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Emergency department (ED) crowding has been an increasing problem worldwide.Prior research has identified factors that contribute to ED crowding. However,the relationships between these remain incompletely understood. This study'sobjective was to analyse the effects of initiating a local protocol toalleviate crowding situations at the expense of increasing returning patientsthrough the development of a system dynamics (SD) simulation model. The SDstudy is from an academic care hospital in Boston, MA. Data sources includedirect observations, semi-structured interviews, archival data from October2013, and peer-reviewed literature from the domains of emergency medicine andmanagement science. The SD model shows interrelations between inpatientcapacity restraints and return visits due to potential premature discharges.The model reflects the vulnerability of the ED system when exposed tounpredicted increases in demand. Default trigger values for the protocol aretested to determine a balance between increased patient flows and the number ofreturning patients. Baseline simulation runs for generic variables assessmentshowed high leverage potential in bed assignment- and transfer times.  A thorough understanding of the complex non-linear behaviour of causes andeffects of ED crowding is enabled through the use of SD. The vulnerability ofthe system lies in the crucial interaction between the physical constraints andthe expedited patient flows through protocol activation. This study is anexample of how hospital managers can benefit from virtual scenario testingwithin a safe simulation environment to immediately visualise the impacts ofpolicy adjustments.

Simulating feedback mechanisms in patient flow and return visits in an emergency department