Flex Serv Manuf J (2016) 28:120–147

DOI 10.1007/s10696-014-9198-7

Improving the efficiency of a hospital emergency

department: a simulation study with indirectly
imputed service-time distributions

Yong-Hong Kuo • Omar Rado • Benedetta Lupia •

Janny M. Y. Leung • Colin A. Graham

Published online: 25 July 2014

 Springer Science+Business Media New York 2014

Abstract This paper presents a case study which uses simulation to analyze
patient flows in a hospital emergency department in Hong Kong. We first analyze
the impact of the enhancements made to the system after the relocation of the
Emergency Department. After that, we developed a simulation model (using
ARENA) to capture all the key relevant processes of the department. When
developing the simulation model, we faced the challenge that the data kept by the
Emergency Department were incomplete so that the service-time distributions were
not directly obtainable. We propose a simulation–optimization approach (integrat-
ing simulation with meta-heuristics) to obtain a good set of estimate of input
parameters of our simulation model. Using the simulation model, we evaluated the
impact of possible changes to the system by running different scenarios. This

Y.-H. Kuo (&)

Big Data Decision Analytics Research Centre, The Chinese University of Hong Kong, Shatin,
New Territories, Hong Kong
e-mail: [email protected]

O. Rado
PriceWaterhouseCoopers Advisory Spa, Milan, Italy
e-mail: [email protected]

B. Lupia
Luxottica Group Spa, Pederobba, Treviso, Italy
e-mail: [email protected]

J. M. Y. Leung
Department of Systems Engineering and Engineering Management, The Chinese University of Hong
Kong, Shatin, New Territories, Hong Kong
e-mail: [email protected]

C. A. Graham
Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Shatin,
New Territories, Hong Kong
e-mail: [email protected]

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Improving the efficiency of a hospital emergency department 121

provides a tool for the operations manager in the Emergency Department to

‘‘foresee’’ the impact on the daily operations when making possible changes (such
as, adjusting staffing levels or shift times), and consequently make much better
decisions.

Keywords Health-care management  Patient flows  Simulation  Meta-

heuristics  Simulated annealing  Simulation optimization  Parameter estimation

1 Introduction

The Prince of Wales Hospital (PWH) is one of the largest public general hospitals in
Hong Kong and the teaching hospital for the Medical Faculty of the Chinese
University of Hong Kong. It provides 1,360 hospital beds, employs around 4,000
people and operates as the regional hospital of the New Territories East (serving
more than 1.5 million people). In order to provide a good quality of service, PWH
has to best-utilize its resources because of the large number of patients served and
its limited budget due to tight government financial support. One of the departments
facing this challenge head-on is the Emergency Department (ED) which provides
24-h Accident and Emergency (A&E) services. In preparation for the growing (and
aging) population in Hong Kong, the ED was relocated in October 2010 to
accommodate increasing patient demand.
The ED handles 420 cases a day on average. In the daytime, the department operates
two independent divisions: the Walking division and the Non-walking division,
respectively treating mobile patients (who can walk) and patients on a trolley or a
wheel chair (thus non-walking). After 23:00, the Walking division is closed and the
walking patients are diverted to the Non-walking division until 07:00 (i.e., walking
patients and non-walking patients are merged to have the same treatment procedure.).
Critical patients arriving by ambulance are rushed to the resuscitation rooms and
treated immediately. Otherwise, after registration, patients are assessed by a triage
nurse and classified by category (level of urgency) so as to assign priorities for
receiving treatments. There are five categories of patients: 1 (critical), 2
(emergency), 3 (urgent), 4 (standard) and 5 (non-urgent). In our work and the rest
of this paper, we put category 5 patients into category 4 as they have the same flow
and priority in real practice and there are only small portion of category 5 patients.
Critically-ill patients (categories 1 and 2 patients), less urgent walking patients
(categories 3 and 4 walking patients) and less urgent non-walking patients
(categories 3 and 4 non-walking patients) follow different procedures of receiving
treatments. Critically-ill patients have the highest priority and category 3 patients
have a higher priority over category 4 patients. Within the same category, patients
are seen on a first-come, first-served (FCFS) basis.
To provide 24-h A&E services, the ED employs different shifts (normally 8 hours a
shift including a meal break of an hour and a short break of 20 min) of doctors to cover
the patient demand over a whole day. Basically, there are three shifts: morning
(08:00–16:00), evening (16:00–midnight) and midnight shifts (00:00–08:00). In
addition, an off-duty doctor is on-call.

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As the ED has to handle a large number of patients a day, it must operate at a

very high level of efficiency and quality. Ineffective operations can lead to serious
consequences such as delay of treatments or even death of critical patients. To
guarantee good quality of services, the ED aims to achieve the following service
targets, as recommended by the Hospital Authority of Hong Kong Special
Administrative Region (2014):

1. Critical patients have to be given immediate care after they are admitted to the
ED.
2. Waiting time of emergency patients should be within 15 min.
3. Waiting time of urgent patients should be within 30 min.

With a large number of patient visits but limited manpower, the ED has the very
difficult task of trying to offer a good quality service (minimizing patients’ waiting
times whilst not compromising the required attention for each patient), and making
sure that valuable resources (e.g., doctors’ and nurses’ time and treatment
equipment) are well-utilized. Our project team was asked by the ED to analyze
and improve patient flows so as to enhance patient satisfaction. We adopt a
simulation approach to provide the operations manager in the ED with estimates of
values for a set of measures (e.g., patients’ waiting times and doctors’ utilization) to
assess the department’s performance and evaluate the impacts on the daily
operations with different policies. However, development of the simulation model
was complicated by the fact that the data records kept by the department were
incomplete for many key operational processes. For example, the duration of key
activities (e.g., doctor’s consultations) were not recorded directly. To tackle this
issue, we assume Weibull distributions for the key activities (such as consultations,
triage, etc.). Next we developed two meta-heuristic search procedures to tune the
distribution parameters to obtain a good estimate of the probability distribution of
their duration. Our results indicate that our search procedure enabled an accurate
model to be built.
This paper is organized as follows. In Sect. 2, we give a literature review on
related work. In Sect. 3, we compare the original and the current layouts of the ED.
In Sect. 4, we describe our simulation model and our parameter estimation
procedures. Section 5 presents the results of the simulation runs with different
scenarios and Sect. 6 summarizes our work.

2 Literature review

For a recent survey of applications of operations management techniques in health-

care, we refer the reader to Rais and Viana (2011). Here, we focus on the
applications to operational enhancements in emergency rooms.
In recent years, researchers have successfully built queueing models for
analyzing and improving patient flows, and have proposed decision strategies and
policies for EDs. Green et al. (2006) used a Lag stationary independent period-by-
period queueing analysis to allocate staff so as to reduce the number of patients who

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leave without being seen. Cochran and Roche (2009) presented a spreadsheet
implementation of a queuing network model with split patient flows (accounting for
patient categories of different acuity and arrival patterns and volume), to help
reduce patient ‘‘walk-aways’’ and improve service provision of the ED. Huang
(2012) considered the control of patient flow, in which physicians have to choose
between seeing patients right after triage (facing deadline constraints on their time-
till-first-service) and those who are in process but possibly need to return to
physicians several times during their ED sojourn (resulting in feedbacks to the
queueing system). They also proposed and analyzed scheduling policies with two
types of costs: queueing costs incurred per individual doctor visit and congestion
costs accumulate over all visits during patient sojourn-times. Saghafian et al.
(2012a, b) proposed patient streaming (based on their likelihood of being admitted
to the hospital) and complexity-based triage (an up-front estimate of patient
complexity) for improving operations in EDs. In both papers, they used a
combination of analytic and simulation models to show the effectivenesses of the
policies. While there has been much work on deriving analytical models for helping
operations enhancements in EDs, we adopt a simulation approach for improving
patient flows in the ED of PWH as it can incorporate randomness into the model and
is easier to examine many ‘‘what-if’’ scenarios with the complex system of the ED
(such as time and category-dependent arrival rates of patients, different service-time
distributions and time-varying staffing levels). Moreover, compared with analytical
approaches, simulation is less sensitive to model parameters (Sinreich and Marmor
2005). Simulation is also particularly suitable for systems of patient care where
resource availability is important (Davies and Davies 1994), where EDs are usually
this case (e.g., insufficient medical staff). More importantly, a simulation approach
is more convenient for real implementation since practitioners, who are not
necessarily equipped with advanced mathematical and programming knowledge,
can easily understand and make changes in the system (by changing some input
parameters of the simulation model once it is successfully established) within a
user-friendly graphical interface. Thus, users can ‘‘foresee’’ outcomes, which are
basic statistical performance measures such as maximum and average waiting time
of patients and utilization of staff, under complex scenarios.
The applications of simulation in the area of health-care management have been
studied for more than half of a century, e.g., Fetter and Thompson (1965); and the
academic literature on simulation in health-care is immense. We refer the reader
to Günal and Pidd (2010) and Jun et al. (1999) for an overview. According
to Brailsford et al. (2009), the number of articles related to health-care simulation or
modelling is currently expanding at the rate of about 30 articles a day,
nonetheless Jahangirian et al. (2012) found that only 8 % of the papers actually
applied simulation to a real problem where real data was used. This proportion is
substantially smaller than the corresponding percentages in the areas of commerce
(49.1 %) and defense (39.4 %). This highlights the fact that real implementations of
simulation models in practice in the health-care sector are still rare and we still need
to put more effort on promoting the use of simulation for advancing health-care
management. In this paper, we present a real case of analyzing and improving
patient flows in an ED in Hong Kong with the use of simulation. In EDs, reported

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successful cases of applying simulation models were mainly to improve the

efficiencies of daily operations. A major proportion of work with the use of
simulation in EDs is staff scheduling. The approaches are mainly to evaluate
process performance with different staff shift schedules, e.g., Evans et al.
(1996), Rossetti et al. (1999) and Wang et al. (2013). Some other papers integrated
optimization techniques with simulation. Ahmed and Alkhamis (2009) presented a
simulation–optimization approach to determine the optimal number of doctors, lab
technicians and nurses required in the ED to maximize patient throughput and to
reduce patient time in the system subject to a set of constraints imposed on budgets,
patient waiting time and number of servers. Centeno et al. (2003) integrated
simulation (for establishing the staffing requirements for each period) and integer
linear programming to help ED managers optimize staff schedules so as to
maximize utilization within given budgets. Yeh and Lin (2007) utilized simulation
and a genetic algorithm to obtain a near-optimal nurse schedule based on
minimizing the patients’ queue time. There has also been work on examining
queueing priorities in EDs by running simulation experiments. Connelly and Bair
(2004) developed a simulation model for system-level investigation of ED
operations and to compare a fast-track triage approach with an acuity-ratio triage
approach. Other related applications include policy/decision making. Hoot et al.
(2008) used simulation of patient flow to predict near-future ED operational
measures and to forecast ED crowding. Lane et al. (2000) used simulation to
analyze the functioning of the ED system under different policies, different bed
capacity and demand pattern scenarios. Baesler et al. (2003) developed a simulation
model to estimate the function of patients’ time-in-system and the maximum level
of patient demand that the system can absorb. Wang et al. (2009) developed a
simulation model by using ARIS and ARENA to identify process bottlenecks and
adjust resource allocation or staff dimensioning. They also proposed doctor’s
efficiency improvement and quick pass process to reduce waiting time. Abo-Hamad
and Arisha (2013) developed an interactive simulation-based decision support
framework to examine the impacts of different potential alternatives (opening a
short stay unit, increasing number of trolleys, adding an additional senior house
officer overnight shift, and their combinations) on some key performance indicators
such as average waiting time, length of stay and resource utilizations.
The development of our simulation model of the ED was challenged by the fact that
the service-time distributions are not directly obtainable. There has been much work in
the literature on estimating service-time distributions. For example, Babes and Sarma
(1991) used Weibull, Gamma, and exponential distributions to estimate the service-
time distributions in a health center. May et al. (2000) and Spangler et al. (2004)
estimated the surgical procedure times by fitting lognormal distributions. However, in
these papers, the actual service durations (i.e., the time differences between services
started and ended) were recorded so that the service-time distribution could be directly
estimated. When real data are incomplete or not available so that service durations
cannot be directly estimated, researchers may need to use indirect approaches to model
or estimate. A major research on handling missing data is using imputation (Enders
2010). The basic idea is to fill in the missing data with some plausible values, such as
mean substitution (Donner 1982), hot-deck imputation (Ford 1983), expectation

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maximization (Dempster et al. 1977), and multiple imputation (Rubin 2009).

However, most of the work in this research direction deals with the cases that, given a
set of variables (or attributes) associated with a dataset, only a proportion of, but not
all, the values are missing so that some statistical tools such as regression or maximum
likelihood function can be used to estimate the missing values. In our application, the
service end times of patients were not recorded in the computer system of the ED so
that service durations of patients could not be directly calculated and hence traditional
imputation approaches could not be applied. In the literature, if no records of the
required activity durations are available, researchers may need to make further
assumptions. For example, Zhang et al. (2004, 2005) used fuzzy numbers instead of
probability distributions to describe activity durations in a building construction
simulation model. For simulation model validation, Kleijen (1999) suggested different
approaches in three different situations: (1) no real data, (2) only real output data, and
(3) both real input and output data. Although in our application the service durations of
patients could not be directly calculated from the historical data, we had some other
time stamps which enable us to derive an indirect approach to estimate the service-
time distributions. In this paper, we propose a simulation–optimization approach (an
integration of simulation and meta-heuristics) to obtain a good estimate of the required
parameters for our simulation model, when records are missing and such parameters
cannot be directly estimated.

3 Comparisons between the original and current settings

Before we introduce our simulation model, we first present some real operational
enhancements made by the ED. In October 2010, the ED of PWH was relocated to a
new building with a new layout. Several changes were also made in the new system
to accommodate the increasing patient demand. In this section, we analyze two
major changes in the operations and compare the efficiencies of the original and
current systems. To make fair comparisons, we present some of the real data of the
month of December 2009 (when operating in the old location) and December 2010
(after relocation) provided by the ED. The data were stored in the computer system
of the ED and contain the triage category, arrival time, start times of service
activities (triage and consultation) and departure time of each patient. All of the data
were recorded by the staff at the service stations. In the data, there were 12,945
patient visits in December 2009, and 13,287 patient visits in 2010, which translate to
around 418 and 429 cases per day respectively. (The reason why we did not choose
the first month after the relocation to make comparisons is that a ‘‘warm-up’’ period
was needed since initially most of the staff needed time to get used to the new
layout, system and settings.) Below, we describe two key changes in layout and
operations and their impacts.

3.1 A closer sub-waiting area for consultation in the walking division

After the relocation of the ED, the waiting area for doctor’s consultation in the
Walking division was moved from the main waiting area to a new sub-waiting area,

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which is closer to the consultation rooms than before. This aims to shorten the
walking time of patients. More importantly, this enables the nurses to more easily
notify the patients that they will soon be seen by a doctor, so that they would not
leave the waiting area (e.g., for a meal) while waiting. Consequently, this reduces
the inactivity times of doctors waiting for ‘‘missing’’ patients, and hence reduces the
waiting times of subsequent patients seen.
We compare the net times from triage to consultation for category 4 patients, who
are mostly walking patients, before and after the relocation. Comparing the data of
2009 and 2010, although there was an increase of 2.64 % in the total number of
patient visits, the average net time from triage to consultation for category 4 patients
decreased from 112.91 to 107.77 min (a 4.55 % decrease). We conducted a two-
sample t test, at the 0.05 level of significance, to test whether the average net time
from triage to consultation for category 4 patients decreased from 2009 to 2010.
H0 : There is no difference between the average net times from triage to
consultation for category 4 patients in 2009 and 2010.
H1 : The average net time from triage to consultation for category 4 patients in
2010 is less than the one in 2009.
The t statistic is 3.31 (larger than 1.645) and the p value is 0.001 (less than 0.05),
and hence the null hypothesis is rejected at the 0.05 level of significance. This
suggests that walking patients benefit from the change of the layout of the waiting
area in the Walking division.
From Fig. 1, we observe the distribution of net time from triage to consultation
for category 4 patients in December 2009 has a heavier tail. The percentage of
category 4 patients who had net time from triage to consultation more than 3 hours
decreased from 21.57 to 16.01 % (a 25.78 % decrease). This indicates the increase
in walking time of patients could amplify the waiting times of patients.

3.2 Consolidation of the walking and non-walking divisions in nighttime

Before the relocation, the walking and non-walking divisions operated indepen-
dently, each with its own staff and resources. After the relocation, the ED started to
implement the policy that during nighttime (from 23:00 to 07:00) the Walking

Fig. 1 Net time from triage to consultation for category 4 patients

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Fig. 2 Average net time from triage to consultation for less urgent patients by arrival time of day

division is closed and the walking patients would join the system of the Non-
walking division. It aims to better-utilize the reduced workforce (about half of the
workforce of daytime) due to the low arrival rates of patients in nighttime.
Figure 2 depicts the average net time from triage to consultation for less urgent
patients (i.e., category 3 and 4 patients) by arrival time of day in 2009 and 2010.
From 07:00 to 20:00, the net times were similar in the two years. From 20:00 to
07:00, a significant improvement was observed. An interesting finding is that
patients arriving after 20:00 but before 23:00 also benefited from the consolidation
of the divisions. We believe it is due to the fact that some of these patients might
need to wait for consultation for more than 3 hours so that they might start
consultation after 23:00 and hence benefited from the change.

4 Simulation model

The system of the ED consists of many stochastic components such as patient

arrivals and service durations. Although a queueing theory approach may be
appropriate to model the uncertainty in the system, as also reported by other
researchers, it is very difficult to build analytical models for EDs as there are many
complicating factors in reality (such as time and category-dependent arrival rates of
patients, multiple shift-times of doctors and re-entrant flows to the many ‘‘service
stations’’ of the system). On the other hand, a simulation approach can incorporate
uncertainty into the model of the ED and also include those complicating factors.
From a modeling point of view, if we would like to evaluate the impacts of some
changes in the system (e.g., priority rules and changes of layout) on the ED
performance, we do not have to rebuild a completely different model, but instead,
only need to modify some modules of the simulation model. More importantly,
practitioners without advanced mathematical knowledge, who may find analytical
approaches difficult, can also easily understand and make changes in the simulation
model in a user-friendly interface. By using simulation, we can explore possible
changes without jeopardizing patient care. For this reason, we adopt a simulation

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approach which facilitates examination of many ‘‘what-if’’ scenarios, and provide

valuable indications as to where the major bottlenecks of the system might be.
In this section, we discuss the technical issues when developing our simulation
model. In Sect. 4.1, we present our time and category-dependent patient arrival
process. In Sect. 4.2, we discuss the challenges that some key parameters in the
simulation model are not directly obtainable and our parameter estimation
procedure to search for the necessary input parameters for the simulation model.

4.1 Time and category-dependent arrivals

From the data provided by the ED at PWH, the interarrival time of each patient
category is observed to follow an exponential distribution. We also observe that the
arrival rates of different categories are heterogeneous. From the ED at PWH, the
numbers of categories 1 and 2 patients are relatively low whereas the vast majority
of the patients are from categories 3 and 4. Another finding from the data is that the
arrival rates vary over time. These two findings are consistent with the literature
(e.g., Kumar and Kapur 1989; Rossetti et al. 1999).
The arrivals of patients with time-dependent arrival rates can be regarded as non-
homogeneous Poisson processes (NHPP), which has been well-studied (see
e.g., Cinlar 1975; Leemis 1991; Eick et al. 1993), although analytical results are
known for only specialized cases. In our simulation, we model the arrival events by
category and by time of day. To simulate an arrival of a patient, we generate an
interarrival time, which follows an exponential distribution with arrival rate k,
corresponding to the arrival rate in the time period of the previous arrival for the
particular patient category. Specifically, we let kk ðtÞ be the arrival rate of patient
category k at time t and Ak;n be the arrival time of the n-th patient of category k. If
Ak;n ¼ t, we let Ik;n ðtÞ be the interarrival time between the n-th patient and the
ðn þ 1Þ-th patient from category k. The time of the next arrival from the same
category is Ak;nþ1 ¼ Ak;n þ Ik;n ðtÞ , where Ak;1  Expðkk ð0ÞÞ and Ik;n ðtÞ  Expðkk ðtÞÞ.
Whenever we generate an interarrival time, we use the arrival rate that was in effect
when the previous arrival occurred. This allows us to incorporate the effects of the
non-stationary time-varying arrival rates of patients. To verify our category-
dependent arrival procedure, we simulated the arrivals of a month. Figure 3 shows
that the proportion of patients observed in the simulation in each category were
quite close to the actual data. We present in Figs. 4 and 5 the actual and simulated
arrival rates of categories 3 and 4 patients (which comprises the majority of
patients), respectively, by time of day.
To further validate the time-varying arrival procedure, we conducted a two
sample Kolmogorov–Smirnov (K–S) test to compare the actual and simulated
interarrival times of category 3 patients for each hour. We choose to report the
interarrival times of category 3 patients because the sample size of category 3
patients is large enough to be analyzed; there were very few category 1 and 2
patients in each month (less than 10 samples in some hours). Another reason is that
the time stamps stored by the computer system of the ED were corrected to the
minute (i.e., discrete); category 4 patients have a very high arrival rate (more than

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Fig. 3 Proportion of patients in each category: actual data versus simulated results

Fig. 4 Arrival rate of category 3 patients by time of day: actual versus simulated

Fig. 5 Arrival rate of category 4 patients by time of day: actual versus simulated

20 patients), or equivalently a very small average interarrival time (2–3 min), in

peak hours so that the actual data are not precise enough to be compared with the
simulated results.
For each hour, we conduct the following K–S hypothesis testing for the actual
and simulated interarrival times of category 3 patients.
H0 : The actual and simulated interarrival times follow the same distribution.
H1 : The actual and simulated interarrival times follow different distributions.

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Table 1 p values of the K–S hypotheses on the actual and simulated interarrival times of category 3
patients
Hour 00:00 01:00 02:00 03:00 04:00 05:00 06:00 07:00
p value 0.8987 0.2597 0.3602 0.7765 0.0835 0.0439 0.5249 0.2309
Hour 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00
p value 0.6541 0.5249 0.0104 0.1941 0.1461 0.0975 0.2545 0.4950
Hour 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00
p value 0.5562 0.3754 0.1076 0.5740 0.4378 0.1258 0.5213 0.2268

Fig. 6 Interarrival time of category 3 patients in the period of 19:00–20:00: actual versus simulated

Table 1 gives the p values of the K–S hypotheses. Of the 24 K–S hypotheses, 22 of
the null hypotheses are not rejected at the 0.05 level of significance. Here, we note
that the arrival times of patients obtained from the ED do not represent the exact
arrival times because the ED recorded patient arrivals at the time of registration (i.e.,
patients may have to queue after their arrivals) and, as mentioned, the system has all
the time stamps only corrected to the minute. Given these considerations, we believe
that the simulated arrivals match the actual arrivals fairly.
For an illustration purpose, we also present the actual and simulated interarrival
times of category 3 patients in the two time periods which have the median arrival
rates (19:00–20:00 and 21:00–22:00) in Figs. 6 and 7, respectively.

4.2 Service activities

Service activities refer to the operations such as registration, triage, consultations

and resuscitation for walking and non-walking patients, where the duration of each
service activity has its own probability distribution. To accommodate the variety of
distributions, we assume that the service times follow Weibull distributions, which
can fit many continuous functions on the positive real line. For example, when the
shape parameter equals one, a Weibull distribution reduces to an exponential
distribution, which is commonly used to model service durations (e.g., De Angelis
et al. 2003; Siddharthan et al. 1996). Weibull distributions can also fairly
approximate normal distributions with some values of the shape parameter (Rinne
2008). Some literature also reported that their service durations follow Weilbull

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Fig. 7 Interarrival time of category 3 patients in the period of 21:00–22:00: actual versus simulated

distributions (e.g., Rohleder et al. 2011). We notice that some literature assumes that
their service durations follow other probability distributions such as uniform
distributions (e.g., Garcı́a et al. 1995), triangular distributions (e.g., Draeger 1992;
Yeh and Lin 2007) and log-normal distributions (e.g., Hoot et al. 2008). Although in
our implementation we assume that the service activities follow Weibull distribu-
tions, our parameter estimation procedures described in Sects. 4.3 and 4.4 are very
general (not restricted only to Weibull distributions) and can also be applied with
any continuous probability distributions.
Let Si;n be the service time for the n-th execution of service operation i. We
assume that Si;n  Weibullðai ; bi Þ. For each service operation, we choose the
appropriate distribution parameters a (the scale parameter) and b (the shape
parameter). We assume the service rates, hence a and b, are constant for all time
periods for a given service operation. Implicitly, this assumes that the doctors and
nurses maintain the same level of effectiveness throughout their shifts.
To build an accurate simulation of the ED, we need the probability distributions
of its activities. Ideally, these distribution parameters can be obtained from
historical data. However, data from the ED at PWH on patient movements were
incomplete. The available data included only the time-stamps when patients started
service for the activities (triage, consultation, etc.) in the ED. Unfortunately, the
time-stamps when patients completed the service were not recorded, so the service
times cannot be measured directly. Figure 8 illustrates the time-stamps we obtained
from the computer system.
In the following, we present some search methods to estimate the parameters for
the distributions required for our simulation model, and discuss the challenges of
such parameter estimations.

4.3 Estimation of service-time distributions

The available data we have are the times in between the start of two different services
for each patient (such as from triage to consultation). This ‘‘time difference’’ consists
of the service time in triage and the waiting time before consultation. Thus, the actual
service durations are not measured, and hence their distribution parameters cannot be
directly estimated. Suppose we simulate with a ‘‘guesstimate’’ for the parameters of

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Fig. 8 Time-stamps recorded when a less non-urgent walking patient visits the ED

the service durations (e.g., for triage and for consultation), the resultant ‘‘time
differences’’ can then be measured from the simulation. If the patterns of the time
differences are consistent with the ones of actual data, it is likely that a good estimate
of the parameters of service times was used for the simulation model. Since the
parameters for different service distributions interact with each other to influence
these ‘‘time differences’’, the whole set of parameters has to be considered
simultaneously to determine if the parameters for all the service durations are
estimated accurately. By trying different sets of values of ai and bi for ALL the
different distributions needed for the simulation model, we choose the set for which
the simulated results are most consistent with the actual data.
Specifically, we let a and bbe the
 vectors of parameters ai and bi ; we denote by
a
ab the appended vector ab ¼ . Let xk;n and xab
k;n respectively be the actual and
b
simulated time differences with parameters ab from triage to consultation for the n-
th patient from category k respectively, where k 6¼ 1; 2. (Since patients from
categories 1 and 2 can receive immediate treatment, with no triage and no waiting
time, these categories are not considered in our consistency measure.) Let lk (lab k
respectively) and rk (rabk respectively) be the average and the standard deviation of
these xk;n ( xab
k;n respectively).
Instead of simply comparing means, we use a more detailed consistency measure
to compare the distribution profiles. We divide the domains of the probability
distributions into intervals. Let pk;j (pab
k;j respectively) be the proportion of patients
N k;j
with xk;n ( xab
k;n respectively) in the j-th interval ½lj ; ljþ1 Þ, i.e., pk;j ¼ Nk
, where N k;j ¼
jfn : lj  xk;n \ljþ1 gj and N k is the total number of patients in the actual data.
ab
Nk;j
Similarly, pab
k;j ¼
ab
, where Nk;j ¼ jfn : lj  xab ab
k;n \ljþ1 gj and Nk is the total number
Nkab
of patients in the simulation with parameters ab. We use the following function to
measure the consistency between the actual data and the simulated result.
  X jlab  lk j X jrab  rk j
c xab ; x ¼ c1 w1;k k þ c2 w2;k k
k
lk k
rk
X X jpab
k;j  pk;j j
þ ð1  c1  c2 Þ w3;k aj
k j
pk;j

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Improving the efficiency of a hospital emergency department 133

P P ab
where 0  ci ; wm;k ; aj  1, and k wm;k ¼ j aj ¼ 1. The function cðx ; xÞ is a
weighted average of the absolute values of the relative errors of the mean, standard
deviation and the proportions of classes for each category of patients. The last term
of the consistency function measures the difference between the actual and simu-
lated distribution profiles. The lower the value, the higher is the consistency
between the data and the simulated result.

4.4 Search procedure for parameter estimation

In the literature on simulation models in health-care, we did not find much

discussion on the problem of service times not directly measurable. One related
work is De Angelis et al. (2003), who estimated the parameters of the approximated
function of average time a patient spent in the system, using simulation and
optimization routines. In our case, the estimation problem is more complicated since
we are estimating parameters of probability distributions and not just a deterministic
function; the parameters of the Weibull distributions to be estimated do not
explicitly appear in our consistency function cðxab ; xÞ.
We estimate the set of parameters jointly using a search procedure. Starting with
an initial guess of the distribution parameters, we compute the consistency function
to evaluate ‘‘goodness of fit’’. We explore iteratively a search neighborhood by
adding/subtracting an increment to/from the current set of parameters, until the
stopping criterion is satisfied, and retain the set of parameters with the smallest
value of the consistency function. We tested two widely-used search methods—the
Descent Method and Simulated Annealing—and report on their effectiveness in
identifying parameters for our simulation model.

4.4.1 Parameter estimation by descent method

In the descent method (DM), one moves along a search direction until no
improvement can be made. At that point, the algorithm selects another search
direction. The procedure stops when there is no further improvement in all
directions examined. In our implementation, a search direction corresponds to
increasing or decreasing the value of a single parameter. i.e., Given a current
combination of parameters ab, the new combination of parameters is obtained from
ab by increasing or decreasing a single parameter. Then we run simulations to
evaluate the new xab and hence cðxab ; xÞ. If an increase (a decrease) in the parameter
value improves the consistency objective cðxab ; xÞ, i.e., the consistency objective
value is smaller, then the algorithm keeps increasing (decreasing) the value until
there is no improvement. When the algorithm cannot reduce the consistency
objective value when moving in that direction, it selects another parameter to adjust
and repeats the above search procedure. The algorithm terminates when it cannot
reduce the consistency objective value by changing any one of the parameter values
or reaches the preset maximum number of iterations. We remark that the increments
of the search step should be small enough to be able to identify optima in the search

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134 Y.-H. Kuo et al.

neighborhood, but at the same time not too small to make our search procedure
inefficient. The procedure is summarized as follows.

Using a more general search direction (instead of co-ordinate direction only) may
improve convergence and find better local optima, but determining the search
direction may not be straightforward. It would certainly be interesting to
considering more general descent directions in our future research.
By the DM, we can obtain a ‘‘good’’ solution quickly. However, the solution can
become trapped at a local optimal point, and global optimality is in general not
guaranteed. Therefore, we apply a ‘‘hill-climbing’’ meta-heuristic—simulated
annealing—to resolve the problem.

4.4.2 Parameter estimation by simulated annealing

Simulated annealing (SA), introduced by Kirkpatrick et al. (1983), is a probabilistic

meta-heuristic widely-adopted for global optimization problems, especially in
combinatorial optimization. SA is designed to avoid the search process being

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Improving the efficiency of a hospital emergency department 135

trapped at a local optimum. To apply the algorithm, a neighborhood structure is

defined. If there is an improvement when moving from the current solution to a
neighboring point, we always make the move. However, if the move would worsen
the objective value, the move is still accepted with some probability, which depends
on the change in the objective function and the current number of iterations. A
temperature, T, is used to determine how the acceptance chance of a worse move
changing with the number of iterations. Thus, our SA search procedure is almost the
same as our DM, except that some worse moves (i.e., increasing or decreasing a
parameter value will increase the consistency objective value) might be accepted by
chance. For comparison with the DM, we define the neighborhood as differing by
one parameter value only. We summarize our SA search procedure as follows.

Note that the acceptance criterion ensures that all improved moves are accepted
d
since eT [ 1 as d [ 0. The temperature T acts to control the search process. As the
number of iterations increases, T becomes smaller and smaller, so non-improving

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136 Y.-H. Kuo et al.

moves have a lower chance of being accepted and the algorithm tends to resemble
the DM. When the algorithm terminates, we can also save the final solution as an
initial solution to restart the procedure again. A good initial guess of the parameters
ab can lead to a good solution using the above two methods. In our computations,
the initial values of the Weibull parameters were estimated based on discussions
with the ED operations manager at PWH.
For each iteration to evaluate a set of parameters, we ran a simulation of 34 days
with a warm-up period of 3 days, i.e., a simulation of 31 days starting from a non-
empty system. This can produce around 13,000 patient records to make comparison
with the real data. We notice that the simulated results would be more accurate if we
increase the number of replications. However, a large number of replications will
make the search procedure inefficient. We applied both the DM and SA to search for
the best parameters to fit the real data. DM made no improvement after 2,000
iterations, with a final consistency value of 0.1736 (i.e., an average absolute relative
error of 17.36 %). We let the SA run 5,000 iterations, then used the final solution to
restart the process again, and repeated this process 3 times. The best combination of
parameters found by the SA has a consistency value of 0.0738. In comparing the
DM and SA for parameter estimation, we observed that the DM became trapped at
local optima, as other researchers have reported. We also observed that this solution
was quite far from the solution that we obtained by the SA, in terms of the objective
value. However, one advantage of using the DM is that the algorithm terminates in a
relatively short time since local optima can always be found easily by just moving in
a beneficial direction. In terms of solution quality, the SA provides a better solution
but the solution time may be long. Figures 9 and 10 illustrate the comparisons
between the actual data and simulated results (with the best parameters found) of the
time spent from triage to consultation for categories 3 and 4 patients. The figures
suggest we obtained reasonably good estimates of the parameters.
With the parameter estimation procedure, we developed a very detailed model of
the new ED to analyze patient flows. Our simulation model captures: all relevant
treatment processes (triage, consultation, lab tests, etc.), the complexities of
intertwining and re-entrant patient-flows, complicated arrival rates that vary by time
and patient category and adjustable staff deployment (shift, breaks, etc.). The
necessary input parameters/data are arrival rates, probability distributions of service
times, available resources and schedules of doctors and nurses. The outputs are the
key performance measures such as patients’ waiting time, queue lengths, utilizations
of doctors, which help us to study and understand the performance of the ED. The
key modules in our simulation model and their uses are as follows:

• Patient arrivals (CREATE modules): Each module generates patients of the

same category according to the arrival time of the previous arrival.
• Patient attributes (ASSIGN modules): Each module assigns attributes (e.g.,
triage duration, consultation duration, binary values to indicate if further
examinations are needed) to a patient according to his/her category.
• Walking or Non-walking division determination (DECIDE module): This
module decides if a patient goes to walking or non-walking division, according

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Improving the efficiency of a hospital emergency department 137

Fig. 9 Time spent from triage to consultation for category 3 patients: actual versus simulated

Fig. 10 Time spent from triage to consultation for category 4 patients: actual versus simulated

to his/her mobility and the current time (the Walking division is closed from
23:00 to 07:00).
• Triage (PROCESS modules): Two modules, respectively for Walking division
and Non-walking division, request for a triage nurse (using Seize Delay Release)
to examine a less urgent patient and assign triage category.
• Consultation (PROCESS modules): Two modules, respectively for Walking
division and Non-Walking division, request for a physician (using Seize Delay
Release) to provide medical service to a less urgent patient.
• Resuscitation (PROCESS module): This module requests for two physicians
from Non-walking division (using Seize Delay Release) to resuscitate a
critically-ill patient.
• Lab tests (PROCESS modules): Each module requests for a resource (using
Seize Delay Release), e.g., an X-ray test technician, to provide an extra test to a
patient.
• Discharge (DEPOSE module): A patient can be discharged from the ED after
all the required medical services.

Through the simulation model, we can identify potential enhancements of the

system and hence improve the service quality. To further validate our simulation
model, we presented the model and the simulated key performance indicators such

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as waiting times of patients to a consultant in the ED. He believed the model was
sufficient to capture all the key activities and those values agreed with his
estimations. Our simulated results are also consistent with the findings in an
independent research of a 5-year study of PWH ED (Wai et al. 2009).

5 Simulation results

By running simulations, we have a way to obtain performance measures for the ED

under different scenarios and, thus, to evaluate possible policies and changes in the
system. We used the current arrival rates and the actual staff schedule as the input
parameters for our base case. We did a series of simulation runs to evaluate different
possible scenarios. For each scenario, we ran 100 replications of simulations of
34 days with a warm-up period of 3 days, which is equivalent to 100 simulations of
31 days starting from non-empty systems, and recorded the net times from registration
to consultation for less urgent patients. The net times from registration to consultation
indicate how long after arrival the patients can receive medical treatments.

5.1 Ten-percent growth in patient arrivals

The population in Hong Kong keeps increasing [with an annual growth of around 1 %,
according to the end-year population report for 2012 issued by the Census and Statistics
Department of the Hong Kong Government (Census and Statistics Department, the
Government of the Hong Kong Special Administrative Region 2013)], mainly due to an
influx of immigrants. Moreover, more and more non-immigrant visitors from Mainland
China also come to Hong Kong for a better quality of medical treatments. Thus, the
demand for medical services in Hong Kong is expected to have significant growth in the
coming future. This is of particular concern for the EDs, which are often viewed as
inexpensive clinics by the non-critical patients who visit them.
To study how the growth of patient visits impact on the daily operations in the
ED, we increased the arrival rates of all patient categories by 10 % (which is
equivalent to the percentage increase in 3–4 years using the estimated annual
increase of 2.64 %) and keep all the capacities and resources at the current levels.
From Table 2, we observe that a 10 % growth of patient arrivals leads to a big
increase in the net times from registration to consultation and larger variances of

Table 2 Net times (in minutes) from registration to consultation for less urgent patients based on the
current arrivals and the simulated scenario (10 % growth in patient arrivals)
Category % of patients Current situation 10 % growth % change

Cat. 3 non-walking 11 16.45 (0.44a) 33.76 (1.49) ?105.23

Cat. 4 non-walking 17 40.38 (1.66) 105.11 (4.58) ?160.30
Cat. 3 walking 16 27.39 (0.54) 39.90 (0.88) ?45.67
Cat. 4 walking 52 172.51 (1.71) 295.64 (14.47) ?71.38
a
The half width

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Improving the efficiency of a hospital emergency department 139

these net times (as indicated by the half widths). The net times from registration to
consultation increase more than 45 % for all less urgent patient categories. Non-
walking patients would suffer from a longer time from registration to consultation
(more than doubled) due to the increase in the number of patients. As expected, a
larger increase in this net time is observed for category 4 patients since a lower
priority is given to them. The 10 % growth in patient arrivals leads to an increase in
doctors’ utilization, from 86.60 to 95.90 %. Some doctors are overloaded with
utilization of more than 100 % (i.e., some doctors are always busy in their
scheduled work shifts plus some extra time to finish providing medical services to
the last patient of their work shifts). Moreover, it is important to point out that,
based on the above results, the service target of ‘‘waiting time of urgent patients
should be within 30 min’’ set by the Hospital Authority of Hong Kong probably
cannot be met after 10 % growth of patients arrivals if the capacities and resources
of the ED are kept at the current levels.

5.2 Adding an extra doctor

In order to analyze the impacts of adding additional resources on the ED

performance, we evaluate the time for patients to receive medical treatments if an
extra doctor is hired, based on the current arrival profile. This activity is useful to
determine the optimal trade-off between the cost of additional workforce and the
services provided.
Before adding an extra doctor to the simulation model, we calculated the
utilization of every doctor in order to assess which doctors are overloaded. We
observe a significant overuse of the doctors working the afternoon shift in the
Walking division and those for the mid-night shift. Therefore, we simulated the two
scenarios when an extra doctor is added to each of the shift.
Table 3 lists the net times from registration to consultation for less urgent
patients if we add an extra doctor to the afternoon shift in the Walking division. Not
surprisingly, on average, the relative time reduction for category 3 patients from
registration to consultation is smaller than category 4 patients’ as category 3 patients
have a higher priority. An interesting finding is that non-walking patients also
benefit from the addition of an extra doctor to the Walking division because more
walking patients are cleared before the consolidation of the walking and non-
walking divisions at 23:00 (i.e., Walking division is closed).
Alternatively, if we add an extra doctor to the mid-night shift, we observe a more
significant reduction in the net times for the patients in the Non-walking division
(see Table 4). Although the walking patients are directed to the Non-walking
division for consultation in nighttime, we can only make a less significant reduction
in the waiting times for walking patients after adding an extra doctor to the mid-
night shift. We believe this is due to the fact that the consultation is still not fast
enough to clear the patients of the lowest priority, who are category 4 walking
patients. Another possible reason is that patients usually experience longer waiting
times during afternoon but not nighttime, which is shown in Fig. 2. Finally, we
report that having an extra doctor can contribute to a decrease in doctors’ utilization
from 86.60 to 80.46 %.

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140 Y.-H. Kuo et al.

Table 3 Net times (in minutes) from registration to consultation for less urgent patients based on the
current situation and the simulated scenario (an extra doctor added to the afternoon shift in the Walking
division)
Category % of patients Current situation Doctor added % change

Cat. 3 non-walking 11 16.45 (0.44) 15.23 (0.35) -7.42

Cat. 4 non-walking 17 40.38 (1.66) 34.56 (1.21) -14.41
Cat. 3 walking 16 27.39 (0.54) 26.46 (0.54) -3.40
Cat. 4 walking 52 172.51 (1.71) 82.16 (0.99) -52.37

Table 4 Net times (in minutes) from registration to consultation for less urgent patients based on the
current situation and the simulated scenario (an extra doctor added to the mid-night shift)
Category % of patients Current situation Doctor added % change

Cat. 3 non-walking 11 16.45 (0.44) 14.99 (0.34) -8.88

Cat. 4 non-walking 17 40.38 (1.66) 32.66 (1.13) -19.12
Cat. 3 walking 16 27.39 (0.54) 27.21 (0.54) -0.66
Cat. 4 walking 52 172.51 (1.71) 154.86 (1.50) -10.23

5.3 Reallocation of doctor

Although adding more resources to the ED is the best way to improve the patient
flows, the financial issue is one of the major concerns of the hospital management.
Given limited budgets, one way to improve the patient flows is to best-utilize the
current resources. Therefore, we would like evaluate how the schedules of the
doctors, who are the most valuable resources in the ED, might be changed to
improve the efficiency of the ED. By measuring the utilizations of doctors in the
current scenario, we can find out the doctors with the heaviest and lightest
workloads. They are the doctors in the Walking division and Non-walking division,
respectively, in the afternoon. An interesting scenario would be to assign the doctor
who has the lightest workload to the shift of heaviest workload. (i.e., In the
afternoon shift, extract a doctor in the Non-walking division and assign him/her to
the Walking division.) The results are shown in Table 5.
As expected, walking patients benefit from this reallocation. A significant
reduction in the net time from registration to consultation is observed for walking
patients. However, this net time for non-walking patients increases as a doctor is
removed from the Non-walking division. The reallocation of doctor, of course,
benefits the majority, but at the same time, hurts the more urgent minority. To
decide whether we should employ this schedule, we have to determine the optimal
trade-off. Simulation is a tool for decision makers to ‘‘predict’’ how good or how
bad a change impacts the system in order to make the right balance. We would like
to point out that, although there is an increase in the time to receive consultation for
category 3 non-walking patients after this reallocation, the absolute increase
(0.46 min) is still small enough to be within range of the target waiting time set by

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Improving the efficiency of a hospital emergency department 141

Table 5 Net times (in minutes) from registration to consultation for less urgent patients based on the
current situation and the simulated scenario (reallocation of doctor)
Category % of patients Current situation Reallocation % change

Cat. 3 non-walking 11 16.45 (0.44) 16.91 (0.31) ?2.80

Cat. 4 non-walking 17 40.38 (1.66) 61.01 (2.25) ?51.09
Cat. 3 walking 16 27.39 (0.54) 26.61 (0.54) -2.85
Cat. 4 walking 52 172.51 (1.71) 85.80 (1.10) -50.26

the Hospital Authority for patients of this category. Moreover, this increase is
comparably much smaller than the absolute reduction for the category 4 walking
patients (86.71 min). As the majority of patients are category 4 walking patients, a
reduction in total average waiting time is achieved after the reallocation.
Nonetheless, this balance between benefits to the majority and urgency of service
to those in need is a difficult decision for the hospital management.

5.4 Staggered shifts

In a setting of staggered shifts, staff start and finish at slightly different times (but
the durations of shifts are usually the same). The use of staggered shifts has been
proven to be effective in better-allocating workforce to match demands. For
example, Sinreich and Jabali (2007) adopted staggered shifts to downsize and
restructure the workforce in an ED while maintaining the original operational
measures. In this research, we explore, with our simulation model, the benefits of an
employment of staggered shifts for physician scheduling in the ED of PWH. By
observing the arrival patterns in Fig. 5, we adopt six different shift staring times,
staggered 30 min from 07:00 to 09:30, to replace the original starting time at 08:00.
Table 6 shows the net times from registration to consultation for less urgent patients
when adopting the staggered shifts. The adoption of staggered shifts benefits most of
the patient categories with reductions in the net times ranging from 0.18 to 5.71 %.
Staggered shifts not only better-matches manpower with patients’ demands, but also
enhances quality of services provided, since staff members would have some overlaps
of shift times so that they can hand over the tasks to those of the following shift. Thus,
the adoption of staggered shifts is expected to benefit the overall operational
performance of the ED more than what the simulation results show. Finally, we remark
that even though a proper use of staggered shifts is usually beneficial to operations, it
may be difficult to implement in practice. For example, staff members may complain
about unfair work schedules (e.g., some people starting very early) and it is hard for the
ED to conduct a briefing before the staff members start to work.

5.5 Having nurse practitioners

A nurse practitioner (NP) is an advanced practice registered nurse who has

completed clinical education beyond that required of a regular registered nurse, and
can diagnose and treat a wide variety of medical problems. Lenz et al. (2004) found

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142 Y.-H. Kuo et al.

Table 6 Net times (in minutes) from registration to consultation for less urgent patients based on the
current situation and the simulated scenario (adopting staggered shifts)
Category % of patients Current situation Staggered shift % change

Cat. 3 non-walking 11 16.45 (0.44) 15.51 (0.32) -5.71

Cat. 4 non-walking 17 40.38 (1.66) 40.00 (1.43) -0.94
Cat. 3 walking 16 27.39 (0.54) 27.34 (0.54) -0.18
Cat. 4 walking 52 172.51 (1.71) 166.93 (1.71) -3.23

Table 7 Net times (in minutes) from registration to consultation for less urgent patients based on the
current situation and the simulated scenario (having nurse practitioners)
Category % of patients Current situation Having NPs % change

Cat. 3 non-walking 11 16.45 (0.44) 14.93 (0.37) -9.24

Cat. 4 non-walking 17 40.38 (1.66) 33.18 (1.26) -17.83
Cat. 3 walking 16 27.39 (0.54) 27.43 (0.56) ?0.15
Cat. 4 walking 52 172.51 (1.71) 144.11 (1.84) -16.46

in their 2-year follow-up study that outcomes of patients assigned for their primary
care to a NP practice do not differ from those of patients assigned to a physician.
Other research (e.g., Blunt 1998; Chamberlain and Klig 2001; McGee and Kaplan
2007) have also proven that the use of NPs can provide high quality, efficient and
cost-effective care in EDs. In this investigation, we evaluate the benefits from
replacing the regular registered nurses at the triage stations by NPs. According
to Niska et al. (2010), 4.0 % of the patients were seen by NPs in EDs in U.S. and we
assume in our simulations that this percentage of patients can be discharged after
being seen by a NP.
Table 7 shows the benefits of replacing regular registered nurses by NPs at the
triage stations. Note that, in Table 7, the statistics of the scenario of having NPs
exclude those patients who could be discharged immediately after being treated by a
NP. There are reductions in the net times from registration to consultation for most
patient types. Although there is a slight increase in this net time for category 3
walking patients, this increase is not statistically significant by observing the
corresponding half widths. We observe that, for some patient types, the benefits of
having NPs are more significant than having an extra doctor. For example, the
reductions in the net times for category 4 walking and category 3 non-walking
patients when having NPs are greater than those when having an extra doctor in the
mid-night shift (see Tables 4, 7). Although a NP (with an average annual salary of
USD 91,450 in 2012 according to the 100 Best Jobs, Money, U.S. News 2014) is, in
general, less expensive than an emergency physician (with an average annual salary
of USD 270,000 in 2012 according to Emergency Medicine Physician Compen-
sation Report, Medscape 2013), replacing all the regular registered nurses (with an
average annual salary of USD 67,930 in 2012 according to the 100 Best Jobs,
Money, U.S. News 2014) by NPs at the triage stations for all shifts can be more

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Improving the efficiency of a hospital emergency department 143

expensive. Thus, when there is an additional financial support given to the ED for
increasing workforce, the ED has to consider all the benefits to different groups of
patients and the total costs of hiring different types of staff. A rough estimate of the
cost of replacing all the regular registered nurses by NPs at the triage stations is
(USD 91,450–USD 67,930)  5 (one triage nurse each at walking and non-walking
divisions for the morning and afternoon shifts, and one triage nurse for the mid-
night shift) ¼ USD 117,600, which is less expensive than an emergency physician.
This appears that having NPs is more cost-effective for the ED. Thus, our simulation
model allows the human resources managers of the ED to examine the trade-offs
between having different workforce plans.
To summarize, although reallocation of doctor (in the afternoon shift, extract a
doctor in the Non-walking division and assign him/her to the Walking division) has
a significant reduction in the time to receive medical treatments for category 4
walking patients, the category 4 non-walking patients experience a significantly
longer time for waiting for consultation. It appears that the implementation of
staggered shifts is better if the ED does not want to increase the waiting time of any
patient category. If there is only a tight financial budget for the ED to hire medical
staff, replacing regular registered nurses by NPs at the triage stations seems to be
more cost-effective. However, if the ED has a generous financial support, hiring an
additional physician for the afternoon shift in the Walking division can reduce a
significant amount of time for patients for waiting for consultation (since adding
more NPs than sufficient would not bring more benefits). Although we just
presented some of the issues examined, the simulation model could be used by the
operations manager in the ED to evaluate many other possible changes in the
system, such as layout, capacities and resources.

6 Conclusions

This paper presents a case study of analyzing patient flows in a hospital ED in Hong
Kong. We analyzed the enhancements of the system changes after the relocation of the
ED in October 2010. We also developed a simulation tool for the ED to evaluate the
impacts on patient flows with different scenarios. When developing our simulation
model, we faced the challenge that the data kept by the ED were incomplete so that the
service-time distributions were not directly obtainable. We propose a simulation–
optimization approach, which integrates simulation with meta-heuristics (descent
method and simulated annealing), to search for a good estimate of the input
parameters. Computational results show that our proposed solution methodology is
effective in producing good estimates of parameters. With a good estimate of
parameters, we did a series of simulation runs to evaluate different possible scenarios.
Although we just presented some of the issues examined, the simulation model could
be used by the operations manager in the ED to evaluate many other possible changes
in the system, such as layout, capacities and resources, which can also throw some light
on key issues of decision making for the operations manager.
Finally, it is important to remark that, in general, it is very difficult (or nearly
impossible) to build a simulation model for an ED to capture all the activities and

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events in the system, particularly when key parameters cannot be estimated directly.
However, the inclusion of the major activities and events, as captured by our
simulation model, was already sufficient to let operations managers in EDs
‘‘foresee’’ the impacts on the daily operations due to possible changes, and
consequently enable them to make much better decisions.

Acknowledgments The research of the first author is supported by Macao Science and Technology
Development Fund 088/2013/A3. The work of the fourth author is partially supported by GRF grant
414313 from the Hong Kong Research Grants Council. The authors would like to thank Mr. Stones
Wong, Operations Manager of the Emergency Department of the Prince of Wales Hospital, for his
assistance in data collection. The authors also thank the referees for their helpful comments on this article.

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Yong-Hong Kuo is currently a research assistant professor at the Big Data Decision Analytics Research
Centre at the Chinese University of Hong Kong. He received his B.Sc. in Mathematics with a minor in
Risk Management Science, and M.Phil. and Ph.D. in Systems Engineering and Engineering Management,
all from the Chinese University of Hong Kong. Prior to returning to the Chinese University of Hong
Kong, he was an assistant professor at the School of Business at Macau University of Science and
Technology. During his studies, he worked at University of California at Berkeley as a visiting researcher
and Oak Ridge National Laboratory as a research student. His research interests include operations
research, combinatorial optimization, logistics management, system simulation and healthcare
management.

Omar Rado received his M.Sc. in Industrial Engineering in 2011 from the University of Padova. During
his academic career he studied at the Chinese University of Hong Kong and the University of California,
Berkeley. He is now working as a Management Consultant at PriceWaterhouseCoopers focusing on
operations management, supply chain and related technologies.

Benedetta Lupia received her M.Sc. in Industrial Engineering in 2011 from the University of Padova and
she conducted her master thesis at the Chinese University of Hong Kong. She is now working as a
Production Planner at Luxottica focusing on manufacturing and supply chain management.

Janny Leung is a professor in the Systems Engineering and Engineering Management Department at the
Chinese University of Hong Kong. She obtained her Ph.D. in Operations Research from the
Massachusetts Institute of Technology and was a faculty member at Yale University and the University
of Arizona before returning to Hong Kong. Her major research interests are combinatorial optimisation,
transportation logistics, health care and urban informatics. She has also investigated problems in
procurement, material-handling, routing/distribution, facility layout and baseball scheduling. In Hong
Kong, she has collaborated with several local companies in projects on container management, warehouse
inventory systems, mass-transit timetabling and manpower planning. Her research has been supported by
the Hong Kong Research Grants Council and the (US) National Science Foundation. She has published
widely, is active in professional societies, and serves on the editorial boards of leading journals in her
field.

Colin Graham qualified in Glasgow in 1994 and undertook higher specialist training in emergency
medicine in Scotland. He moved to Hong Kong in 2004 and was appointed Professor in the Accident and

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Improving the efficiency of a hospital emergency department 147

Emergency Medicine Academic Unit at the Chinese University of Hong Kong in 2007. He is a Fellow of
Morningside College at the Chinese University of Hong Kong. He practices clinical emergency medicine
at the Prince of Wales Hospital. He has broad research interests within emergency medicine and he has
published widely. He is an active clinical teacher and he is one of the authors of the Oxford Handbook of
Emergency Medicine, a popular book for emergency department staff. He serves on the Council of the
Hong Kong College of Emergency Medicine. He has been Editor-in-Chief of the European Journal of
Emergency Medicine since 2009 and he serves on the Executive Committee and Council of the European
Society for Emergency Medicine.

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