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Crisis-level overcrowding conditions in emergency departments (EDs) have led hospitals to seek out new patient-flow designs to improve both responsiveness and safety. One approach that has attracted attention and experimentation in the emergency medicine community is a system in which ED beds and care teams are segregated and patients are “streamed” based on predictions of whether they will be discharged or admitted to the hospital. In this paper, we use a combination of analytic and simulation models to determine whether such a streaming policy can improve ED performance, where it is most likely to be effective, and how it should be implemented for maximum performance. Our results suggest that the concept of streaming can indeed improve patient flow, but only in some situations. First, ED resources must be shared across streams rather than physically separated. This leads us to propose a new “virtual-streaming” patient flow design for EDs. Second, this type of streaming is most effective in EDs with (1) a high percentage of admitted patients, (2) longer care times for admitted patients than discharged patients, (3) a high day-to-day variation in the percentage of admitted patients, (4) long patient boarding times (e.g., caused by hospital “bed-block”), and (5) high average physician utilization. Finally, to take full advantage of streaming, physicians assigned to admit patients should prioritize upstream (new) patients, whereas physicians assigned to discharge patients should prioritize downstream (old) patients.

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