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Objectives: To evaluate the different internal factors influencing patient flow, effectiveness, and overcrowding in the emergency department (ED), as well as the effects of ED reorganisation on these indicators. Methods: The study compared measurements at regular intervals of three hours of patient arrivals and patient flow between two comparable periods (from 10 February to 2 March) of 1999 and 2000. In between, a structural and staff reorganisation of ED was undertaken. The main reason for each patient remaining in ED was recorded and allocated to one of four groups: (1) factors related to ED itself ; (2) factors related to ED-hospital interrelation; (3) factors related to hospital itself; and (4) factors related to neither ED nor hospital. The study measured the number of patients waiting to be seen and the waiting time to be seen as effectiveness markers, as well as the percentage of time that ED was overcrowded, as judged by numerical and functional criteria. Results: Effectiveness of ED was closely related with some ED related and hospital related factors. After the reorganisation, patients who remained in ED because of hospital related or non-ED-non-hospital related factors decreased. ED reorganisation reduced the number of patients waiting to be seen from 5.8 to 2.5 (p<0.001) and waiting time from 87 to 24 minutes (p<0.001). Before the reorganisation, 31% and 48% of the time was considered to be overcrowded in numerical and functional terms respectively. After the reorganisation, these figures were reduced to 8% and 15% respectively (p<0.001 for both). Conclusions: ED effectiveness and overcrowding are not only determined by external pressure, but also by internal factors. Measurement of patient flow across ED has proved useful in detecting these factors and in being used to plan an ED reorganisation. E mergency department (ED) overcrowding is closely related to a decrease in both subjective patient satisfaction, 1 2 and objective care quality. 3-5 Attendance peaks have frequently been invoked as one of the major reasons for overcrowding, and the "number of arrivals per hour" has been proposed as an explanation for ED performance.6-10 However, this indicator does not take into account the effect of patients who remain in ED because of internal reasons. American studies have demonstrated that measurement of patient flow in ED might be valuable tool to analyse the influence of internal factors on overcrowding. 12Although similar studies have not been conducted, it is conceivable that this methodology would be practical in European countries. In this sense, in a preliminary assessment of the relative effect of external and internal factors performed in Spain, it has been demonstrated that such internal factors are at least (if not more) as important as external factors in determining ED overcrowding.13 However, the question of whether ED patient flow can actually be improved by uncovering ED internal dysfunction or modifying ED structures, has been poorly studied.14 This study was designed in two separate p...

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Lean thinking is a methodology that can improve triage acuity level-3 patient flow in the ED, resulting in better throughput along with reduced waiting time.