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Decreased length of stay after addition of healthcare provider in emergency department triage: a comparison between computer-simulated and real-world interventions
  1. Theodore Eugene Day1,
  2. Abdul Rahim Al-Roubaie2,
  3. Eric Jonathan Goldlust3
  1. 1HSR&D, St. Louis Veterans Affairs Medical Center, St. Louis, Missouri, USA
  2. 2St. Louis Veterans Affairs Medical Center, St. Louis, Missouri, USA
  3. 3The Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
  1. Correspondence to Dr Theodore Eugene Day, John Cochran VAMC, JC/151, 915 N Grand Blvd, St. Louis, MO 63106, USA;{at}


Objective (1) To determine the effects of adding a provider in triage on average length of stay (LOS) and proportion of patients with >6 h LOS. (2) To assess the accuracy of computer simulation in predicting the magnitude of such effects on these metrics.

Methods A group-level quasi-experimental trial comparing the St. Louis Veterans Affairs Medical Center emergency department (1) before intervention, (2) after institution of provider in triage, and discrete event simulation (DES) models of similar (3) ‘before’ and (4) ‘after’ conditions. The outcome measures were daily mean LOS and percentage of patients with LOS >6 h.

Results The DES-modelled intervention predicted a decrease in the %6-hour LOS from 19.0% to 13.1%, and a drop in the daily mean LOS from 249 to 200 min (p<0.0001). Following (actual) intervention, the number of patients with LOS >6 h decreased from 19.9% to 14.3% (p<0.0001), with the daily mean LOS decreasing from 247 to 210 min (p<0.0001).

Conclusion Physician and mid-level provider coverage at triage significantly reduced emergency department LOS in this setting. DES accurately predicted the magnitude of this effect. These results suggest further work in the generalisability of triage providers and in the utility of DES for predicting quantitative effects of process changes.

  • Discrete event simulation
  • length of stay
  • performance measures
  • computer simulation
  • efficiency
  • operational
  • quality assurance
  • comparative system research
  • emergency care systems
  • efficiency
  • emergency department management
  • research
  • operational
  • systems

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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  • Funding The authors received no direct support for this work. Software and computing facilities, provided through 2009 VHA Innovations Award, Greenfield Incubation, #123, were used to develop the simulation described.

  • Competing interests None.

  • Ethics approval This study was declared exempt by the St. Louis VA Medical Center Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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