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Patient waiting times and service quality problems characterize emergency departments worldwide. The purpose of this research is to develop a reliable decision support system using the emergency severity index (ESI©) triage method to drive improvements in the care delivery process, as part of a hospital emergency care delivery system. Models were developed using first a relatively low fidelity software, process model, and then in Arena, a relatively high fidelity simulation software, to test new proposals for service delivery improvements in an academic ED in York Hospital, Pennsylvania, where the ESI© triage system has been implemented. We pair the case mix derived from ESI© triage with simulation to support resource deployment to improve service metrics and support strategic decision making in academic EDs. The lessons learned could be re-analyzed in a simulation model more representative of a nonacademic (regular hospital) ED that implements ESI© five level triage.