast-track, dynamic resource allocation,
grouping/prioritization of patients, and triage approaches. Finally, we discuss sci-
entific methodologies used to analyze and optimize these approaches: algorithms,
priority models, queueing models, simulation, and statistical approaches.

Keywords Discrete-event simulation · Emergency department · Length of stay ·

Queueing · Literature review

1 Introduction

In recent decades, healthcare systems—and emergency departments (EDs) in

particular—have been facing a massive increase in demand, which has led to
a continuous need to improve and optimize operational processes and quality

* Amir Elalouf
[email protected]
Guy Wachtel
[email protected]
1
Department of Management, Bar-Ilan University, Ramat‑Gan, Israel
2
Department of Industrial Engineering and Management, Ariel University, Ariel, Israel

13
Vol.:(0123456789)
2 Page 2 of 46 Operations Research Forum (2022) 3: 2

control methods. Along with this trend, healthcare systems’ managers have begun
to encounter logistical and operational problems that previously did not present
a most noticeable concern. Many of these problems relate to the deployment of
resources and patient flow planning through hospital departments: How should we
schedule nurse and physician shifts to optimize their schedules and maximize the
quality of care that patients receive? How can we optimize the workflow of staff
members faced with large numbers of incoming patients? How should we direct the
patient flow in emergency and routine scenarios?
Queueing theory and models have the capacity to address questions such as these
in a systematic way, thereby providing managers with efficient solutions and tools
for maintaining and improving performance. In 2013, Lakshmi and Sivakumar [1]
produced a comprehensive literature review regarding the application of queueing
theory in healthcare. Yet, in recent years, there has been increasing focus on prob-
lems that are specific to the ED, along with an urgent need to solve them. In 2018,
Hu et al. [2] reviewed relevant articles published since 1970 to examine the contri-
butions of queueing theory (QT) in modeling EDs and assess the strengths and limi-
tations of this application: the ED is the first station that patients encounter when
entering the hospital system; therefore, it is characterized by high demand levels.
Every patient must get treatment and be assigned correctly to a specific department
(being hospitalized or not), as the ED professional staff also needs to deal with a
vast variety of medical conditions and injuries, high levels of uncertainty, and as
a result, high-stress levels. More recently, in 2020, Ortíz-Barrios and Alfaro-Saíz
[3] undertook a systematic review of methodological approaches to support process
improvement in EDs. They reviewed scholarly articles published between 1993 and
2019 and categorized the selected papers considering the leading ED problems.
In our present work, we aim to provide researchers and healthcare managers with
a clear summary of the current managerial approaches used for solving queueing-
related problems in EDs and the scientific methodologies used for investigating
these problems.
In Fig. 1, we show a diagram of the ED process flow and the relevant issues that
address it. The figure presents the patient flow through the healthcare system and

Fig. 1  ED’s process flow diagram and its relevant queueing theory aspects

13
Operations Research Forum (2022) 3: 2 Page 3 of 46 2

emphasizes the need for coordination between interacting departments. At each

phase of the process, we show the relevant corresponding queueing theory aspect.
The present paper conducts a systematic literature review to answer the primary
question of which theories and models can provide efficient solutions and tools to
maintain and improve ED performance. Answers to this question allow detecting
and classifying the scope and topics of the current state-of-the-art, gaps and limita-
tions, managerial implications, and future research directions.
Ultimately, our review is intended to serve as an efficient guide for navigating
through the extensive research literature in those diverse aspects that are related to
queueing applications in the EDs.

2 Methodology

The main purpose of the study was to answer the following research questions:
What are the applications of queueing theory to healthcare and especially to prob-
lems related to the EDs? What managerial approaches help improve the efficiency of
these EDs? What are the scientific methodologies used to analyze and optimize the
organizational methods? Since we aimed for relevant high-quality literature that fits
the above purposes and topics, we used a systematic method for collecting potential
literature. The papers were first retrieved by identifying search keywords and explor-
ing various electronic journal databases, such as Google Scholar, PubMed, Science
Direct, JSTOR, ProQuest, Emerald, Elsevier, SpringerLink, and Wiley. To ensure
that we collect as much data as possible, those databases were explored both using a
Python script and manually for applications of queueing problems, healthcare, oper-
ations research, simulations, and modeling. The main keywords and their frequency
of occurrence are presented in Fig. 2. The letters’ size and boldness illustrate their
dominance and occurrence in published papers. This gives the reader a wide look on
the queueing-related frequency of topics in the ED environment.
The search process yielded many references, including referred journal articles,
conference proceedings, dissertations, unpublished works, and books, which we sys-
tematically investigated for inclusion in the review. Relevant works were extracted
by carrying out a comprehensive search of various databases. Figure 3 emphasizes
the distribution and frequency throughout the years of published articles on ED
queueing problems that have been considered for this literature review.
As shown in Fig. 3, the number of studies has grown significantly as the
addressed fields are expanding greatly, mainly in the last decade, and there was a
need to perform a deep verification of the studies. Therefore, we checked each paper
or work manually and studied it to verify its quality and relevance to the literature
review and ignored works that did not meet the criteria. Eventually, we reviewed
229 peer-reviewed works, papers, and books from the last seven decades dealing
with queueing theory or related healthcare and operations research topics. We iden-
tified keywords corresponding to research methodologies such as discrete-event
simulation (DES), algorithms, queueing models, and priority models; keywords cor-
responding to ED operational concerns such as overcrowding, patient flow, length of
stay (LOS), and waiting time; and general keywords such as hospital and emergency

13
2 Page 4 of 46 Operations Research Forum (2022) 3: 2

Fig. 2  Illustration of key words frequency in the review

department. In selecting studies for inclusion in this review, we sought to cover both
the origins of research on ED queueing and state-of-the-art research and methods.
Hence, we read each study, arranged its data (authors, title, date, and keywords), and

Fig. 3  Frequency of published studies related to the field of queueing theory with emphasis to ED envi-
ronment

13
Operations Research Forum (2022) 3: 2 Page 5 of 46 2

summarized its contents into a Microsoft Excel 365 table. We subsequently grouped
the studies according to specific topics to organize the information in a straight-
forward manner that would enable researchers to access the specific information
they need. Papers were excluded based on their irrelevance to the study. We only
included articles that were written in English and focused on queueing methods. Our
study method was as follows: we performed a general literature survey including
all the leading publications and conference proceedings. The literature survey was
conducted by search using keywords that include words such as queueing, emer-
gency department, scheduling, discrete-event-simulation, length-of-stay, waiting
time, patients flow, hospitals, and more. The data were arranged in a final Microsoft
Excel 2016 table that includes the title, authors, journal, date of publication, num-
ber of citations, keywords (given by the authors of the papers or us), and a sum-
mary. A review of this initial survey was concluded to fill possible holes and make
it more comprehensive. In the last step, we searched for the relevant DOI (Digital
Object Identifier) assigned to each publication that will provide a continuous link to
its location on the web and allow its quick availability to the searcher. Since the DOI
link is assigned by the publisher only at the time of publication of the article, activa-
tion of each of the links has resulted in a final update of the data previously collected
in the electronic databases mentioned above.
This review is organized as follows: We first present a historical survey of early
research (1950s–1980s) on queueing-related problems in healthcare systems in gen-
eral and in EDs specifically. We then discuss methods used in practice to manage
patient flow and workflow in EDs and related to queueing theory. Next, we present
scientific methods applied to the investigation of queueing-related problems in EDs.

3 Early Applications of Queueing Theory in Research of Healthcare

Systems

Research related to queueing in healthcare systems dates back to the early 1950s,
beginning with the works by Bailey [4, 5] who examined queues and appointment
systems in hospital outpatient departments, focusing on patient waiting times as an
outcome of interest. Bailey was the first to simplify the patient flow problem into a
problem description that could be modeled using queueing theory and to use this
approach to evaluate appointment systems and emergency bed allocations. In 1952,
Welch and Bailey [6] carried out a study on appointment systems (an extension was
published by Welch in 1964, after his death [7]). They offered recommendations to
reduce patient waiting time while ensuring that medical staff’s time would not be
wasted. The researchers’ suggestions, which took into account the punctuality of
the patients and medical staff, included dividing appointment intervals into periods
equal to the average time spent on each patient and calling two patients to arrive at
the clinic’s opening time.
In 1969, Bell and Allen [8] used queueing theory to investigate emergency ambu-
lance service planning with a constraint to fulfill 95% or 99% of the demand. A 1969

13
2 Page 6 of 46 Operations Research Forum (2022) 3: 2

study by Taylor et al. [9] was the first to adopt a pure queueing theory approach
to examine emergency services. Specifically, the authors gathered 8 weeks of data
regarding emergency anesthetic services in a hospital in Northampton. They used a
queueing theory approach to make predictions regarding the outcomes (in terms of
patient waiting times) of various alternative scenarios (e.g., one versus two anesthe-
tists on-call). They highlighted the potential benefits of this prediction approach for
decision-making regarding the number of staff members on-call and the allocation
of duties among them.
In the 1970s, the foundations for most current research on queueing in health-
care systems began to be established. During this time, studies began to apply
queueing theory to diverse healthcare-related problems while considering patient
waiting time as the primary index for quality of care. For example, Haussmann
[10] modeled patient care processes in a burn unit and, in line with prior studies on
queueing in healthcare systems, used empirical data to define the model’s param-
eters. He used the model to predict how staffing or inpatient load changes would
affect the quality of nursing care (as measured by waiting time). Gupta et al. [11]
considered allocating workforce for messenger services in a hospital. Milliken et al.
[12] developed a queueing theory model to predict hospital delivery rooms’ utili-
zation. Keller and Laughhunn [13] proposed an application of queueing theory to
a congestion problem in an outpatient clinic, and Cooper and Corcoran [14] and
McClain [15] addressed bed planning models in hospitals. Larson [16] designed
efficient algorithms for facility location and redistricting in urban ambulance ser-
vices. Moore [17] used queueing theory to address a problem of dissatisfaction due
to waiting time for healthcare services in Dallas, TX, and Scott et al. [18] addressed
reducing the response time of ambulance systems.
Notably, preliminary simulation- and algorithm-based studies of ED queueing
were published during this period as well. In 1976, Collings and Stoneman [19] were
the first to present a general queue approach that can be applied in an ED environ-
ment. They studied the M/M/ ∞ queue with varying arrival and departure rates in
a hospital ICU (intensive care unit) and showed that their model is well-suited to
the ED environment, where it is important to meet nearly all demands immediately.
The authors showed that it is unlikely that the hourly variation in patient arrival rates
to the unit will significantly affect the number of occupied beds. In 1978, Ladany
and Turban [20] developed a pioneering simulation model for operational planning
and staffing of EDs, which they used to identify optimal numbers of service stations
and their staffing patterns under various conditions. The authors suggested that their
simulation framework could serve as a tool for planning, budgeting, decision-making,
and managerial control since it provided decision-makers with the capacity to make
predictions about costs, patient waiting times, and facility idleness.
By the 1980s, queueing theory had become a well-established approach to vari-
ous problems encountered in healthcare settings. Researchers and managers, such
as Kao and Tung [21] and Worthington [22, 23], began to build on this knowl-
edge to solve straightforward queueing problems (e.g., optimizing the number of
staff members allocated to a department, given data on the typical rate of incom-
ing patients), and devising new means of addressing queueing-related challenges

13
Operations Research Forum (2022) 3: 2 Page 7 of 46 2

in practice. In parallel, researchers began to develop increasingly sophisticated

methodologies to understand these challenges and identify means of improving
healthcare systems’ capacity to handle them. We address these developments in
what follows, with a specific focus on EDs.

4 Practical Approaches to Managing ED Queueing

As noted above, in recent decades, researchers and practitioners have developed

creative new methods to improve ED performance. In Fig. 4, we present the
distribution of such managerial studies over the years; we can observe a drastic
increase in the number of studies during the years which shows the interest and
importance of such studies. Extensive research has sought to provide guidance
on how such practices should be implemented and identify which infrastructure
changes ED managers might need to initiate in their departments. In what fol-
lows, we review these methods, addressing their history, development, and cur-
rent potential research opportunities. Mainly, we shed light on the following
techniques: triage approaches, bed management, dynamic resource allocation, the
grouping of patients and prioritization of specific groups, and fast-track.

Fig. 4  Frequency of published queueing-related studies on the managerial approaches applied to the ED
environment

13
2 Page 8 of 46 Operations Research Forum (2022) 3: 2

4.1 Triage Approaches

The word “triage” comes from the French word “trier,” which means “to sort.” The
medical usage of the term dates back to the 1800s when medical officers on the
battlefield realized that sorting wounded soldiers according to their medical needs
(unsalvageable; in need of immediate attention; less urgent) could improve the effi-
ciency of their treatment. The formal concept of triage was first introduced in EDs in
the late 1950s and early 1960s when a significant patient volume increase occurred.
During this time, triage was carried out by triage nurses, whose competence had to
be tested.
Brillman et al. [24] and Gilboy et al. [25] were among the first to point out the
problematic nature of this type of triage. Brillman et al. examined agreement among
observers regarding the need for ED care and the ability to predict at triage the need
for admission to the hospital. They used a crossover design in which each subject
was subjected to three types of triage: nurse-guided triage first, computer-guided
triage second (or vice versa), and physician triage last. The authors found signifi-
cant variability among physicians, nurses, and the computer program regarding tri-
age decisions. Gilboy et al. emphasized the need for standardization and quality to
ensure reliable, reproducible triage nurse decisions. Additional researchers began to
question the reliability of triage methods: Wuertz et al. [26] and Fernandes et al.
[27], for example, measured inter-rater and intra-rater agreement within existing ED
triage systems. Wuertz et al., who based their study on five standardized patient sce-
narios of complaints, concluded that triage assessments (both inter-rater and intra-
rater) by experienced personnel are inconsistent. These results challenged the reli-
ability of current ED triage practices. Fernandes et al. conducted an experimental
study using standardized patient scenarios with emergency triage nurses and attend-
ing emergency physicians. They found fair intra-rater agreement among the nurses
rating the severity of patient conditions and a consensus in inter-rater assessment
(between nurses and physicians) of triage classification.
In light of these concerns, subsequent studies sought to improve the triage pro-
cess using a combination of nurse and doctor triage, referred to as team triage.
Subash et al. [28] observed a scenario of 3 h of combined doctor and nurse triage
within 8 days. They found that this type of triage led to earlier medical assessment
compared with nurse triage and that the benefit would carry on for the rest of the
day, even after standard nurse triage had resumed. The authors concluded that the
implementation of team triage has the potential to improve ED efficiency substan-
tially. In 2006, Choi et al. [29] evaluated how stationing a senior ED doctor in tri-
age instead of a separate consultation room influenced the waiting time and pro-
cessing time of an ED without extra staff. The approach, called Triage Rapid Initial
Assessment by a doctor (TRIAD), was implemented in an ED for seven shifts of
9 h each. The authors found that TRIAD use substantially reduced the waiting time
and processing time of the ED. Two systematic literature reviews of triage-related
interventions were done by Wiler et al. [30] who dealt with triage strategies that
may improve front-end operations in EDs, and Oredsson et al. [31] who showed that
team triage is likely to result in a shorter waiting time and shorter LOS; furthermore,
it is most likely to result in fewer patients leaving without being seen, compared

13
Operations Research Forum (2022) 3: 2 Page 9 of 46 2

with triage processes that do not involve physicians. Burström et al. [32] compared
the performance of different triage models (physician-led team triage, nurse first/
emergency physician second, and nurse first/junior physician second) used in three
Swedish EDs. They observed that physician-led team triage seemed advantageous in
efficiency and quality indicators compared to the other two models. In a subsequent
study, Burström et al. [33] compared efficiency and quality measures before and
after the replacement of a nurse triage model in an ED with physician-led team tri-
age (implemented during the daytime and early evenings on weekdays). Physician-
led triage was shown to improve the efficiency and quality of EDs.
Additional recent studies concerning team triage methods include the work of
Traub et al. [34], who proposed that the mechanism by which team triage improves
ED throughput is that of Rapid Medical Assessment (RMA). Namely, a physician’s
presence enables patient medical needs to be assessed and processed more quickly.
The authors observed that implementing an RMA system in the ED of their insti-
tution (the Mayo Clinic) improved patient LOS but did not reduce the number of
patients left without being seen. Lauks et al. [35] introduced the concept of the Med-
ical Team Evaluation (MTE), encompassing team triage, quick registration, redesign
of triage rooms, and electronic medical records. The authors carried out an obser-
vational study investigating how the implementation of such a method affects door-
to-doctor (waiting) time and ED LOS. Notably, the authors observed an improve-
ment in LOS only among the least urgent patients. Jarvis [36] performed a literature
review to identify evidence-based strategies to reduce the amount of time spent by
patients in the ED. The author noted that 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.
Several studies based on queueing principles have sought to evaluate and com-
pare various triage approaches. Connelly and Bair [37], for example, showed that
DES could be used to assess the efficacy of triage operations and used the approach
to compare two triage methods. Ruohonen et al. [38] used a simulation model to
evaluate a team triage method (in their study, the triage team comprised a nurse and
a doctor, in addition to a receptionist). He et al. [39] also proposed a simulation
approach to examine different triage strategies.
Finally, several studies have examined specific characteristics of the triage pro-
cess to identify potential areas for improvement. Farrohknia et al. [40] evaluated the
reliability of several triage scales designed as decision support systems to guide the
triage nurse to a correct decision. Similarly, a study by Claudio et al. [41] evalu-
ated the ESI’s (Emergency Severity Index) usefulness as a clinical decision support
method for prioritizing triage patients, and more recently, Hinson et al. [42] checked
the influence of its accuracy on nurse triage. Olofsson et al. [43] investigated the
influence of staff behavior during triage on ED elderly patients’ feelings and satis-
faction. O’Connor et al. [44] evaluated the effect of ED crowding on triage destina-
tion and waiting times. In 2018, Gardner et al. [45] studied a revised triage approach
identifying eligible patients at triage based on complaint and illness severity and
reallocating a nurse practitioner (NP) into the triage area of an urban ED. This pro-
cess was shown to improve the ED throughput and reduce the number of patients
left without being seen.

13
2 Page 10 of 46 Operations Research Forum (2022) 3: 2

A more recent paper by Hodgson and Traub [46] deals with diverse variations of
patient assignment systems, including provider-in-triage/team triage, fast-tracks/ver-
tical pathways, and rotational patient assignment. The authors discussed the theory
behind such system variations and reviewed potential benefits of specific models of
patient assignment found in the current literature.
It results from the above review, and is shown in Fig. 5, that triage approaches
in healthcare and more specifically in the EDs have been studied and applicated
throughout the years, with a massive increase in the recent decade. This is due to the
technological improvements over those years, from both academic and managerial
points of view. As noted above, in the early years, the medical triage methods were
rather simple and even intuitive, and the breakthrough in that field occurred in the
1990s with studies regarding the usefulness of the triage methods and their reliabil-
ity. Since the first decade of the twenty-first century, additional methods could be
developed thanks to the increasing computation capacity and availability of data in
hospital systems. A large amount of information is continuously gathered into those
systems and is now available, not only to medical decision-makers but also for aca-
demic use. As online data are available, more than ever, to the triage staff, real-time
decisions are now made possible that considerably improve the ED triage process. It
is also expected that future technological developments will make this process more
and more effective and increase its importance in resolving queueing problems in
the EDs.

Fig. 5  Frequency of published queueing-related studies in the managerial field of triage in the ED envi-
ronment

13
Operations Research Forum (2022) 3: 2 Page 11 of 46 2

4.2 Bed Management

ED departments have always dealt with bed management problems, well before the
problem was formally defined. Broadly, bed management refers to the allocation
of beds to incoming patients in a manner that ensures that enough beds are avail-
able for emergency patients while not “wasting” bed space, i.e., leaving too many
beds empty for too long. Traditionally, bed management decisions have been the ED
staff’s responsibility (sometimes, but not always, formally referred to as bed manag-
ers): the shift manager, triage staff, or the nurses/physicians who received patients.
Until recently, these decisions were not necessarily made systematically but rather
were based on the decision-maker’s experience.
In 1994, Green and Armstrong [47] formally defined the problem of bed manage-
ment as “keeping a balance between flexibility for admitting emergency patients and
high bed occupancy” and outlined the bed manager’s responsibilities. Boaden et al.
[48] adopted a similar definition of the problem while emphasizing that a bed man-
ager’s decisions should take into account operational (immediate) considerations
and strategic factors that affect the flow of patients. They also identified several key
criteria that bed managers must fulfill to be effective in their roles: For example, the
bed manager should be able to deal with crisis scenarios and resource shortages. To
do so, the bed manager should have knowledge about the specific ED and its work
methods, as well as familiarity with the patients in it; he or she should be able to
exercise authority over the staff and patients and should possess the ability to obtain
relevant information and send data to other parts of the hospital if needed (for exam-
ple, information relating to occupancy in other departments).
Several field studies published in the 2000s have shown that effective bed manage-
ment can indeed improve ED efficiency. Proudlove et al. [49] claimed that efficient
bed management can play a key role in resolving overcrowding in EDs and acci-
dent departments. In their work, the authors provided a clear scheme of the patient’s
“journey” through the hospital and bed management’s role in that journey. In 2008,
a study by Howell et al. [50] empirically showed that “active” bed management —
in which a designated bed manager assesses bed availability in various departments
and “reshuffles” bed assignments according to the needs — can substantially reduce
patient waiting times. A study by Ben-Tovim et al. [51] showed that applying the
managerial approach of “lean thinking” to hospital processes such as bed manage-
ment enabled a hospital in Australia to cope with increasing demand. Notably, the
approaches adopted in these studies were not based on queueing theory principles but
rather on managerial expertise.
The study of bed management from a queueing theory perspective is still in rela-
tively early stages of development, suggesting that there is a great deal of room for
researchers to improve and optimize bed management procedures. The first stud-
ies in queueing theory that began to address bed management were published in
the 1980s and early 1990s. These included the papers by Kao and Tung [21] and
Worthington [23, 24] which referred to waiting lists for healthcare services, in which
patients effectively queued for available beds.
In 2001, Mackay [52] proposed quantitative models for bed occupancy man-
agement and planning (the bed occupancy management and planning system and

13
2 Page 12 of 46 Operations Research Forum (2022) 3: 2

Sorensen’s multi-phased bed modeling) and elaborated on his experiences applying

these models to healthcare systems in Australia. Mackay noted that these models
could provide healthcare planners and managers with important information about
patient flows and bed numbers suitable for different resource planning strategies.
However, they cannot yet replace the information obtained through the day-to-day
process of bed management. In 2002, Gorunescu et al. [53, 54] published two of the
best-known papers addressing queueing theory and bed management combined. In
the first paper [53], they used an M/PH/c queueing theory model to describe patient
movement through a hospital department and proposed an optimization approach to
improve the use of hospital resources. Their model was based on the premise of bal-
ancing the cost of empty beds against the cost of turning patients away. In their sec-
ond paper, Gorunescu et al. [54] checked how changing admission rates, LOS, and
bed allocation affects bed occupancy. They found that 10–15% of the beds should
stay empty to ensure high responsiveness and cost-effectiveness.
In the last 10 years, bed management studies using operation research and queue-
ing theory have gained momentum. In 2012, Hall [55] devoted a chapter of his
Handbook of Healthcare System Scheduling to an overview of bed management
from an operations research perspective. He defined the need for beds as a function
of the population’s health and age, technology (e.g., the capacity to serve patients in
an outpatient setting rather than to hospitalize them), efficiency and quality of serv-
ing patients, and, finally, efficiency in bed management (e.g., capacity to coordinate
and predict patient flow). The purpose of bed management, according to Hall, is
to reduce the time when beds are unoccupied and thus unproductive. He noted the
importance of acknowledging that not all beds are alike and provided a classification
of hospital beds according to their availability and purpose (adult/young care, surgi-
cal, etc.). Finally, he proposed a few indices for measuring the performance of bed
management processes: e.g., throughput per bed, waiting time for beds, and occu-
pancy level.
Recent operations-focused modeling studies of bed management include the work
of Mackay et al. [56], who built a simulation model aimed at facilitating collab-
orative decision-making in hospitals with regard to patient flow and bed manage-
ment. Tsai and Lin [57] proposed a multi-attribute-value theory application for bed
management using preference-based decision rules. Building on previous research
in queueing theory, they developed and solved a mathematical programming model
that used empirical data from EDs and took into account patient preferences. Their
simulations suggested that it is possible to significantly improve bed assignment
quality in the ED regarding resource utilization and patient satisfaction. Recently,
an interesting simulation study of bed allocation to reduce blocking probability in
EDs has been performed by Wu et al. [58] using a case study in China. They dem-
onstrated that the blocking probabilities can be significantly reduced under different
priority assignment cases and total number of beds.
Wargon et al. [59] proposed a queueing model and a DES approach to optimize
bed management in the ED, with the ultimate aim of reducing transfers from the
ED to other institutions. Like Mackay et al. [56], they suggested that simulation is
a powerful tool for bed management decision-making. Their model’s key benefit is
its simplicity, making it very flexible and easy for ED staff to adapt to their needs.

13
Operations Research Forum (2022) 3: 2 Page 13 of 46 2

In 2015, Belciug and Gorunescu [60] proposed a complex “What-if analysis” of

resource allocation by creating a framework that integrated (1) an M/PH/c/N queue-
ing system (N is the maximum capacity of patients in the ED); (2) a compartmen-
tal model; and (3) an evolution-based optimization approach. The efficiency of the
combination of queueing theory and evolutionary optimization was proven on the
task of optimizing patient management and healthcare costs. They illustrated their
model’s applicability using data from a geriatric department of a hospital in Lon-
don, UK. Most recently, Folake et al. [61] analyzed the use of queueing models in
healthcare with an emphasis on accident and emergency department (AED) of a city
hospital. They determined the optimal bed count and its performance measure for
improving the patient flow.
As noted above, and is shown in Fig. 6, bed management was already an
addressed issue, even before its formal definition in the 1990s and has undergone
a steady increase in interest since then. Since 1980 and also during the first decade
of the current millennium, its importance was shown by researchers to help with
the crowding, waiting times, and utilization of the hospital’s resources. At the same
time, a new stream of literature began to improve this important task: the queue-
ing models for bed managing. Using theoretical models of increasing complex-
ity, researchers were able to design various real-life case studies and to optimize
them analytically, by heuristics and simulations. Those models remain in place, but
as already available resources continuously experience wear and tear and new or
improved resources are brought into the hospitals, they can still be improved and

Fig. 6  Frequency of published queueing-related studies on bed management in the ED environment

13
2 Page 14 of 46 Operations Research Forum (2022) 3: 2

modified to suit real-life scenarios. This could be done, for example, by dividing the
various resources into servers and sub-servers, for various beds and armchairs etc.;
that in addition to applying those models to various and specific EDs with different
settings.

4.3 Dynamic Resource Allocation

About two decades ago, researchers and practitioners began to propose flexibility in
resources such as the number of beds (and the number of patients occupying them),
nurses, physicians, and even patients as a means of reducing crowding in hospital
departments. Baschung et al. [62], for example, described a concept of “floating
bed,” in which individual clinic departments only have the minimum of fixed beds
and the other beds are shared among the different departments in a flexible way. The
method was implemented successfully in a Swiss hospital; however, the authors did
not specify how it influenced ED processes. Notably, no further practical application
of the specific method was reported.
In 2005, Bard and Purnomo [63] designed a branch-and-price algorithmic
methodology for dynamic nurse scheduling based on fix shifts and floating nurses
according to the needs. The computational results showed that a daily adjustment
problem can be solved efficiently for up to 200 nurses. Another example of the
“floating nurses” method can be found in the study from 2012 by Wang et al. [64].
The authors constructed a simulation-based research at a large community hospi-
tal and showed, among other findings, that adding a floating nurse can substantially
improve the LOS in the ED, and it can lead to a 33% reduction in LOS, which is
substantial. Zlotnik et al. [65] used support vector regression and M5P trees to fore-
cast visits and to create dynamic nursing allocation. Their results showed that ED
visits can be potentially managed with dynamic nurse staff allocation, resulting in
improvements in both understaffing risk reduction and direct personnel cost savings.
The aim of a research by Bornemann-Shepherd et al. [66] was to improve safety, as
well as patient and staff satisfaction. They found a significant improvement of that
satisfaction when creating an inpatient unit within the ED in which floating nurses
from the hospitalization department work when the ED’s crowding demands that.
Another use of flexible resources can be found in the paper of Tan et al. [67] who
considered the dynamic allocation of physicians at the ED. They proposed an online
and historical data-driven approach and showed by simulation that their approach
allows the ED to better cope with the demands and service levels needed. In 2017,
Bakker and Tsui [68] proposed a dynamic allocation method of specialists for effi-
cient patient scheduling using a data-driven approach and a DES. The authors were
able to show that their method improves patient service quality as well as waiting
times without change in resource capacity. In a more classical aspect of resources,
Luscombe and Kozan [69] proposed a dynamic scheduling framework to provide
real-time support for managing resources in the ED. The authors used the settings
of parallel machine and flexible job shop environments to schedule beds and task
resources allocation in a dynamic way. The heuristic solution method was imple-
mented as a dynamic algorithm that receives information about patient arrivals and

13
Operations Research Forum (2022) 3: 2 Page 15 of 46 2

treatment tasks and incorporates the new data into an efficient resource allocation
schedule.
A novel definition of dynamic resource allocation was made in 2015 by Elalouf
and Wachtel [70], who studied the use of dynamic patient allocation for the ED and
patient benefits. In this article, the authors proposed an algorithmic approach for
optimizing the implementation of the so-called floating patient method and assessed
the approach using empiric observations. They showed that they could thus amelio-
rate the work rate and crowding balance between the ED and the other departments.
In subsequent work, Elalouf and Wachtel [71] incorporated the method into an algo-
rithm aimed at optimizing the scheduling of patient examinations, assuming a con-
straint on the maximal LOS allowed in the ED. In 2017, they analyzed a holistic
approach to the dynamic patient allocation method, considering crowding in the ED
and other hospital departments [72]. They also considered the extent to which infor-
mation has been made available about the patient’s condition in addition to other
factors such as its severity and the effect of crowding on treatment time. They sug-
gested that their tool can enhance decision-makers’ capacity to balance crowding in
the ED with crowding in other hospitalization departments.
In contrary to other fields, the dynamic resource allocation field is relatively a
new one in the EDs, as research in this area has gained momentum only in the last
decade. Although the field has not been studied in depth before and therefore no
research literature is available, the term “floating” applied to nurses and beds was
familiar and used in practice with respect to ED teams. The resources previously
considered were beds and nurses as they were available and flexible for allocation.
In the last decade, additional resources have been taken into account as the need for
limited budget solutions has arisen and the quantity and availability of online data
from hospital information systems are constantly increasing. Thanks to advances in
information availability, these resources can now be managed in the same way as in
other industries to improve the efficiency of the ED queuing system. As shown in
Fig. 7, the massive growth in the number of relevant publications involving dynamic
allocation in EDs began in the second decade of the present century with the men-
tioned increase in availability of data and the possibility to “float” physicians, spe-
cialists, and even patients themselves for the benefit of the system and patients.
Future research may address those new areas and look for the best strategies to
assign them.

4.4 Grouping of Patients and Prioritization of Specific Groups

The concept of grouping and prioritizing patients in the hospital is not a new one. It
entails giving shift managers/ED managers the ability to group patients with simi-
lar conditions together or prioritize specific treatments when resources are limited.
The most widely known patient classification system is the diagnosis-related groups
(DRG) system. This classification system was first introduced by McGuire [73] and
has undergone considerable modifications over the years. Sanderson and Mountney
[74] reviewed the concepts on which patient groups are based in order to identify
means of better adapting healthcare grouping designs to the needs of the population.

13
2 Page 16 of 46 Operations Research Forum (2022) 3: 2

Fig. 7  Frequency of published queueing-related studies on dynamic resource allocation in the ED envi-
ronment

They emphasized the potential of appropriate group design to facilitate data analy-
sis and, consequently, contribute to effective planning and management of health-
care resources. King et al. [75] applied lean thinking concepts to show the impact
of streaming on waiting times and total durations of stay in the ED. El-Darzi et al.
[76] proposed a novel grouping methodology based on the premise that identifying
groups of patients with common characteristics and detecting the workload associ-
ated with each group might help predict resource needs and improve resource uti-
lization. The methodology involved grouping patients according to their LOS, by
fitting Gaussian mixture models to empirical LOS observations. Gorunescu et al.
[77] further developed this method and used surgical data to assess the models they
proposed. Xu et al. [78] proposed a patient grouping method based on their required
medical procedures and compared several grouping techniques applied to real ED
data.
In recent years, a group at Pennsylvania State University has produced extensive
research on methodologies for prioritizing ED patients, though not with a queue-
ing-related focus. Claudio and Okudan [79], for example, used a hypothetical case
study to investigate the use of multi-attribute utility theory in the prioritization of
ED patients. Their method addressed cases where it is necessary to prioritize multi-
ple patients who present the same acuity level (implying that treatment prioritization
is not a straightforward task) but with different vital signs. Fields et al. [80] subse-
quently carried out a study that acknowledged the reality in which multiple decision-
makers (e.g., nurses and other staff members) disagree on the priority rankings of

13
Operations Research Forum (2022) 3: 2 Page 17 of 46 2

different patients, a problem called the rank aggregation problem. Ashour and
Okudan Kremer [81] developed an algorithm based on a management philosophy
called Group Technology (GT), which is grounded on the premise that knowledge
about groups leads to efficient problem-solving. The authors applied the algorithm to
triage analysis in an ED system. In a subsequent study [82], they extended this idea to
develop a Dynamic Grouping and Prioritization (DGP) algorithm that identifies the
appropriate criteria for grouping patients and prioritizes them according to patient-
and system-related information. This approach’s simulation demonstrated its superi-
ority to a baseline grouping and prioritization method (based on the ESI) in terms of
patient average LOS in the ED.
Recently, several grouping and prioritization methods have emerged that explic-
itly address queueing problems in the ED. Tan et al. [83] proposed using a dynamic-
priority queue to dispatch patients to consultations with doctors. They tested the
proposed model using a simulation and observed that it effectively reduced patient
LOS and improved patient flow. In 2019, Ding et al. [84] analyzed the patient rout-
ing behaviors of ED decision-makers in four EDs of metro Vancouver. They pro-
posed a general discrete choice framework, consistent with queueing literature, as
a tool to analyze prioritization behaviors in multi-class queues. They observed that
decision-makers in all four EDs applied a delay-dependent (dynamic) prioritization
approach across different triage levels. In the same year, Zhang et al. [85] proposed
a new patient queueing model with priority weight to optimize the ED management
and analyze the impact of prioritization on the outpatient queueing system in an ED
with limited medical resources.
Since it was first formally introduced, the concept of grouping patients changed
drastically. Although it is proven, and well known, that efficient implementation of
patient grouping can improve patient care and workload management in the ED,
the optimal way to apply the concept is still not found. Since the ESI was devel-
oped in 1999 by Gilboy et al. [25] who brought the idea of grouping to all EDs, the
grouping and prioritization methods have been addressed in studies whose number
has increased significantly in the recent years as shown in Fig. 8. Grouping criteria
evolved, since the initial one defined by the first use of the ESI, i.e., the character-
istics of patients such as symptoms and risk situation and now commonly involve
the required medical procedures. Other streams attacked the prioritization of patient
groups when using the entire hospital’s information systems and the real-life cases
that can arise from such use. From the perspective of queueing theory, this field is
still very open for improvement as it can be well combined with other managerial
methods with various definitions and models.

4.5 Fast‑Track

The fast-track method is one of the best-known and most commonly used meth-
ods for directing patient flow in EDs. In effect, this method’s premise is similar to
that of the grouping and prioritization approach discussed above. It entails treat-
ing acutely ill patients separately from minimally ill patients in the ED, such that
the latter can be seen and discharged rapidly. The fast-track method originated in

13
2 Page 18 of 46 Operations Research Forum (2022) 3: 2

Fig. 8  Frequency of published queueing-related studies in the managerial field of grouping and prioriti-
zation in the ED environment

the EDs themselves during the 1980s. Researchers in medicine and management
began to write about it in the late 1980s and 1990s; they studied its usefulness and
explored means of improving its implementation. Meislin et al. [86], for example,
tested a fast-track method for 10 weeks in a teaching hospital and showed that it
decreased patient waiting times (as compared with the previous system the hospital
had in place) and increased patient satisfaction. In 1992, Wright et al. [87] reviewed
a 1-year implementation of this method and reported high satisfaction levels among
patients and medical staff. Cardello [88] studied the introduction of nurse practi-
tioners to help reduce waiting time for ambulant nonurgent cases in fast-track pro-
gram. Fernandes et al. [89] applied a managerial approach called Continuous Qual-
ity Improvement (CQI) to improve fast-track care in a hospital ED; the authors
observed that the approach reduced patient LOS. They continued [90] to explore
the outcomes of their hospital’s fast-track approach; they observed that (1) reducing
patient LOS was associated with a decrease in the number of ED patients who left
without seeing a physician; and (2) many patients leaving the ED without being seen
had been classified as urgent (opposed to nonurgent) at presentation. Cooke et al.
[91] investigated the influence of the use of a fast-track on waiting times within acci-
dent and emergency (A&E) departments in the UK. They assessed that it decreases
the number of patients enduring long waits without delaying the care of those with a
more severe injury.
Subsequent field studies on the implementation of the fast-track method include the
work of Sanchez et al. [92], who studied the influence of the opening of a fast-track

13
Operations Research Forum (2022) 3: 2 Page 19 of 46 2

area in an ED in a US hospital. They concluded that the opening of the fast-track area
improved ED effectiveness, as measured by a decrease in waiting times and LOS, with-
out leading to deterioration in the quality of care provided, as measured by rates of
mortality and revisits. Darrab et al. [93] examined the use of a fast-track method in a
Canadian hospital; they showed that fast-tracking lower-acuity patients reduced overall
LOS and the left-without-being-seen rate without affecting higher-acuity patients in the
ED. A study by Nash et al. [94] evaluated the efficacy of a newly developed fast-track
area in a university-affiliated ED and concluded that patients did move more quickly
through the department after adding the fast-track unit. Combs et al. [95] evaluated the
outcomes of adopting a fast-track approach in an Australian hospital. They determined
that the fast-track reduced congestion in the ED waiting area and improved staff morale.
Considine et al. [96], who also studied a fast-track program in Australia, concluded that
the fast-track decreased LOS in the ED for non-admitted patients without compromis-
ing waiting times and LOS for other ED patients. Oredsson et al. [31], discussed above,
carried out a systematic review of studies on interventions aimed at improving flow
processes in EDs. They showed that introducing a fast-track for patients with less severe
symptoms consistently results in shorter waiting time, shorter LOS, and fewer patients
leaving without being seen.
Recent field studies evaluating adjustments to fast-track processes include a con-
trolled study by White et al. [97], who showed that a Lean-based reorganization
of fast-track process flow improved fast-track ED performance (in terms of LOS,
percent of patients discharged within 1 h, and room use), without adding expense.
Manno et al. [98] examined a fast-track system in which lower-acuity patients were
streamed to specialized care areas and determined that they were seen quickly
by specialists and safely discharged or admitted to the hospital without diverting
resources from patients with high-acuity illness or injury.
During the 1990s, owing to advancements in technology and processing power,
many researchers began to use simulation models (as will be discussed in detail
in the section dealing with scientific modeling) to evaluate and seek methods of
improving the implementation of the fast-track method. Kraitsik and Bossmeyer
[99], for example, developed a simulation to evaluate the establishment of a fast-
track lane adjacent to the main ED and a large-capacity lab to improve patient flow.
McGuire [100] carried out a simulation study for improving patient flow in the ED
of a specific hospital that implemented a fast-track system. Their simulations yielded
several recommendations, including adding an additional registration clerk during
peak hours, adding a holding area for waiting patients, extending the fast-track lane
hours, and using more senior physicians instead of residents in the fast-track area.
Garcia et al. [101] used a simulation approach to determine whether a specific hospi-
tal would benefit from implementing a fast-track method; they found that a fast-track
system using a minimal number of resources would indeed greatly reduce patient
waiting times. Kirtland et al. [102] examined 11 alternatives to improve patient flow
in an ED in Maryland and found that the use of a fast-track method, combined with
treating the patients at the same place in which they wait and using point-of-care
lab testing procedures, could substantially reduce the average patient’s LOS. In the
early 2000s, Sinreich and Marmor [103–105] developed simulation tools to assist
ED decision-makers; these tools divided patients into categories—one of them

13
2 Page 20 of 46 Operations Research Forum (2022) 3: 2

was a “fast-track” category—and used these categories to predict patient LOS (see
“Sect. 5.3” for additional details). Marmor et al. [106] also developed a methodol-
ogy for ED design to help the ED managers and used it to compare triage and fast-
track operational models in different hospitals. La and Jewkes [107] used DES to
model an ED’s fast-track system and determined an optimal fast-track strategy to
improve performance measures. They used real data to evaluate the effectiveness of
several fast-track strategies within a hospital ED and showed practical implications
for reducing patient wait times in EDs.
Additional queueing theory-based approaches to the analysis of fast-track appli-
cations include the works of Roche and Cochran in 2007 [108] and 2009 [109], who
developed a queueing network model to describe a scenario in which acute patients
are treated in specific areas of the ED and “fast-tracked” patients are flexible in
terms of where in the ED they can be treated. Their model can be used to derive
recommendations to increase ED utilization and minimize the number of “walk-
aways,” i.e., patients who leave without receiving treatment, with the help of opera-
tion research methods. Recently, Fitzgerald et al. [110] used a queue-based Monte
Carlo analysis to support decision-making for implementing an ED fast-track. They
expanded the simple queueing model with a DES that enabled them to calculate
waiting times. Their results indicated that implementing a fast-track can reduce
patient waiting times without increasing demand for nursing resources.
In conclusion, the fast-track is one of the most intuitive method for reducing the
average LOS in the ED, and therefore, it has been well studied during the years since
the late 1980s, as shown in Fig. 9, and proved to be very effective in terms of both
LOS and patient satisfaction. Two major streams of literature are strongly recogniz-
able for this method: one includes the field studies, which are most common as the
fast-track method is applied in many places around the world and with many set-
tings. The other stream is the simulation-based research that increased drastically
since the early years of the millennium, with the growing availability of data from
the hospital information systems. Although case studies with specific implementa-
tion are still used commonly, most of the current research in the field is based on
simulations whose effectiveness varies with the data availability of the specific hos-
pital or ED.

5 Scientific Modeling Methods

This section focuses on the diverse scientific modeling methods and approaches
used to investigate ED applications of queueing-related problems in operations
research. In 2010, Eitel et al. [111] described the ED as a service business and
then discussed specific methods, such as triage, bedside registration, Lean and
Six Sigma management methods, statistical forecasting, queueing systems,
discrete-event simulation modeling, and others, to improve the ED quality and
flow. In 2011, Wiler et al. [112] reviewed and compared modeling approaches
to describe, and at times predict, ED patient load and crowding and evaluated
their limitations. Saghafian et al. [113] reviewed many papers to demonstrate the

13
Operations Research Forum (2022) 3: 2 Page 21 of 46 2

Fig. 9  Frequency of published fast-track studies in the ED environment

contribution of operations research and management science to ED patient flow

problems. More recently, Palmer et al. [114] performed a systematic literature
review of operations research methods for modeling patient flow and outcomes
within community healthcare. Ahsan et al. [115] reviewed various analytical
models utilized to optimize ED resources for the improvement of patient flow
and highlighted the benefits and limitations of these models. A range of modeling
techniques including agent-based modeling and simulation, discrete-event simula-
tion, queueing models, simulation optimization, and mathematical modeling have
been reviewed in their work. In the present work, we built on Wiler et al. [110]
classification, presenting a similar one and expanding it to accommodate addi-
tional approaches and more recent research. The methods included in our work
are presented in the following order: queueing, priority and simulation models,
statistical methods, and additional algorithms and computational methods.
The total number of relevant articles reviewed in this section as function of
the year of publication is shown in Fig. 10. Its growth in recent years emphasizes
the interest and importance of further research and development of such mod-
eling methods. It is expected that the continuously growing technological devel-
opments and the increasing availability of data as previously mentioned in “4.1”
change the way that the EDs (and healthcare systems) work, and therefore can
change the models needed.

13
2 Page 22 of 46 Operations Research Forum (2022) 3: 2

Fig. 10  Frequency of published queueing-related studies on the scientific modeling methods used in the
ED environment

5.1 Queueing Models

Computational queueing models arise directly from general queueing theory. Lead-
ing textbooks on fundamentals of queueing theory and modeling that can contrib-
ute to general knowledge are those of Gross et al. [116] and Bhat [117]. According
to Green’s chapter (“Queueing Theory and Modeling”) [118] in the Handbook of
Healthcare Delivery Systems: “A queueing model is a mathematical description of
a queueing system which makes some specific assumptions about the probabilistic
nature of the arrival and service processes, the number and type of servers, and the
queue discipline and organization.” A basic queueing system is defined in the same
chapter as “a service system where ‘customers’ arrive at a bank of ‘servers’ and
require some service from one of them.” As noted in “Sect. 3” above, one of the
first prominent works to be published in this field was Keller and Laughhunn’s [13]
discussion of a queueing model addressing physician capacity in an outpatient clinic
and its influence on clinic efficiency. A good review of queueing models in the field
of healthcare may be found in the above chapter by Green [118]. Fomundam and
Herrmann [119] also reviewed queueing models in healthcare systems, focusing on
waiting time and utilization analysis, system design, and appointment systems.
Later on, Mehandiratta [120] attempted to analyze in his paper the theory and
instances of use of queueing theory in healthcare organizations around the world and
the benefits acquired from the same. Palvannan and Teow [121] applied queueing

13
Operations Research Forum (2022) 3: 2 Page 23 of 46 2

theory to healthcare, using queueing models in two hospitals to estimate and analyze
service capacity. Some additional papers, such as that of Bain et al. [122] and more
recent ones by Cho et al. [123], Bittencourt et al. [124], and Lin et al. [125], deal
with the application of queueing theory and modeling to healthcare in general.
This area has been continually studied over the years since the 1990s, although
it has received much attention during the last 2 decades, as shown in Fig. 11. Even
before that, there were works referring to queueing models specifically in the ED envi-
ronment. One of the first works in this area was presented by Collings and Stoneman
[19]. They derived an M/M/∞ queue with varying arrival and departure rates to
study the influence of patient arrival rates on bed occupancy levels. However, the
most significant works involving ED queueing models began to appear around the
beginning of the twenty-first century. Gorunescu et al. [53, 54], for example, used
a queueing approach to model bed occupancy in EDs as well as in other hospital
departments. In 2004, McManus et al. [126] constructed a queueing theory-based
model for resource allocation in various hospital activities, including EDs, and vali-
dated it in an intensive care unit. Green et al. [127] evaluated the effectiveness of a
queueing model in identifying ED staffing patterns to reduce the fraction of patients
who leave the ED without being seen. De Bruin et al. [128] used a queueing model
to analyze congestion in the flow of emergency cardiac patients and to allocate num-
bers of beds, given a required service level (operationalized as percentage of refused
admissions). Creemers et al. [129] showed how queueing models could quantify the

Fig. 11  Frequency of published studies on computational queueing models arising directly from general
queueing theory, with emphasis to the ED environment

13
2 Page 24 of 46 Operations Research Forum (2022) 3: 2

relationship between capacity utilization, waiting time, and patient service, thus ena-
bling decision-makers to improve the performance of healthcare systems, including
that of EDs. Mayhew and Smith [130] used a queueing model to analyze patient
flow in accident and emergency departments to evaluate government-imposed tar-
gets’ feasibility for treatment completion times. Laskowski et al. [131] utilized both
agent-based and queueing models to investigate patient access and patient flow
through EDs towards identifying means of reducing waiting times. Further examples
of application of queueing models to ED systems and their improvement in the first
decade of the twenty-first century may also be found in the publications of Morton
and Bevan [132], Au et al. [133], and Tseytlin [134].
More recently, Tan et al. [83] presented a hospital ED case where the queueing
process can be modeled using a time-varying M/M/s queue with re-entrant patients,
and tested this model using simulation. Hagen et al. [135] dealt more specifically
with priority queueing models applied to ICUs and EDs; these specific models
deserve special attention and will be referred to in a separate section. Wiler et al.
[136] derived an ED patient flow model based on queueing theory that predicts the
effects of various patient crowding scenarios on the number of patients who leave
the ED without being seen. Yom-Tov and Mandelbaum [137] analyzed — in a paper
based also on a previous work by Yom-Tov from 2010 [138] — a queueing model
called Erlang-R that helps answer questions such as how many servers (physicians/
nurses) are required to achieve predetermined service levels. Batt and Terwiesch
[139] reviewed a number of queueing models and focused on the so-called Erlang-
A model when studying queue abandonment from an ED. Vass and Szabo [140]
applied M/M/3 queueing model to ED patient data collected over 1 year to evalu-
ate the ED’s performance. Additional publications of interest by Alavi-Moghaddam
et al. [141], Cantero and Redondo [142], Mohseni [143], and Huang et al. [144]
deal to some extent with potential contribution of queueing theory and models to the
improvement of that performance and will not be expanded here.
Rotich [145] used M/M/s queueing model to determine the optimum waiting and
service cost in a hospital ICU emergency service. Xu and Chan [146] used queue-
ing models which accurately predict the number of patient arrivals to the ED for the
purpose of reducing waiting times in the ED via diversion and analyzed the qual-
ity of those models. Jáuregui et al. [147] analyzed the emergency service of a pub-
lic hospital in Mexico by applying the concepts and relations of queueing theory.
They evaluated the minimum number of doctors necessary to satisfy the current and
future emergency service demands for different scenarios and added recommen-
dations to the managerial staff. Recently, Hu et al. [2] evaluated the contributions
of queueing theory in modeling EDs and assessed the strengths and limitations of
this application. They concluded that queueing models tend to oversimplify opera-
tions but that combining these models with simulations (as further discussed in the
specific subsection on simulation modeling) should be a powerful approach. Joseph
[148] reviewed and analyzed the use and benefits of the application of queueing the-
ory and modeling to ED resources and operations in general.
Additional noteworthy queueing models include priority queueing models such
as those of Siddharthan et al. [149] and more recent ones in the 2000s; they will be
discussed separately in the following subsection.

13
Operations Research Forum (2022) 3: 2 Page 25 of 46 2

5.2 Priority Models

Priority models (sometimes called priority queueing models) are a family of queue-
ing models developed to be goal-oriented and deserve special mention. Here we
address a field of models that uses pure queueing theory models and definitions and
is different from the grouping and prioritization field that arose in parallel. As such,
this field is rather new in the ED environment as shown in Fig. 12.
Green [150] referred to the triage system in an ED as a classic example of a pri-
ority queue. In their review of methodologies for modeling ED patient flow (dis-
cussed above), Wiler et al. [110] suggested that models based on priority principles
are appropriate for ED settings, where acuity, in addition to the time of presenta-
tion, determines the order in which patients are serviced (i.e., the sickest patients
are prioritized over less-acute patients). Already in 1996, Siddharthan et al. [149]
classified patients into emergency and non-emergency care and provided evidence
that non‐emergency patients contribute to lengthy delays in the ED for all classes of
patients. They proposed a priority queueing model to reduce average waiting times.
Two additional works of Au-Yeung et al. are of interest: In the first one dated 2006
[151], they used a simulation modeling to provide some insights into the effects of
prioritizing different classes of patients in a real accident and emergency unit based
in London, UK. In the second one from 2007 [152], they developed an Approxi-
mate Generating Function Analysis (AGFA) technique, experimenting it with differ-
ent patient-handling priority schemes and comparing the AGFA moments with the
results from a discrete-event simulation.

Fig. 12  Frequency of published priority models studies in the ED environment

13
2 Page 26 of 46 Operations Research Forum (2022) 3: 2

Additional examples of studies using priority queueing models include the work
of Laskowski et al. [131], who developed a framework of multiple-priority queue
systems as a means of forecasting patient waiting times. Tan et al. [83] developed
a dynamic-priority queue model in which the priority levels are assigned to queue-
ing patients in the ED shift with staff availability. The authors modeled the queue-
ing process using a time-varying M/M/s queue with re-entrant patients and tested it
using simulation. Hagen et al. [135] used a priority queueing model to analyze the
differences between prioritizing admissions by expected LOS or patient severity. An
interesting conclusion of this work was that prioritizing patients by severity not only
considerably reduced delays for critical cases but also increased the average waiting
time for all patients. Lin et al. [153] developed a priority queueing model to describe
the flow and waiting times of patients waiting for ED service and subsequently for
hospitalization in an inpatient unit. The model assumed that emergency patients are
characterized by different priority levels and incorporated priority-specific waiting
time targets.
More recently, a paper by De Boeck et al. [154] dealt with confronting the phy-
sicians with the challenging task of prioritizing between boarding patients and
patients currently under treatment in the ED. Their case study showed that system
performance is optimized by applying a policy that gives priority to patients cur-
rently under treatment in the ED. In 2020, Hou and Zhao [155] presented a prac-
tical approach to estimate the waiting times for multi-class patients and applied it
to reduce the waiting time for high priority patients. Using a case study from an
ED, they found that the proposed approach can efficiently prioritize patient flows in
decreasing waiting times.

5.3 Simulation Models

Simulation is a very popular approach for describing complex processes and the ED
environment as such is not different. As visible in Fig. 13, this area has been well
studied since the 1990s with massive growth in the 2000s due to the availability of
data and computational power. We see on the figure a peak in the occurrence of such
studies at the end of the first decade of the present century. It can be explained by the
fact that their use has been very effective since then, thus reducing to some extent
the demand for further theoretical research. A vast number of ED studies using com-
puter simulations have been published over the years; thus, we will review in detail
only the most important ones.
Ladany and Turban [20] were among the first to use a queueing simulation model
to provide a framework for the planning and staffing of an ED. They emphasized
the benefits of a simulation approach as a means for ED managers to obtain infor-
mation about costs, waiting times of patients, and idleness of facilities. Saunders
et al. [156] used simulation software to develop a computer simulation model of ED
operations. The authors varied selected input data systematically to determine the
effects of various (simulated) factors on patient throughput time, queue sizes, and
resource utilization rates. Lopez-Valcarcel and Perez [157] claimed that simulation
is an effective tool for the analysis of the complex problem of scheduling in the ED

13
Operations Research Forum (2022) 3: 2 Page 27 of 46 2

Fig. 13  Frequency of published simulation-based studies in the ED environment

and that the result can be used to improve its quality care and efficiency. In the same
year, McGuire [100] also used simulation software to identify means of reducing
patient LOS in EDs. Nearly a decade later, Samaha et al. [158] published a similar
model based on empirical data that proved to be very helpful in the ED of their
hospital. Ruohonen et al. [38] used a simulation approach — that was previously
discussed in “Sect. 4.1” — to demonstrate the capacity of a team triage method to
improve ED operations.
The increasing availability of powerful computers has led to the development and
extensive use of DES, a computerized simulation approach in which discontinuous
systems are modeled as networks of interdependent discrete events. DES has proven
to be effective for representing queueing systems in general and ED systems in par-
ticular and has become a preferred simulation method over the years. Indeed, a lit-
erature review by Günal and Pidd [159] noted that the number of studies of DES
applications to EDs has increased since the beginning of the twenty-first century.
Jun et al. [160] reviewed applications of DES modeling to healthcare clinics and
systems (including EDs), primarily in areas of patient flow and resource alloca-
tion. Connelly and Bair [37] explored the potential of DES methods as a tool for
analyzing ED operations and illustrated its potential by comparing the efficacy of
two alternative triage methods (as discussed above in “Sect. 4.1”). Komashie and
Mousavi [161] also developed a DES approach to model the operations of an ED.
They used their model to provide ED managers of a London hospital with new
insights and system improvement recommendations. Duguay and Fatah [162] used

13
2 Page 28 of 46 Operations Research Forum (2022) 3: 2

Arena software to carry out a DES study of a Canadian ED in order to derive rec-
ommendations to reduce patient waiting times and improve overall service delivery
and system throughput. Hoot et al. [163] drew from theoretical studies to develop a
DES of patient flow and used it to forecast overcrowding occurrences in an ED in
real-time; they subsequently used observational data to validate the model’s fore-
casts [164]. Bair et al. [165] used a DES model of ED patient flow to investigate the
effect of inpatient boarding on ED efficiency in terms of the US National Emergency
Department Crowding Scale (NEDOCS) score and the rate of patients who leave
without being seen. The results of their analysis helped to quantify the impact of
patient boarding on ED crowding. Further papers that use DES modeling for solv-
ing queueing issues in EDs have been published in the same years, among them
we notice those of Brailsford and Hilton [166], Davies [167], Kolker [168], Khare
et al. [169], and Fletcher and Worthington [170]. Between 2009 and 2011, we also
identify the works of Marmor et al. [171], Tseytlin [133], Marmor [172], and Zeltyn
et al. [173], who belong to a common research group that specializes in the develop-
ment of DES modeling techniques and their application to decision support for ED
issues like staffing.
Lim et al. [174] used DES analysis to model interactions between physicians and
“delegates” they supervise (such as residents, nurse practitioners, and assistants).
They compared their model with a simulation model that did not incorporate such
interactions and showed that the formerly produced recommendations yielding
substantially better outcomes (e.g., in terms of patient LOS) than the latter did. In
the same year, La et al. [107] used DES to model an ED’s “fast-track” system to
derive recommendations for improving performance measures. Hurwitz et al. [175]
developed an event-driven flexible simulation platform to quantify and manage ED
crowding. In a further work [176], they demonstrated the ability of such a simulation
model to recreate and predict site-specific patient flow in two very different EDs. El-
Rifai et al. [177] focused on human resources organization in an ED and developed
a stochastic optimization model for shift scheduling in it. Then they evaluated the
resulting personnel schedules using a DES model and performed numerical analyses
with data from a French hospital to compare different personnel scheduling strate-
gies. Ahalt et al. [178] used DES to address ED crowding problems when the identi-
fied need for emergency services exceeds available resources for patient care in the
ED, hospital, or both. Using data from a large academic hospital, they evaluated and
compared three metrics commonly used in practice as future crowding indicators.
More recently, Gulhane [179] presented a study that aimed to manage queues in hos-
pital using DES simulation. He concluded that issues in hospital were well resolved
through that simulation and modifications in queueing have been done. Castanheira-
Pinto et al. [180] presented a methodology to assist the design process of an ED
using a DES simulation technique. The ED of a hospital in Portugal was considered
for testing that technique. The methodology proved to be very useful in determining
an optimized operation for complex and non-linear systems.
Although DES has proven to be a beneficial simulation approach for ED contexts,
several additional simulation approaches have been used successfully in these settings
and warrant a mention here. Some of these are discussed in the work of Mohiuddin
et al. [181], who undertook a systematic review to investigate the different computer

13
Operations Research Forum (2022) 3: 2 Page 29 of 46 2

simulation methods and their contribution to the analysis of patient flow within EDs
in the UK. One of these approaches is the system dynamics approach (SD), which
is used to understand complex healthcare systems’ behavior over time by capturing
aggregate (instead of individual) patient flows. Brailsford et al. [182], for example,
applied a system dynamics simulation to an extensive complex ED distribution sys-
tem in the UK city of Nottingham and used it to identify potential bottlenecks and
points that might benefit from intervention. Thorwarth et al. [183] used a simulation
model within structured modeling methods, to investigate flexible workload manage-
ment for an ED environment. They applied the results to derive a generalized analytic
expression describing settings that lead to an instable queueing system and affected
service quality; they provided thus the decision-makers with a tool which allows
identifying and preventing such conditions.
In 2010, Van Sambeek et al. [184] carried out a literature review of decision-
making models according to healthcare problems and showed that 46% of the stud-
ies used computer simulation. Paul et al. [185] performed a systematic review of
ED simulation literature from 1970 to 2006 to highlight these simulation studies’
contributions to their understanding of ED overcrowding and to discuss how simu-
lation can be better used as a tool to address this problem. Their review did not
include a more recent simulation technique — the so-called agent-based simulation
(ABS) approach, commonly used to model complex systems composed of interact-
ing, autonomous “agents.” Laskowski and Mukhi [186] used this approach to sim-
ulate the performance of a stand-alone ED and multiple interacting EDs through-
out a Canadian city. Jones and Evans [187] used an agent-based approach to model
the influence of ED physician scheduling on patient waiting times. Liu et al. [188]
identified ABS modeling as an excellent tool to deal with complex system like an
ED and introduced such a generalized computational model for simulating ED per-
formance. More recently, Yousefi and Ferreira [189] presented a pure agent-based
simulation combined with a group decision-making technique to improve the perfor-
mance of an ED.
Additional simulation studies in ED queueing use multiple simulation methods
or simulations combined with a simple queueing model. The recent review by Hu
et al. [2] provides a detailed discussion of such combinations and their advantages.
To avoid model complexity and requirement of large amount of data collection,
Ceglowski et al. [190] described a unique approach of simulation by combining
data mining with discrete-event simulation and could thus provide insight into
the complex relationship between patient urgency, treatment and disposal, and
the occurrence of queues for treatment in the ED. Saghafian et al. [191] separated
patients (and resources) into different streams and used various analytic and simu-
lation models to determine that this streaming policy will improve ED performance
in some situations. Uriarte et al. [192] used a combination of DES with multi-
objective optimization to help decision-makers reduce ED patient LOS and waiting
times. Fitzgerald et al. [110] supplemented DES with a queue-based simulation to
demonstrate the impact of implementing a fast-track method in an ED on patient
waiting times and service quality.
Finally, a new literature review of simulation modeling applied to EDs by Salmon
et al. [193] covering all English language papers from the year 2000 expanded

13
2 Page 30 of 46 Operations Research Forum (2022) 3: 2

previous reviews on simulation models in EDs such as the systematic review by Paul
et al. [185]. They showed that most of the works are academic, based essentially on
DES, and focused on capacity, process, and workforce issues at an operational level.

5.4 Statistical Methods (Regression Analysis and Forecasting)

Statistical methods can provide robust mathematical tools for forecasting crowding
in EDs. As such, and in a similar way to other fields that address the ED environ-
ment, we can observe a big and increasing interest in this field in the present cen-
tury, as shown in Fig. 14. As noted in a review by Wargon et al. [194], two of the
most commonly used mathematical approaches for predicting patient attendance at
EDs or walk-in clinics are regression analysis and time series analysis. (The authors
noted that these models tend to achieve good performance, with errors ranging from
4.2 to 14.4%.) Regression and time series analyses applied to ED issues are dis-
cussed comprehensively in the paper of Wiler et al. [112]. A thorough description of
regression techniques to be used in EDs can be found in that of Jones et al. [195] and
will not be expanded here.
Notable examples of applications of these methods to ED settings are included
in the works of Krochmal and Ryley [196], who analyzed the increase in LOS and
its resultant costs in a given ED using a two-tailed t-test regression method, and
of Forster et al. [197], who used a time series method to investigate the effect of

Fig. 14  Frequency of published statistical models studies in the ED environment

13
Operations Research Forum (2022) 3: 2 Page 31 of 46 2

hospital occupancy on ED LOS and patient disposition. Asaro et al. [198] applied
regression methods to data from a large urban academic hospital to analyze the fac-
tors influencing ED patients’ likelihood of leaving the ED without being seen. In
2008, McCarthy et al. [199] evaluated the appropriateness of prediction models by
whether the data met key Poisson regression assumptions, for predicting demand for
ED services in an academic hospital. They found that the demand at that facility
was well approximated by a Poisson regression model. Jones et al. [200] presented
a multivariate time series approach to modeling and forecasting demand in the ED.
They concluded that this approach provides an adequate ED census forecast but is
insufficient for predicting and managing ED resource availability. Schweigler et al.
[201] investigated whether models using time series methods can generate accurate
short-term forecasts of ED bed occupancy. Two of the models the authors exam-
ined were found to robustly forecast ED bed occupancy 4 and 12 h in advance at
three different EDs. Further applications of those statistical methods to ED issues in
the first decade of the twenty-first century may be found in papers by Steindel and
Howanitz [202], Liew et al. [203], Rogers et al. [204], and Jones et al. [205]. Jones
and Olsen [206], Oskaynak and Brennan [207], and Mandelbaum et al. [208] also
published papers that apply methods of statistical data analysis to queueing and LOS
studies in diverse EDs. Cote et al. [209] created a tutorial for ED medical directors
in which they applied regression-based forecasting models to data obtained from a
large teaching hospital’s ED; the versatility of the regression analysis was shown to
accommodate a variety of forecasting situations readily. Shanmugam [210] demon-
strated by an analysis and interpretation of real data from a hospital ED in Malta that
queueing concepts and tools using probabilistic- and statistical-based approach help
to efficiently manage the ED in the presence of impatient waiting patients. Afilal
et al. [211] proposed a new approach to classifying ED patients in addition to time
series-based models to forecast long- and short-term daily census in a city hospital
in France. These models showed outstanding performance in terms of their capacity
to predict the annual total flow of ED patients (accuracy of up to 91.24%) and their
robustness to epidemic periods. Whitt and Zhang [212] developed an aggregate sto-
chastic model of an ED based on a careful study of data on individual patient arrival
times and length of stay in a specific hospital. In 2019, Das et al. [213] proposed a
functional regression model based on customer arrival and departure time instances
from an in-control ED system in a major academic hospital, and validated it using
simulation and real data case studies. In 2020, Wachtel and Elalouf [214] proposed
an algorithm based on a statistical analysis that considered combination of data from
the hospital’s information systems and field observations to identify known and new
influential factors on LOS and crowding at the ED and to treat them.

5.5 Additional Algorithms and Computational Methods

According to Wiler et al. [112], implementation of complex mathematical mod-

els aims to forecast or optimize various ED outcomes. Larson [13] was one of the
first to develop a computationally efficient algorithm to analyze queueing problems
related to emergency healthcare services; his model was designed for vehicle location

13
2 Page 32 of 46 Operations Research Forum (2022) 3: 2

and response district design problems. Panayiotopoulos and Vassilacopoulos [215]

approached sophisticated operational problems related to a hospital ED using a gen-
eral simulation algorithm that could be implemented on a small computer. However,
algorithmic methods acquired strong momentum only at the beginning of the present
century with the increasing use of large computers in healthcare systems, as shown in
Fig. 15.
Topaloglu [216] presented a multi-objective goal programming model for sched-
uling work hours for emergency medicine residents. The model was tested in the ED
of a prominent local university hospital and allowed good quality scheduling at rea-
sonable times. Yeh and Lin [217] used a genetic algorithm coupled with simulation
techniques to derive a nurse schedule that optimized the quality of service at a hospital
ED. El-Darzi et al. [76] and Gorunescu et al. [77] applied various clustering algorithms
to evaluate LOS-based methods of grouping and prioritizing patients (see discussion
in “Sect. 4.4 ,” above). Wang et al. [218] utilized the expectation–maximization (EM)
algorithm for modeling the throughput of EDs via available time series data. Real-world
data from an ED in London helped to demonstrate the effectiveness of the introduced
algorithm. Lin et al. [153] used two numerical algorithms to estimate patient waiting
time in the ED.
Elalouf and Wachtel [70, 71] developed fully polynomial-time approximation
scheme (FPTAS) algorithms to assist ED decision-makers in optimally scheduling
evaluations for waiting patients. The authors used these algorithms in combination

Fig. 15  Frequency of published algorithmic-based models studies in the ED environment

13
Operations Research Forum (2022) 3: 2 Page 33 of 46 2

with the “floating patients” method discussed above and evaluated their efficacy in
simulations with real-life data [71, 72]. Memari et al. [219] used genetic algorithms
to optimize service allocations and patient flow in EDs. Ashour et al. (2016) [82]
developed a dynamic algorithm that optimizes patient classification and prioritiza-
tion to minimize patient LOS. Luscombe and Kozan [69] also used a dynamic algo-
rithm to provide real-time support for managing resources in the ED. Their algo-
rithm was tested against several test instances based on data from a real ED and
achieved solutions within 5% of the optimal. Allihaibi et al. [220] developed a novel
blocking patient flow (BPF) heuristic algorithm for predicting waiting times in the
ED. Kuo et al. [221] applied machine learning algorithms for real-time and person-
alized waiting time prediction in EDs. At last, a most recent study by Pak et al. [222]
uses such machine learning (ML) algorithms to optimize waiting times and signifi-
cantly improve their forecasting. We are aware that this domain is a very promising
one and therefore a serious candidate for intensive future research.
Finally, some researchers have experimented with alternative scientific approaches
to solving ED queueing problems which have not yet been widely adopted. Examples
include a game theory approach (Nash equilibrium) introduced by Hamilton et al.
[223] to characterize ED overcrowding as an equilibrium state, optimal control meth-
ods described by Chockalingam et al. [224] for solving resource allocation problems,
and additional studies by Do and Shunko [225] and Wang et al. [226]. A review of
ED computational methods that are “not classified elsewhere” can be found in the
work of Armony et al. [227]. Chaou et al. [228] and Li et al. [229] also used such
interesting approaches in EDs systems analysis.

6 Conclusion

This study constitutes a systematic review of literature related to queueing-related

problems in ED (and other healthcare) settings. We have sought to provide an over-
view of practical approaches used by ED decision-makers to manage patient flow, in
addition to an in-depth discussion of the scientific methodologies used to study and
improve ED operations. The increasing number of studies addressing the ED queues
makes it beneficial and crucial to combine state-of-the-art queueing theory methods
with managerial methods that are already applicable in practice.
Our primary goal was to provide researchers with an accessible and well-organized
tool for extracting information on specific topics of interest, and our efforts concen-
trated throughout this work on its achievement. We reviewed 229 articles and books,
from 1952 to 2021, all addressing queueing theory models and managerial methods
applicable in the ED. As a result, we have been exposed to the fact that the number of
studies has increased significantly as the addressed fields are expanding greatly, espe-
cially in the last decade. Our paper categorizes ED crowding into two parts: queue-
ing theory and managerial techniques. This approach allows researchers from both
aspects to find the most relevant models for their interests easily. As explained above,
finding the proper model for a specific scenario is crucial for applying it in real life.
This categorization can also help researchers that are new to queueing theory in EDs
to get a good insight into the historical and more recent developments of this area.

13
2 Page 34 of 46 Operations Research Forum (2022) 3: 2

As for the managerial point of view, we aimed that the methodology and detailed
literature review will improve the availability of needed queuing concepts and tools
to decision-makers who continuously face queueing issues in EDs. We hope also
that the use of the present paper will help them to make their work more efficient
and to achieve better performance in their systems.
It is a challenging task to introduce changes in an ongoing system without hav-
ing a significant, and eventually bad, influence on the system and the patients.
Using queueing theory models as a tool helps ED decision-makers to observe
solutions and changes before their application becomes mandatory. It is even
more important to combine the managerial method with the corresponding queue-
ing model and ensure that this model fits the real-life settings. The present review
aims to be an efficient tool for queueing theory scientists and healthcare managers
to help them achieve the best fit between the managerial method and the scientific
model.
Furthermore, some specified methods are still evolving and advancing, and the
amount of data is growing continuously. Hence upcoming works that are still needed
to reduce the remaining gaps between the current study and the ED needs can rely
on newer approaches. Modern optimization methods such as machine learning ones
have shown to be promising and we feel they justify future research. New manage-
rial approaches like “floating” physicians, specialists, and patients are also promis-
ing and have the potential for further deliberations.
Although the present literature review examined an abundance of papers and iden-
tified multiple queueing methods for improving performance in the EDs, it could not
fully address the whole scope of the domain. For example, key modeling methodolo-
gies that analyze and predict ED patient load and crowding, such as formula-based
equations and other mathematical models, are expected to improve significantly in
further studies. Future research should focus on those effective models and tech-
niques that still require more development or are absent from this research.
Also, any future research from the managerial or the mathematical side should
address the real life, changing environments of EDs in recent years. Until two dec-
ades ago, most studies aimed to evaluate and describe the managerial methods.
With the technological developments since the early 2000s and the increasing avail-
ability of data and methods to analyze them, researchers are now able to evaluate
mathematical and managerial models accurately and efficiently with greater ease.
Technological advances in recent years seem to be bringing the next breakthrough
in this field with more frequent use of the Internet of Things, high distribution of
cellphones, radio-frequency identification (RFID), Bluetooth and Wi-Fi sensors, and
strong hardware. These new technologies change the way that EDs (and healthcare
systems) work, and therefore can change the models needed. For example, dynamic
and online data regarding patients in the ED and even the hospitalization depart-
ments can now be considered and influence grouping, prioritization and resource
decisions, and staff allocation. Hence, future studies can focus on technological
developments that have the potential to improve and solve queueing problems in
EDs.
Another aspect, that should be considered in future research, is the dynamic and
hybrid structure of healthcare systems in recent years, which emphasizes the impor-

13
Operations Research Forum (2022) 3: 2 Page 35 of 46 2

tance of combining the mathematical and managerial models with the technologi-
cal aspects. This may open the door to new field studies and completely innova-
tive methods. The COVID-19 pandemic had stressed the significance of a rapid and
dynamic response in EDs. Even in a time of “no crisis,” with population growth, the
need arises for a quick response in a time of high uncertainty and a limited budget,
emphasizing the importance of effective implementation of queuing methods; even
under these conditions, the proposed techniques as well as future ones are expected
to increase efficiency and aid medical teams in providing adequate care for patients
in the ED.

Funding This study was funded by The Israel National Institute for Health Policy Research.

Data Availability The datasets generated during and/or analyzed during the current study are available
from the corresponding author on reasonable request.

Declarations

Conflict of Interest The authors declare no competing interests.

References
1. Lakshmi C, Sivakumar A (2013) Application of queueing theory in health care: a literature review.
Oper Res Health Care 2(1–2):25–39. https://​doi.​org/​10.​1016/j.​orhc.​2013.​03.​002
2. Hu X, Barnes S, Golden B (2018) Applying queueing theory to the study of emergency depart-
ment operations: a survey and a discussion of comparable simulation studies. Int Trans Oper Res
25(1):7–49. https://​doi.​org/​10.​1111/​itor.​12400
3. Ortíz-Barrios MA, Alfaro-Saíz JJ (2020) Methodological approaches to support process improve-
ment in emergency departments: a systematic review. Int J Environ Res Pub Health 17(8):2664–
2704. https://​doi.​org/​10.​3390/​ijerp​h1708​2664
4. Bailey NT (1952) A study of queues and appointment systems in hospital out-patient departments,
with special reference to waiting-times. J R Stat Soc Series B (Methodological) 14(2):185–199. ‫‏‬
https://​doi.​org/​10.​1111/j.​2517-​6161.​1952.​tb001​12.x
5. Bailey NT (1954) Queueing for medical care. J Royal Stat Soc Series C (Appl Statt) 3(3):137–145.
‫ ‏‬https://​doi.​org/​10.​2307/​29853​72
6. Welch JD, Bailey NJ (1952) Appointment systems in hospital outpatient departments. The Lancet
259(6718):1105–1108. https://​doi.​org/​10.​1016/​S0140-​6736(52)​90763-0
7. Welcht JD (1964) Appointments systems in hospitals and general practice: appointment systems in
hospital outpatient departments. J Oper Res Soc 15(3):224–232. https://​doi.​org/​10.​1057/​jors.​1964.​
43
8. Bell CE, Allen D (1969) Optimal planning of an emergency ambulance service. Socioecon Plann
Sci 3(2):95–101. https://​doi.​org/​10.​1016/​0038-​0121(69)​90001-9
9. Taylor TH, Jennings AMC, Nightingale DA, Barber B, Leivers D, Styles M, Magner J (1969) A
study of anaesthetic emergency work. Br J Anaesth 41(1):70–75. https://​doi.​org/​10.​1093/​bja/​41.1.​
70
10. Haussmann RD (1970) Waiting time as an index of quality of nursing care. Health Serv Res
5(2):92–105
11. Gupta I, Zoreda J, Kramer N (1971) Hospital manpower planning by use of queueing theory.
Health Serv Res 6(1):76–82
12. Milliken RA, Rosenberg L, Milliken GM (1972) A queueing theory model for the prediction of
delivery room utilization. Am J Obstet Gynecol 114(5):691–699. https://​doi.​org/​10.​1016/​0002-​
9378(72)​90850-2

13
2 Page 36 of 46 Operations Research Forum (2022) 3: 2

13. Keller TF, Laughhunn DJ (1973) An application of queueing theory to a congestion problem in an
outpatient clinic. Decis Sci 4(3):379–394. https://​doi.​org/​10.​1111/j.​1540-​5915.​1973.​tb005​63.x
14. Cooper JK, Corcoran TM (1974) Estimating bed needs by means of queueing theory. N Engl J
Med 291(8):404–405. https://​doi.​org/​10.​1056/​NEJM1​97408​22291​0807
15. McClain JO (1976) Bed planning using queueing theory models of hospital occupancy: a sensitiv-
ity analysis. Inquiry 13(2):167–176
16. Larson RC (1974) A hypercube queueing model for facility location and redistricting in urban
emergency services. Comput Oper Res 1(1):67–95. https://​doi.​org/​10.​1016/​0305-​0548(74)​90076-8
17. Moore BJ (1977) Use of queueing theory for problem solution in Dallas, Tex., Bureau of Vital Sta-
tistics. Pub Health Rep 92(2):171–175.‫‏‬
18. Scott DW, Factor LE, Gorry GA (1978) Predicting the response time of an urban ambulance sys-
tem. Health Serv Res 13(4):404–417
19. Collings T, Stoneman C (1976) The M/M/∞ queue with varying arrival and departure rates. Oper
Res 24(4):760–773. https://​doi.​org/​10.​1287/​opre.​24.4.​760
20. Ladany SP, Turban E (1978) A simulation of emergency rooms. Comput Oper Res 5(2):89–100.
https://​doi.​org/​10.​1016/​0305-​0548(78)​90001-1
21. Kao EP, Tung GG (1981) Bed allocation in a public health care delivery system. Manage Sci
27(5):507–520. https://​doi.​org/​10.​1287/​mnsc.​27.5.​507
22. Worthington DJ (1987) Queueing models for hospital waiting lists. J Oper Res Soc 38(5):413–422.
https://​doi.​org/​10.​1057/​jors.​1987.​69
23. Worthington D (1991) Hospital waiting list management models. J Oper Res Soc 42(10):833–843.
https://​doi.​org/​10.​1057/​jors.​1991.​164
24. Brillman JC, Doezema D, Tandberg D et al (1996) Triage: limitations in predicting need for emer-
gent care and hospital admission. Ann Emerg Med 27(4):493–500. https://​doi.​org/​10.​1016/​S0196-​
0644(96)​70240-8
25. Gilboy N, Travers D, Wuerz R (1999) Re-evaluating triage in the new millennium: a comprehen-
sive look at the need for standardization and quality. J Emerg Nurs 25(6):468–473. https://​doi.​org/​
10.​1016/​S0099-​1767(99)​70007-3
26. Wuertz R, Fernandes CM, Alarcon J (1998) Inconsistency of emergency department triage. Ann
Emerg Med 32(4):431–435. https://​doi.​org/​10.​1016/​S0196-​0644(98)​70171-4
27. Fernandes CMB, Wuerz R, Clark S, Djurdjev O (1999) How reliable is emergency department tri-
age? Ann Emerg Med 34(2):141–147. https://​doi.​org/​10.​1016/​S0196-​0644(99)​70248-9
28. Subash F, Dunn F, McNicholl B, Marlow J (2004) Team triage improves emergency department
efficiency. Emerg Med J 21(5):542–544. https://​doi.​org/​10.​1136/​emj.​2002.​003665
29. Choi YF, Wong TW, Lau CC (2006) Triage rapid initial assessment by doctor (TRIAD) improves
waiting time and processing time of the emergency department. Emerg Med J 23(4):262–265.
https://​doi.​org/​10.​1136/​emj.​2005.​025254
30. Wiler JL, Gentle C, Halfpenny JM et al (2010) Optimizing emergency department front-end opera-
tions. Ann Emerg Med 55(2):142–160. https://​doi.​org/​10.​1016/j.​annem​ergmed.​2009.​05.​021
31. Oredsson S, Jonsson H et al (2011) A systematic review of triage-related interventions to improve
patient flow in emergency departments. Scand J Trauma, Resusc Emerg Med 19(1):1–9. https://​doi.​
org/​10.​1186/​1757-​7241-​19-​43
32. Burström L, Nordberg M, Ornung G et al (2012) Physician-led team triage based on lean princi-
ples may be superior for efficiency and quality? A comparison of three emergency departments
with different triage models. Scandinavian J Trauma, Resuscitation and Emerge Med 20(1):1–10.
https://​doi.​org/​10.​1186/​1757-​7241-​20-​57
33. Burström L, Engström ML, Castrén M, Wiklund T, Enlund M (2016) Improved quality and effi-
ciency after the introduction of physician-led team triage in an emergency department. Upsala J
Med Sci 121(1):38–44. https://​doi.​org/​10.​3109/​03009​734.​2015.​11002​23
34. Traub SJ, Wood JP, Kelley J et al (2015) Emergency department rapid medical assessment: over-
all effect and mechanistic considerations. J Emerg Med 48(5):620–627. https://​doi.​org/​10.​1016/j.​
jemer​med.​2014.​12.​025
35. Lauks J, Mramor B et al (2016) Medical team evaluation: effect on emergency department waiting
time and length of stay. PLoS One 11(4)
36. Jarvis PRE (2016) Improving emergency department patient flow. Clinic Exp Emerg Med 3(2):63–
68. https://​doi.​org/​10.​15441/​ceem.​16.​127

13
Operations Research Forum (2022) 3: 2 Page 37 of 46 2

37. Connelly LG, Bair AE (2004) Discrete event simulation of emergency department activity: a plat-
form for system-level operations research. Acad Emerg Med 11(11):1177–1185. https://​doi.​org/​10.​
1197/j.​aem.​2004.​08.​021
38. Ruohonen T, Neittaanmäki P, Teittinen J (2006) Simulation model for improving the operation of
the emergency department of special health care. In Proceedings of the 2006 Winter Simulation
Conference, IEEE, pp 453–458. https://​doi.​org/​10.​1109/​WSC.​2006.​323115
39. He Y, Lei T, Okudan Kremer GE (2014) Performance comparison of four triage–based patient flow
interventions in the emergency department. Int J Collab Enterp 4(1–2):115–135. https://​doi.​org/​10.​
1504/​IJCENT.​2014.​065058
40. Farrohknia N, Castrén M et al (2011) Emergency department triage scales and their components: a
systematic review of the scientific evidence. Scand J Trauma, Resuscitation Emerg Med 19(1):1–
13. https://​doi.​org/​10.​1186/​1757-​7241-​19-​42
41. Claudio D, Ricondo L, Freivalds A, Kremer G (2012) Physiological and descriptive variables as
predictors for the Emergency Severity Index. IIE Trans Healthcare Syst Eng 2(2):131–141. https://​
doi.​org/​10.​1080/​19488​300.​2012.​680572
42. Hinson JS, Martinez DA, Schmitz PSK et al (2018) Accuracy of emergency department triage
using the Emergency Severity Index and independent predictors of under-triage and over-triage
in Brazil: a retrospective cohort analysis. Int J Emerg Med 11(1):1–10. https://​doi.​org/​10.​1186/​
s12245-​017-​0161-8
43. Olofsson P, Carlström ED, Bäck-Pettersson S (2012) During and beyond the triage encounter:
chronically ill elderly patients’ experiences throughout their emergency department attendances.
Int Emerg Nurs 20(4):207–213. https://​doi.​org/​10.​1016/j.​ienj.​2012.​03.​006
44. O’Connor E, Gatien M, Weir C, Calder L (2014) Evaluating the effect of emergency department
crowding on triage destination. Int J Emerg Med 7(1):1–7. https://​doi.​org/​10.​1186/​1865-​1380-7-​16
45. Gardner RM, Friedman NA, Carlson M, Bradham TS, Barrett TW (2018) Impact of revised triage
to improve throughput in an ED with limited traditional fast track population. Am J Emerge Med.
36(1):124–127. https://​doi.​org/​10.​1016/j.​ajem.​2017.​10.​016
46. Hodgson NR, Traub SJ (2020) Patient assignment models in the emergency department. Emer-
gency Medicine Clinics 38(3):607–615. https://​doi.​org/​10.​1016/j.​emc.​2020.​03.​003
47. Green J, Armstrong D (1994) The views of service providers. In: Five essays on emergency path-
ways: a study of acute admissions to London hospitals. Kings Fund Institute, London,
48. Boaden R, Proudlove N, Wilson M (1999) An exploratory study of bed management. J Manag Med
13(4):234–250. https://​doi.​org/​10.​1108/​02689​23991​02929​45
49. Proudlove NC, Gordon K, Boaden R (2003) Can good bed management solve the overcrowding in
accident and emergency departments? Emerg Med J 20(2):149–155. https://​doi.​org/​10.​1136/​emj.​
20.2.​149
50. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S (2008) Active bed manage-
ment by hospitalists and emergency department throughput. Ann Intern Med 149(11):804–810.
https://​doi.​org/​10.​7326/​0003-​4819-​149-​11-​20081​2020-​00006
51. Ben-Tovim DI, Bassham JE, Bennett DM, Dougherty ML, Martin MA, O’Neill SJ et al (2008)
Redesigning care at the Flinders Medical Centre: clinical process redesign using “lean thinking.”
Med J Aust 188(S6):S27–S31. https://​doi.​org/​10.​5694/j.​1326-​5377.​2008.​tb016​71.x
52. Mackay M (2001) Practical experience with bed occupancy management and planning systems: an
Australian view. Health Care Manag Sci 4(1):47–56. https://​doi.​org/​10.​1023/A:​10096​53716​457
53. Gorunescu F, McClean SI, Millard PH (2002) A queueing model for bed-occupancy management
and planning of hospitals. J Oper Res Soc. 53(1):19–24. https://​doi.​org/​10.​1057/​palgr​ave.​jors.​
26012​44 or: http://​www.​palgr​ave-​journ​als.​com/​jors/​journ​al/​v53/​n1/​pdf/​26012​44a.​pdf
54. Gorunescu F, McClean SI, Millard PH (2002) Using a queueing model to help plan bed allocation
in a department of geriatric medicine. Health Care Manag Sci 5(4):307–312. https://​doi.​org/​10.​
1023/A:​10203​42509​099
55. Hall R (2012) Bed assignment and bed management. In: Handbook of healthcare system schedul-
ing. Springer, US, ‫‏‬pp 177–200. https://​doi.​org/​10.​1007/​978-1-​4614-​1734-7_8
56. Mackay M, Qin S, Clissold A, Hakendorf P, Ben-Tovim D, McDonnell G (2013) Patient flow
simulation modelling—an approach conducive to multi-disciplinary collaboration towards hos-
pital capacity management. In 20th International Congress on Modelling and Simulation (MOD-
SIM2013), pp 50–56. ‫‏‬

13
2 Page 38 of 46 Operations Research Forum (2022) 3: 2

57. Tsai PF, Lin FM (2014) An application of multi-attribute value theory to patient-bed assignment
in hospital admission management: an empirical study. J Healthcare Eng 5(4):439–456. https://​doi.​
org/​10.​1260/​2040-​2295.5.​4.​439
58. Wu X, Xu R, Li J, Khasawneh MT (2019) A simulation study of bed allocation to reduce blocking
probability in emergency departments: a case study in China. J Oper Res Soc 70(8):1376–1390.
https://​doi.​org/​10.​1080/​01605​682.​2018.​15064​30
59. Wargon M, Taright N, Casalino E, Pateron D, Guidet B (2014) A simulated discrete-event and
queueing model to reduce transfers from the emergency department and to optimize hospital bed
management. Adv Emerg Med 2014:1–7. https://​doi.​org/​10.​1155/​2014/​478675
60. Belciug S, Gorunescu F (2015) Improving hospital bed occupancy and resource utilization through
queueing modeling and evolutionary computation. J Biomed Inform 53:261–269. https://​doi.​org/​
10.​1016/j.​jbi.​2014.​11.​010
61. Folake, A. O., Agu, M. N., & Okebanama, U. F. Application of Queue Model in Health Care Sec-
tor (2020) Int Res J Adv Eng Sci. 5(3):48–50. Available online at http://​irjaes.​com/​wp-​conte​nt/​
uploa​ds/​2021/​01/​IRJAES-​V5N2P​274Y20.​pdf
62. Baschung NS, Henz M, Ruppli TE (1999) Floating beds—a flexible bed-management-system in a
Swiss acute hospital. In: Global production management 1999, pp. 43–49. Springer, Boston, MA.
https://​doi.​org/​10.​1007/​978-0-​387-​35569-6_6
63. Bard JF, Purnomo HW (2005) Hospital-wide reactive scheduling of nurses with preference con-
siderations. IIE Trans 37(7):589–608. https://​doi.​org/​10.​1080/​07408​17059​09484​68
64. Wang J, Li J, Tussey K, Ross K (2012) Reducing length of stay in emergency department: a sim-
ulation study at a community hospital. IEEE Transactions on Systems, Man, and Cybernetics-
Part A: Syst Hum 42(6):1314–1322. https://​doi.​org/​10.​1109/​TSMCA.​2012.​22102​04
65. Zlotnik, A., Gallardo-Antolin, A., Alfaro, M. C., Pérez, M. C. P., & Martínez, J. M. M. (2015).
Emergency department visit forecasting and dynamic nursing staff allocation using machine
learning techniques with readily available open-source software. CIN: Computers, Informatics,
Nursing, 33(8): 368–377. https://​doi.​org/​10.​1097/​CIN.​00000​00000​000173
66. Bornemann-Shepherd M, Le-Lazar J, Makic MBF, DeVine D, McDevitt K, Paul M (2015) Car-
ing for inpatient boarders in the emergency department: improving safety and patient and staff
satisfaction. J Emerg Nurs 41(1):23–29. https://​doi.​org/​10.​1016/j.​jen.​2014.​04.​012
67. Tan, K. W., Tan, W. H., & Lau, H. C. (2013) Improving patient length-of-stay in emergency
department through dynamic resource allocation policies. In 2013 IEEE International Confer-
ence on Automation Science and Engineering (CASE), IEEE, pp 984–989. https://​doi.​org/​10.​
1109/​CoASE.​2013.​66539​88
68. Bakker M, Tsui KL (2017) Dynamic resource allocation for efficient patient scheduling: a data-
driven approach. J Syst Sci Syst Eng 26(4):448–462. https://​doi.​org/​10.​1007/​s11518-​017-​5347-3
69. Luscombe R, Kozan E (2016) Dynamic resource allocation to improve emergency department effi-
ciency in real time. Eur J Oper Res 255(2):593–603. https://​doi.​org/​10.​1016/j.​ejor.​2016.​05.​039
70. Elalouf A, Wachtel G (2015) An alternative scheduling approach for improving patient-flow in
emergency departments. Oper Res Health Care 7:94–102. https://​doi.​org/​10.​1016/j.​orhc.​2015.​08.​
002
71. Elalouf A, Wachtel G (2016) An alternative scheduling approach for improving emergency depart-
ment performance. Int J Prod Econ 178:65–71. https://​doi.​org/​10.​1016/j.​ijpe.​2016.​05.​002
72. Elalouf A, Wachtel G (2017) Using the “Floating Patients” method to balance crowding between
the hospital emergency department and other departments. Comput Ind Eng 110:289–296. https://​
doi.​org/​10.​1016/j.​cie.​2017.​06.​023
73. McGuire TE (1991) DRGs: the state of the art, circa 1990. Health Policy 17(2):97–119. https://​doi.​
org/​10.​1016/​0168-​8510(91)​90048-3
74. Sanderson H, Mountney L (1997) The development of patient groupings for more effective man-
agement of health care. Eur J Pub Health 7(2):210–214. https://​doi.​org/​10.​1093/​eurpub/​7.2.​210
75. King DL, Ben-Tovim DI, Bassham J (2006) Redesigning ED patient flows application of lean
thinking to health care. Emerg Med Australas 18(4):391–397. https://​doi.​org/​10.​1111/j.​1742-​6723.​
2006.​00872.x
76. El-Darzi E, Abbi R, Vasilakis C, Gorunescu F, Gorunescu M, Millard P (2009) Length of stay-
based clustering methods for patient grouping. In: McClean SI et al (ed.) Intelligent patient man-
agement, Springer Berlin Heidelberg, pp. 39–56. https://​doi.​org/​10.​1007/​978-3-​642-​00179-6_3
77. Gorunescu F, Belciug S, El-Darzi E, Gorunescu M (2010) Patient grouping optimization using a
hybrid self-organizing map and Gaussian mixture model for length of stay-based clustering system.

13
Operations Research Forum (2022) 3: 2 Page 39 of 46 2

In 2010 5th IEEE International Conference Intelligent Systems, IEEE, pp 173–178. https://​doi.​org/​
10.​1109/​IS.​2010.​55483​52
78. Xu M, Wong TC, Chin KS (2014) A medical procedure-based patient grouping method for an
emergency department. Applied Soft Computing 14(A): 31–37. https://​doi.​org/​10.​1016/j.​asoc.​
2013.​09.​022
79. Claudio D, Okudan GE (2010) Utility function-based patient prioritization in the emergency
department. Eur J Indust Eng 4(1):59–77. https://​doi.​org/​10.​1504/​EJIE.​2010.​029570
80. Fields EB, Okudan GE, Ashour OM (2013) Rank aggregation methods comparison: a case for tri-
age prioritization. Expert Syst Appl 40(4):1305–1311. https://​doi.​org/​10.​1016/j.​eswa.​2012.​08.​060
81. Ashour OM, Okudan Kremer GE (2013) Group technology-based patient grouping and prioritizing
algorithm. In IIE Annual Conference Proceedings, Institute of Industrial and Systems Engineers
(IISE), pp 1512–1521.
82. Ashour OM, Okudan Kremer GE (2016) Dynamic patient grouping and prioritization: a new
approach to emergency department flow improvement. Health Care Manag Sci 19(2):192–205.
https://​doi.​org/​10.​1007/​s10729-​014-​9311-1
83. Tan KW, Wang C, Lau HC (2012, August) Improving patient flow in emergency department
through dynamic priority queue. In Automation Science and Engineering (CASE), 2012 IEEE
International Conference. IEEE, pp 125–130. https://​doi.​org/​10.​1109/​CoASE.​2012.​63864​09
84. Ding Y, Park E, Nagarajan M, Grafstein E (2019) Patient prioritization in emergency department
triage systems: an empirical study of Canadian Triage and Acuity Scale (CTAS). Manuf Serv Oper
Manag 21(4):723–741. https://​doi.​org/​10.​1287/​msom.​2018.​0719
85. Zhang A, Zhu X, Lu Q, Zhang R (2019) Impact of prioritization on the outpatient queuing system
in the emergency department with limited medical resources. Symmetry 11(6):796–810. https://​
doi.​org/​10.​3390/​sym11​060796
86. Meislin HW, Coates SA, Cyr J, Valenzuela T (1988) Fast track: urgent care within a teaching hos-
pital emergency department: can it work? Ann Emerg Med 17(5):453–456. https://​doi.​org/​10.​1016/​
S0196-​0644(88)​80235-X
87. Wright SW, Erwin TL, Blanton DM, Covington CM (1992) Fast track in the emergency depart-
ment: a one-year experience with nurse practitioners. J Emerg Med 10(3):367–373. https://​doi.​org/​
10.​1016/​0736-​4679(92)​90345-T
88. Cardello DM (1992) Implementation of a one-hour fast-track service: one hospital’s experience. J
Emerg Nurs 18(3):239–243
89. Fernandes CM, Christenson JM, Price A (1996) Continuous quality improvement reduces length
of stay for fast-track patients in an emergency department. Acad Emerg Med 3(3):258–263. https://​
doi.​org/​10.​1111/j.​1553-​2712.​1996.​tb034​30.x
90. Fernandes CM, Price A, Christenson JM (1997) Does reduced length of stay decrease the number
of emergency department patients who leave without seeing a physician? J Emerg Med 15(3):397–
399. https://​doi.​org/​10.​1016/​S0736-​4679(97)​00030-9
91. Cooke MW, Wilson S, Pearson S (2002) The effect of a separate stream for minor injuries on acci-
dent and emergency department waiting times. Emerg Med J 19:28–30. https://​doi.​org/​10.​1136/​
emj.​19.1.​28
92. Sanchez M, Smally AJ, Grant RJ, Jacobs LM (2006) Effects of a fast-track area on emergency
department performance. J Emerg Med 31(1):117–120. https://​doi.​org/​10.​1016/j.​jemer​med.​2005.​
08.​019
93. Darrab AA, Fan J, Fernandes CM, Zimmerman R, Smith R, Worster A, Smith T, O’Connor K
(2006) How does fast track affect quality of care in the emergency department? Eur J Emerg Med
13(1):32–35. https://​doi.​org/​10.​1097/​00063​110-​20060​2000-​00008
94. Nash K, Zachariah B, Nitschmann J, Psencik B (2007) Evaluation of the fast-track unit of a univer-
sity emergency department. J Emerg Nurs 33(1):14–20. https://​doi.​org/​10.​1016/j.​jen.​2006.​08.​003
95. Combs S, Chapman R, Bushby A (2007) Evaluation of fast track. Accid Emerg Nurs 15(1):40–47.
https://​doi.​org/​10.​1016/j.​aaen.​2006.​07.​006
96. Considine J, Kropman M, Kelly E, Winter C (2008) Effect of emergency department fast track on
emergency department length of stay: a case-control study. Emerg Med J 25(12):815–819. https://​
doi.​org/​10.​1136/​emj.​2008.​057919
97. White BA, Chang Y, Grabowski BG, Brown DFM (2014) Using lean-based systems engineering
to increase capacity in the emergency. West J Emerge Med 15(7):770–776. https://​doi.​org/​10.​5811/​
westj​em.​2014.8.​21272

13
2 Page 40 of 46 Operations Research Forum (2022) 3: 2

98. Manno E, Pesce M, Stralla U, Festa F, Geninatti S, Fausta Balzarro M, Di Leo D, Gelain B (2015)
Specialized fast track: a sustainable model to improve emergency department patient flow. J Hosp
Admin 4(5):40–46. https://​doi.​org/​10.​5430/​jha.​v4n5p​40
99. Kraitsik MJ, Bossmeyer A (1993) Simulation applied to planning an emergency department expan-
sion. In Proceedings of the 1993 SCS Western Multiconference on Simulation: Simulation in
Health Sciences and Services, pp 19–27.‫‏‬
100. McGuire F (1994). Using simulation to reduce length of stay in emergency departments. In Pro-
ceedings of Winter Simulation Conference 1994, IEEE, pp 861–867. Further published in J Soc
Health Syst. 1997; 5(3):81–90. https://​doi.​org/​10.​1109/​WSC.​1994.​717446
101. Garcia ML, Centeno MA, Rivera C, DeCario N (1995). Reducing time in an emergency room via
a fast-track. In Proceedings of 1995 Winter Simulation Conference, IEEE, ‫ ‏‬pp 1048–1053. ‫ ‏‬https://​
doi.​org/​10.​1145/​224401.​224771
102. Kirtland A, Lockwood J, Poisker K, Stamp L, Wolfe P (1995). Simulating an emergency depart-
ment “is as much fun as...”. In Winter Simulation Conference Proceedings, 1995, IEEE, pp 1039–
1042. https://​doi.​org/​10.​1109/​WSC.​1995.​478896
103. Sinreich D, Marmor YN (2004). A simple and intuitive simulation tool for analyzing emergency
department operations. In Proceedings of the 2004 Winter Simulation Conference, IEEE, Vol 2, pp
1994–2002. ‫‏‬https://​doi.​org/​10.​1109/​WSC.​2004.​13715​61
104. Sinreich D, Marmor Y (2005) Ways to reduce patient turnaround time and improve service quality in emer-
gency departments. J Health Organ Manag 19(2):88–105. https://​doi.​org/​10.​1108/​14777​26051​06000​22
105. Sinreich D, Marmor Y (2005) Emergency department operations: the basis for developing a simu-
lation tool. IIE Trans 37(3):233–245. https://​doi.​org/​10.​1080/​07408​17059​08996​25
106. Marmor YN, Golany B, Israelit S, Mandelbaum A (2012) Designing patient flow in emergency
departments. IIE Transactions on Healthcare Systems Engineering 2(4):233–247. https://​doi.​org/​
10.​1080/​19488​300.​2012.​736118
107. La J, Jewkes EM (2013) Defining an optimal ED fast track strategy using simulation. J Enterprise
Inform Manag. 26(1–2): 109–118. https://​doi.​org/​10.​1108/​17410​39131​12895​78
108. Roche KT, Cochran JK (2007) Improving patient safety by maximizing fast-track benefits in the
emergency department—a queueing network approach. In IIE Annual Conference 2007. Proceed-
ings. Ins Ind Syst Eng (IISE), pp 619–625. ‫‏‬
109. Cochran JK, Roche KT (2009) A multi-class queueing network analysis methodology for improv-
ing hospital emergency department performance. Comput Oper Res 36(5):1497–1512. https://​doi.​
org/​10.​1016/j.​cor.​2008.​02.​004
110. Fitzgerald K, Pelletier L, Reznek MA (2017) A queue-based Monte Carlo analysis to support deci-
sion making for implementation of an emergency department fast track. J Healthcare Eng 2017:1–
8. https://​doi.​org/​10.​1155/​2017/​65365​23
111. Eitel DR, Rudkin SE, Malvehy MA, Killeen JP, Pines JM (2010) Improving service quality by
understanding ED flow. J Emerg Med 38(1):70–79. https://​doi.​org/​10.​1016/j.​jemer​med.​2008.​03.​
038
112. Wiler JL, Griffey RT, Olsen T (2011) Review of modeling approaches for emergency department
patient flow and crowding research. Acad Emerg Med 18(12):1371–1379. https://​doi.​org/​10.​1111/j.​
1553-​2712.​2011.​01135.x
113. Saghafian S, Austin G, Traub SJ (2015) Operations research/management contributions to emer-
gency department patient flow optimization: review and research prospects. IIE Trans Healthcare
Syst Eng 5(2):101–123. https://​doi.​org/​10.​1080/​19488​300.​2015.​10176​76
114. Palmer R, Fulop NJ, Utley M (2018) A systematic literature review of operational research meth-
ods for modelling patient flow and outcomes within community healthcare and other settings.
Health Syst 7(1):29–50. https://​doi.​org/​10.​1057/​s41306-​017-​0024-9
115. Ahsan KB, Alam MR, Morel DG, Karim MA (2019) Emergency department resource optimiza-
tion for improved performance: a review. J Ind Eng Int 15(1):253–266. https://​doi.​org/​10.​1007/​
s40092-​019-​00335-x
116. Gross D et al (2008) Fundamentals of queueing-theory, 4th edn. John Wiley & Sons, New York
117. Bhat UN (2015) An introduction to queueing-theory—modeling and analysis in applications.
Birkhäuser, Boston, MA. https://​doi.​org/​10.​1007/​978-0-​8176-​8421-1
118. Green LV (2011) Queueing theory and modeling. In: Yih Y (ed) Handbook of healthcare delivery
systems. Taylor & Francis Group, London, 2011. https://​doi.​org/​10.​1201/​b10447
119. Fomundam S, Herrmann JW (2007) A survey of queuing theory applications in healthcare. Techni-
cal Report from the Institute for Systems Research at the University of Maryland (USA).

13
Operations Research Forum (2022) 3: 2 Page 41 of 46 2

120. Mehandiratta R (2011) Applications of queueing-theory in health care. Int J Comput Business Res. 2(2)
:2229–6166. Available online at http://​www.​resea​rchma​nuscr​ipts.​com/​Paper​sVol2​N2/​IJCBR​VOL2N​2P9.​
pdf
121. Palvannan R, Teow K (2012) Queueing for healthcare. J Med Syst 36(2):541–547. https://​doi.​org/​
10.​1007/​s10916-​010-​9499-7
122. Bain CA, Taylor PG, McDonnell G, Georgiou A (2010) Myths of ideal hospital occupancy. Med J
Aust 192(1):42–43. https://​doi.​org/​10.​5694/j.​1326-​5377.​2010.​tb034​01.x
123. Cho KW, Kim SM, Chae YM, Song YU (2017) Application of queueing-theory to the analysis
of changes in outpatients waiting times in hospitals introducing EMR. Healthcare Inform Res
23(1):35–42. https://​doi.​org/​10.​4258/​hir.​2017.​23.1.​35
124. Bittencourt O, Verter V, Yalovsky M (2018) Hospital capacity management based on the queueing-
theory. Int J Product Perform Manag 67(2):224–238. https://​doi.​org/​10.​1108/​IJPPM-​12-​2015-​0193
125. Lin CC, Wu CC, Chen CD, Chen KF (2019) Could we employ the queueing theory to improve
efficiency during future mass causality incidents? Scand J Trauma, Resusc Emerge Med
27(1):1–9. https://​doi.​org/​10.​1186/​s13049-​019-​0620-8
126. McManus ML, Long MC, Cooper A, Litvak E (2004) Queuing theory accurately models the
need for critical care resources. Anesthesiology: J Am Soc Anesthesiol. 100(5):1271–1276.
https://​doi.​org/​10.​1097/​00000​542-​20040​5000-​00032
127. Green LV, Soares J, Giglio JF, Green RA (2006) Using queueing theory to increase the effec-
tiveness of emergency department provider staffing. Acad Emerg Med 13(1):61–68. https://​doi.​
org/​10.​1197/j.​aem.​2005.​07.​034
128. De Bruin AM, Van Rossum AC, Visser MC, Koole GM (2007) Modeling the emergency car-
diac in-patient flow: an application of queuing theory. Health Care Manag Sci 10(2):125–137.
https://​doi.​org/​10.​1007/​s10729-​007-​9009-8
129. Creemers S, Lambrecht M, Vandaele N (2007) Queueing models in healthcare. Tijdschrift voor
Economie en Management 52(3):471–497
130. Mayhew L, Smith D (2008) Using queuing theory to analyse the government’s 4-h comple-
tion time target in accident and emergency departments. Health Care Manag Sci 11(1):11–21.
https://​doi.​org/​10.​1007/​s10729-​007-​9033-8
131. Laskowski M, McLeod RD, Friesen MR, Podaima BW, Alfa AS (2009) Models of emergency
departments for reducing patient waiting times. PLoS One 4(7)
132. Morton A, Bevan G (2008) What’s in a wait contrasting management science and economic per-
spectives on waiting for emergency care. Health Pol 85(2):207–217. https://​doi.​org/​10.​1016/j.​
healt​hpol.​2007.​07.​014
133. Au L, Byrnes GB, Bain CA et al (2009) Predicting overflow in an emergency department. IMA
J Manag Math 20(1):39–49. https://​doi.​org/​10.​1093/​imaman/​dpn007
134. Tseytlin Y (2009) Queueing systems with heterogeneous servers—on fair routing of patients in
EDs. MSC Thesis, Technion, Haifa.
135. Hagen MS, Jopling JK, Buchman TG, Lee EK (2013) Priority queuing models for hospital
intensive care units and impacts to severe case patients. In AMIA Annual Symposium Proceed-
ings Vol 2013. Am Med Inform Assoc pp 841–850.
136. Wiler JL, Bolandifar E, Griffey RT, Poirier RF, Olsen T (2013) An emergency department
patient flow model based on queueing theory principles. Acad Emerg Med 20(9):939–946.
https://​doi.​org/​10.​1111/​acem.​12215
137. Yom-Tov GB, Mandelbaum A (2014) Erlang-R: a time-varying queue with reentrant customers,
in support of healthcare staffing. Manuf Serv Oper Manag 16(2):283–299. https://​doi.​org/​10.​
1287/​msom.​2013.​0474
138. Yom-Tov G (2010) Queues in hospitals: stochastic-networks with reentering customers in the
QED regime (QED—quality and efficiency driven). PHD Thesis, Technion, Haifa.
139. Batt RJ, Terwiesch C (2015) Waiting patiently: an empirical study of queue abandonment in an
emergency department. Manage Sci 61(1):39–59. https://​doi.​org/​10.​1287/​mnsc.​2014.​2058
140. Vass H, Szabo ZK (2015) Application of queuing model to patient flow in emergency depart-
ment. Case study Procedia Economics and Finance 32:479–487. https://​doi.​org/​10.​1016/​S2212-​
5671(15)​01421-5
141. Alavi-Moghaddam M, Forouzanfar R, Alamdari S et al (2012) Application of queuing analytic the-
ory to decrease waiting time in ED—does it make sense? Archives of Trauma Research 1(3):101–
107. https://​doi.​org/​10.​5812/​atr.​7177

13
2 Page 42 of 46 Operations Research Forum (2022) 3: 2

142. Cantero FM, Redondo M (2014) Queuing theory to decrease waiting times in emergency
department. Archives of Trauma Research 3(1):e10473. https://​doi.​org/​10.​5812/​atr.​10473
143. Mohseni A (2014) Queuing theory can solve flow and wait problems. Emergency Medicine
News 36(12):5. https://​doi.​org/​10.​1097/​01.​EEM.​00004​59002.​81450.​02
144. Huang J, Carmeli B, Mandelbaum A (2015) Control of patient flow in emergency departments
or multiclass queues with deadlines and feedback. Oper Res 63(4):892–908. https://​doi.​org/​10.​
1287/​opre.​2015.​1389
145. Rotich TK (2016) Utility analysis of an emergency medical service model using queuing theory.
J Adv Math Comp Sci 19(1):1–18. https://​doi.​org/​10.​9734/​BJMCS/​2016/​29369
146. Xu K, Chan CW (2016) Using future information to reduce waiting times in the emergency depart-
ment via diversion. Manuf Serv Oper Manag 18(3):314–331. https://​doi.​org/​10.​1287/​msom.​2015.​
0573
147. Jáuregui G, Rodríguez R et al (2017) Analysis of the emergency service applying the queueing
theory. Contaduría y Administración 62(3):733–745. https://​doi.​org/​10.​1016/j.​cya.​2017.​05.​001
148. Joseph JW (2020) Queuing theory and modeling emergency department resource utilization. Emer-
gency Medicine Clinics 38(3):563–572. https://​doi.​org/​10.​1016/j.​emc.​2020.​04.​006
149. Siddharthan K, Jones WJ, Johnson JA (1996) A priority queuing model to reduce waiting times in emer-
gency care. Int J Health Care Qual Assur 9(5):10–16. https://​doi.​org/​10.​1108/​09526​86961​01249​93
150. Green L (2006) Queueing analysis in healthcare. In: Hall R.W. (eds) Patient flow: reducing delay
in healthcare delivery. International Series in Operations Research & Management Science, vol 91.
Springer, Boston, MA, pp 281–307. https://​doi.​org/​10.​1007/​978-0-​387-​33636-7_​10
151. Au-Yeung SWM, Harrison P, Knottenbelt WJ (2006) A queueing network model of patient flow in an
accident and ED. In European Simulation & Modelling Conference (ESM 2006). EUROSIS, pp 60–67.
152. Au-Yeung SWM, Harrison P, Knottenbelt WJ (2007) Approximate queueing network analysis of
patient treatment times. In Proc. 2nd Conference on Performance Evaluation Methodologies and
Tools No. 45. https://​doi.​org/​10.​4108/​value​tools.​2007.​1775
153. Lin D, Patrick J, Labeau F (2014) Estimating the waiting time of multi-priority emergency
patients with downstream blocking. Health Care Manag Sci 17(1):88–99. https://​doi.​org/​10.​1007/​
s10729-​013-​9241-3
154. De Boeck K, Carmen R, Vandaele N (2019) Needy boarding patients in emergency departments:
an exploratory case study using discrete-event simulation. Operations Research for Health Care
21:19–31. https://​doi.​org/​10.​1016/j.​orhc.​2019.​02.​002
155. Hou J, Zhao X (2020) Using a priority queuing approach to improve emergency department perfor-
mance. Journal of Management Analytics 7(1):28–43. https://​doi.​org/​10.​1080/​23270​012.​2019.​16919​45
156. Saunders CE, Makens PK, Leblanc LJ (1989) Modeling emergency department operations using
advanced computer simulation systems. Ann Emerg Med 18(2):134–140. https://​doi.​org/​10.​1016/​
S0196-​0644(89)​80101-5
157. Lopez-Valcarcel BG, Perez PB (1994) Evaluation of alternative functional designs in an ED by
means of Simulation. Simul 63(1):20–28. https://​doi.​org/​10.​1177/​00375​49794​06300​103
158. Samaha S, Armel WS, Starks DW (2003). Emergency departments I: the use of simulation to
reduce the length of stay in an emergency department. In Proceedings of the 2003 Winter Simula-
tion Conference, IEEE, pp 1907–1911. https://​doi.​org/​10.​1109/​WSC.​2003.​12616​52
159. Günal MM, Pidd M (2010) Discrete event simulation for performance modelling in health care: a
review of the literature. J Simul 4(1):42–51. https://​doi.​org/​10.​1057/​jos.​2009.​25
160. Jun JB, Jacobson SH, Swisher JR (1999) Application of discrete-event simulation in health care
clinics: a survey. J Oper Res Soc 50(2):109–123. https://​doi.​org/​10.​1057/​palgr​ave.​jors.​26006​69
161. Komashie A, Mousavi A (2005) Modeling emergency departments using discrete event simula-
tion techniques. In Proceedings of the 2005 Winter Simulation Conference, IEEE, pp 2681–2685.
https://​doi.​org/​10.​1109/​WSC.​2005.​15745​70
162. Duguay C, Fatah C (2007) Modeling and improving emergency department systems using discrete
event simulation. SIMULATION 83(4):311–320. https://​doi.​org/​10.​1177/​00375​49707​083111
163. Hoot NR, LeBlanc LJ, Jones I, Levin SR, Zhou C, Gadd CS, Aronsky D (2008) Forecasting emer-
gency department crowding: a discrete event simulation. Ann Emerg Med 52(2):116–125. https://​
doi.​org/​10.​1016/j.​annem​ergmed.​2007.​12.​011
164. Hoot NR, LeBlanc LJ, Jones I (2009) Forecasting ED crowding—a prospective real time eval-
uation forecasting ED crowding—a prospective real time evaluation. J Am Med Inform Assoc.
16(3):338–345. https://​doi.​org/​10.​1197/​jamia.​M2772

13
Operations Research Forum (2022) 3: 2 Page 43 of 46 2

165. Bair AE, Song WT, Chen YC, Morris BA (2010) The impact of inpatient boarding on ED effi-
ciency: a discrete-event simulation study. J Med Syst. 34(5):919–929. https://​doi.​org/​10.​1007/​
s10916-​009-​9307-4
166. Brailsford SC, Hilton NA (2001) A comparison of discrete event simulation and system dynamics
for modelling health care systems. In: Riley J (ed) Planning for the future: health service quality
and emergency accessibility. Operational Research Applied to Health Services (ORAHS) Glasgow
Caledonian University, UK, pp 18–39
167. Davies R (2007) “See and treat” or “see” and “treat” in an emergency department. In Proceedings of the
2007 Winter Simulation Conference, IEEE, pp 1519–1522. https://​doi.​org/​10.​1109/​WSC.​2007.​44197​65
168. Kolker A (2008) Process modeling of ED patient flow effect of patient LOS on ED diversion. J
Med Syst 32(5):389–401. https://​doi.​org/​10.​1007/​s10916-​008-​9144-x
169. Khare RK, Powell ES, Reinhardt G, Lucenti M (2009) Adding more beds to the emergency depart-
ment or reducing admitted patient boarding times. Ann Emerg Med 53(5):575–585. https://​doi.​org/​
10.​1016/j.​annem​ergmed.​2008.​07.​009
170. Fletcher A, Worthington D (2009) What is a ‘generic’ hospital model?—a comparison of ‘generic’
and ‘specific’ hospital models of emergency flow patients. Health Care Manag Sci 12(4):374–391.
https://​doi.​org/​10.​1007/​s10729-​009-​9108-9
171. Marmor YN, Wasserkrug S, Zeltyn S, et al (2009) Toward simulation-based real-time decision-
support systems for EDs. In Proceedings of the 2009 Winter Simulation Conference (WSC), IEEE,
pp 2042–2053. https://​doi.​org/​10.​1109/​WSC.​2009.​54294​16
172. Marmor Y (2010) EDs Simulation in support of service engineering staffing design and real time
tracking. PHD Thesis, Technion, Haifa.
173. Zeltyn S, Marmor YN, Mandelbaum A et al (2011) Simulation-based models of emergency depart-
ments operational, tactical, and strategic staffing. ACM Trans Model Comput Simul 21(4):1–25.
https://​doi.​org/​10.​1145/​20004​94.​20004​97
174. Lim ME, Worster A, Goeree R, Tarride JÉ (2013) Simulating an emergency department: the
importance of modeling the interactions between physicians and delegates in a discrete event simu-
lation. BMC Med Inform Decis Mak 13(1):1–11. https://​doi.​org/​10.​1186/​1472-​6947-​13-​59
175. Hurwitz JE, Lee JA, Lopiano KK, McKinley SA, Keesling J, Tyndall JA (2014) A flexible simula-
tion platform to quantify and manage emergency department crowding. BMC Med Inform Decis
Mak 14(1):1–11. https://​doi.​org/​10.​1186/​1472-​6947-​14-​50
176. Hurwitz, J. E., Lopiano, K. K., Bohrmann, T. F., Swan, W., Falgiani, M., & Tyndall, J. A. (2016).
Predictive analytics in practice: a novel simulation application for addressing patient flow chal-
lenges in today’s emergency departments. PeerJ Preprints, 4, e1891v2. https://​doi.​org/​10.​7287/​
peerj.​prepr​ints.​1891v2
177. El-Rifai O, Garaix T, Augusto V, Xie X (2015) A stochastic optimization model for shift sched-
uling in emergency departments. Health Care Manag Sci 18(3):289–302. https://​doi.​org/​10.​1007/​
s10729-​014-​9300-4
178. Ahalt V, Argon NT, Ziya S, Strickler J, Mehrotra A (2016) Comparison of emergency department
crowding scores: a discrete-event simulation approach. Health Care Manag Sci 21(1):144–155.
https://​doi.​org/​10.​1007/​s10729-​016-​9385-z
179. Gulhane K (2020) Enhancing queuing efficiency using discrete event simulation. Int J Logist Syst
Manag 36(4):531–546. https://​doi.​org/​10.​1504/​IJLSM.​2020.​108930
180. Castanheira-Pinto A, Gonçalves BS, Lima RM, Dinis-Carvalho J (2021) Modeling, assessment and
design of an emergency department of a public hospital through discrete-event simulation. Appl
Sci 11(2):805–824. https://​doi.​org/​10.​3390/​app11​020805
181. Mohiuddin S, Busby J, Savović J, Richards A, Northstone K, Hollingworth W et al (2017) Patient
flow within UK emergency departments: a systematic review of the use of computer simulation
modelling methods. BMJ Open 7(5):e015007. https://​doi.​org/​10.​1136/​bmjop​en-​2016-​015007
182. Brailsford SC, Lattimer VA, Tarnaras P, Turnbull JC (2004) Emergency and on-demand health care:
modelling a large complex system. J Oper Res Soc 55(1):34–42. https://​doi.​org/​10.​1057/​palgr​ave.​
jors.​26016​67
183. Thorwarth M, Harper P, Arisha A (2009) Simulation model to investigate flexible workload man-
agement for healthcare and service scape environment. In Proceedings of the 2009 Winter Simula-
tion Conference (WSC), IEEE, pp 1946–1956. https://​doi.​org/​10.​1109/​WSC.​2009.​54292​10
184. Van Sambeek JR, Cornelissen FA, Bakker PJ, Krabbendam JJ (2010) Models as instruments for
optimizing hospital processes: a systematic review. Int J Health Care Qual Assur 23(4):356–377.
https://​doi.​org/​10.​1108/​09526​86101​10374​34

13
2 Page 44 of 46 Operations Research Forum (2022) 3: 2

185. Paul SA, Reddy MC, DeFlitch CJ (2010) A systematic review of simulation studies investigating
emergency department overcrowding. SIMULATION 86(8–9):559–571. https://​doi.​org/​10.​1177/​
00375​49709​360912
186. Laskowski M, Mukhi S (2008). Agent-based simulation of emergency departments with patient
diversion. In International Conference on Electronic Healthcare, pp 25–37. Springer, Berlin, Hei-
delberg. https://​doi.​org/​10.​1007/​978-3-​642-​00413-1_4
187. Jones SS, Evans RS (2008) An agent-based simulation tool for scheduling emergency department
physicians. In AMIA Annual Symposium Proceedings, Vol 2008, pp 338–342. American Medical
Informatics Association.
188. Liu, Z., Cabrera, E., Rexachs, D., & Luque, E. (2014). A generalized agent-based model to simu-
late emergency departments. In Sixth International Conference on Advances in System Simulation,
pp 65–70.
189. Yousefi M, Ferreira RPM (2017) An agent-based simulation combined with group decision-making
technique for improving the performance of an emergency department. Braz J Med Biol. 50(5).
https://​doi.​org/​10.​1590/​1414-​431X2​01759​55
190. Ceglowski R, Churilov L, Wasserthiel J (2007) Combining data mining and discrete event simula-
tion for a value-added view of the hospital ED. J Oper Res Soc 58(2):246–254. https://​doi.​org/​10.​
1057/​palgr​ave.​jors.​26022​70
191. Saghafian S, Hopp WJ, Van Oyen MP, Desmond JS, Kronick SL (2012) Patient streaming as a
mechanism for improving responsiveness in emergency departments. Oper Res 60(5):1080–1097.
https://​doi.​org/​10.​1287/​opre.​1120.​1096
192. Uriarte AG, Zúñiga ER, Moris MU, Ng AH (2015) System design and improvement of an emer-
gency department using simulation-based multi-objective optimization. J Phys Conference Series
616(1):012015. IOP Publishing. https://​doi.​org/​10.​1088/​1742-​6596/​616/1/​012015
193. Salmon A, Rachuba S, Briscoe S, Pitt M (2018) A structured literature review of simulation mod-
elling applied to emergency departments: current patterns and emerging trends. Oper Res Health
Care 19:1–13. https://​doi.​org/​10.​1016/j.​orhc.​2018.​01.​001
194. Wargon M, Guidet B, Hoang TD, Hejblum G (2009) A systematic review of models for forecasting
the number of emergency department visits. Emerg Med J 26(6):395–399. https://​doi.​org/​10.​1136/​
emj.​2008.​062380
195. Jones SS, Thomas A, Evans RS, Welch SJ, Haug PJ, Snow GL (2008) Forecasting daily patient
volumes in the emergency department. Acad Emerg Med 15(2):159–170. https://​doi.​org/​10.​1111/j.​
1553-​2712.​2007.​00032.x
196. Krochmal P, Ryley TA (1994) Increased health care costs associated with ED overcrowding. Am J
Emerg Med. 12(3):265–266. https://​doi.​org/​10.​1016/​0735-​6757(94)​90135-X
197. Forster AJ, Stiell I, Wells G, Lee AJ, Van Walraven C (2003) The effect of hospital occupancy on
emergency department length of stay and patient disposition. Acad Emerg Med 10(2):127–133.
https://​doi.​org/​10.​1197/​aemj.​10.2.​127
198. Asaro PV, Lewis LM, Boxerman SB (2007) Emergency department overcrowding: analysis of the
factors of renege rate. Acad Emerg Med 14(2):157–162. https://​doi.​org/​10.​1197/j.​aem.​2006.​08.​011
199. McCarthy ML, Zeger SL, Ding R, Aronsky D, Hoot NR, Kelen GD (2008) The challenge of pre-
dicting demand for ED services. Academic Emergency Medicine 15(4):337–346. https://​doi.​org/​
10.​1111/j.​1553-​2712.​2008.​00083.x
200. Jones SS, Evans RS, Allen TL, Thomas A, Haug PJ, Welch SJ, Snow GL (2009) A multivariate
time series approach to modeling and forecasting demand in the emergency department. J Biomed
Inform 42(1):123–139. https://​doi.​org/​10.​1016/j.​jbi.​2008.​05.​003
201. Schweigler LM, Desmond JS, McCarthy ML, Bukowski KJ, Ionides EL, Younger JG (2009) Fore-
casting models of emergency department crowding. Acad Emerg Med 16(4):301–308. https://​doi.​
org/​10.​1111/j.​1553-​2712.​2009.​00356.x
202. Steindel SJ, Howanitz PJ (2001) Physician satisfaction and ED lab test turnaround time. Archives of
Pathology & Laboratory Medicine 125(7):863–871. https://​doi.​org/​10.​5858/​2001-​125-​0863-​PSAEDL
203. Liew D, Liew D, Kennedy MP (2003) Emergency department length of stay independently predicts excess
inpatient length of stay. Med J Aust 179(10):524–526. https://​doi.​org/​10.​5694/j.​1326-​5377.​2003.​tb056​76.x
204. Rogers T, Ross N, Spooner D (2004) Evaluation of a ‘see and treat’ pilot study introduced to an
emergency department. Accid Emerg Nurs 12(1):24–27. https://​doi.​org/​10.​1016/j.​aaen.​2003.​08.​005
205. Jones SS, Allen TL, Flottemesch TJ, Welch SJ (2006) An independent evaluation of four quan-
titative ED crowding scales. Academic Emergency Medicine 13(11):1204–1211. https://​doi.​org/​
10.​1197/j.​aem.​2006.​05.​021

13
Operations Research Forum (2022) 3: 2 Page 45 of 46 2

206. Jones PG, Olsen S (2011) Point prevalence of access block and overcrowding in NZ EDs in
2010 and their relationship to the shorter stays in ED target. Emergency Medicine. Australasia
23(5):587–592. https://​doi.​org/​10.​1111/j.​1742-​6723.​2011.​01451.x
207. Oskaynak M, Brennan P (2012) Characterizing patient care in hospital emergency departments.
Health Systems 1(2):104–117. https://​doi.​org/​10.​1057/​hs.​2012.​14
208. Mandelbaum A, Momčilović P, Tseytlin Y (2012) On fair routing from emergency departments
to hospital wards QED queues with heterogeneous servers. Manage Sci 58(7):1273–1291.
https://​doi.​org/​10.​1287/​mnsc.​1110.​1491
209. Cote MJ, Smith MA, Eitel DR, Akçali E (2013) Forecasting emergency department arrivals:
a tutorial for emergency department directors. Hosp Top 91(1):9–19. https://​doi.​org/​10.​1080/​
00185​868.​2013.​757962
210. Shanmugam R (2014) How do queuing concepts and tools help to efficiently manage hospitals?
A demonstration. Int J Res Med Sci. 2(3):1076–1084. Available online at https://​www.​msjon​line.​
org/​index.​php/​ijrms/​artic​le/​view/​2357
211. Afilal M, Yalaoui F, Dugardin F, Amodeo L, Laplanche D, Blua P (2016) Forecasting the emer-
gency department patients flow. J Med Syst 40(7):1–18. https://​doi.​org/​10.​1007/​s10916-​016-​0527-0
212. Whitt W, Zhang X (2017) A data-driven model of an emergency department. Operations
Research for Health Care 12:1–15. https://​doi.​org/​10.​1016/j.​orhc.​2016.​11.​001
213. Das D, Pasupathy KS, Storlie CB, Sir MY (2019) Functional regression-based monitoring of
quality of service in hospital emergency departments. IISE Transactions 51(9):1012–1024.
https://​doi.​org/​10.​1080/​24725​854.​2018.​15363​03
214. Wachtel G, Elalouf A (2020) Addressing overcrowding in an emergency department: an
approach for identifying and treating influential factors and a real-life application. Israel J
Health Pol Res 9(1):1–12. https://​doi.​org/​10.​1186/​s13584-​020-​00390-5
215. Panayiotopoulos JC, Vassilacopoulos G (1984) Simulating hospital emergency departments
queuing systems:(GI/G/m (t)):(IHFF/N/∞). Eur J Oper Res 18(2):250–258. https://​doi.​org/​10.​
1016/​0377-​2217(84)​90191-7
216. Topaloglu S (2006) A multi-objective programming model for scheduling emergency medicine
residents. Comput Ind Eng 51(3):375–388. https://​doi.​org/​10.​1016/j.​cie.​2006.​08.​003
217. Yeh JY, Lin WS (2007) Using simulation technique and genetic algorithm to improve the qual-
ity care of a hospital emergency department. Expert Syst Appl 32(4):1073–1083. https://​doi.​
org/​10.​1016/j.​eswa.​2006.​02.​017
218. Wang Z, Eatock J, McClean S, Liu D, Liu X, Young T (2013) Modeling throughput of emer-
gency departments via time series: an expectation maximization algorithm. ACM Transactions
on Management Information Systems (TMIS) 4(4):1–16. https://​doi.​org/​10.​1145/​25441​05
219. Memari H, Rahimi S, Gupta B, Sinha K, Debnath N (2016) Towards patient flow optimization in
emergency departments using genetic algorithms. In 2016 IEEE 14th International Conference on
Industrial Informatics (INDIN). IEEE, pp 843–850. https://​doi.​org/​10.​1109/​INDIN.​2016.​78192​77
220. Allihaibi WG, Cholettea ME, Masoudc M, Burked J, Karima A (2020) A heuristic approach for
scheduling patient treatment in an emergency department based on bed blocking. Int J Ind Eng
Comput 11(4):565–584. https://​doi.​org/​10.​5267/j.​ijiec.​2020.4.​005
221. Kuo YH, Chan NB, Leung JM, Meng H, So AMC, Tsoi KK, Graham CA (2020) An integrated
approach of machine learning and systems thinking for waiting time prediction in an emergency
department. Int J Med Informatics 139:104143. https://​doi.​org/​10.​1016/j.​ijmed​inf.​2020.​104143
222. Pak A, Gannon B, Staib A (2021) Predicting waiting time to treatment for emergency department
patients. Int J Med Informatics 145:104303. https://​doi.​org/​10.​1016/j.​ijmed​inf.​2020.​104303
223. Hamilton R, McCain R (2011) Linnehan F (2011) Emergency department overcrowding as a Nash
equilibrium: hypothesis and test by survey methodology. In: Osinga S, Hofstede G, Verwaart T
(eds) Lecture notes in economics and mathematical systems. Springer, Amsterdam, the Nether-
lands, pp 90–102
224. Chockalingam A, Jayakumar K, Lawley MA (2010) A stochastic control approach to avoiding
emergency department overcrowding. In Proceedings of the 2010 Winter Simulation Conference.
IEEE, pp 2399–2411. https://​doi.​org/​10.​1109/​WSC.​2010.​56789​36
225. Do, H., & Shunko, M. (2013). Pareto improving coordination policies in queueing systems: appli-
cation to flow control in emergency medical services. Available online at SSRN Electronic Jour-
nal: https://​doi.​org/​10.​2139/​ssrn.​23519​65 https://​ssrn.​com/​abstr​act=​23519​65
226. Wang J, Li J, Howard PK (2013) A system model of workflow in the patient room of hospital ED.
Health Care Manag Sci. 16(4):341–351. https://​doi.​org/​10.​1007/​s10729-​013-​9235-1

13
2 Page 46 of 46 Operations Research Forum (2022) 3: 2

227. Armony M, Israelit S, Mandelbaum A, Marmor YN, Tseytlin Y, Yom-Tov GB (2015) On patient
flow in hospitals: a data-based queueing-science perspective. Stochastic Systems 5(1):146–194.
https://​doi.​org/​10.​1287/​14-​SSY153
228. Chaou CH, Chiu TF, Yen AM, Ng CJ, Chen HH (2016) Analyzing factors affecting emergency
department length of stay using a competing risk-accelerated failure time model. Medicine
95(14):e3263. https://​doi.​org/​10.​1097/​MD.​00000​00000​003263
229. Li N, Stanford DA, Sharif AB, Caron RJ, Pardhan A (2019) Optimising key performance indicator
adherence with application to emergency department congestion. Eur J Oper Res 272(1):313–323.
https://​doi.​org/​10.​1016/j.​ejor.​2018.​06.​048

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.

13