The South African health system faces a quadruple burden of disease: HIV/AIDS and tuberculosis; maternal and child morbidity and mortality; noncommunicable diseases; and violence, injuries and trauma. This places significant pressure on emergency centres which for many is the entry point into the health care system. With variable clinical case load but finite inpatient bed capacity, emergency centre observation wards (ECOWs) are a novel approach to address the challenge of maintaining effective EC through-put. As part of a strategy to decrease emergency centre (EC) and hospital overcrowding, ECOWs when properly utilised, enable management for subgroups of patients who meet specific clinical criteria and require treatment for longer periods than normal for the EC, but who are deemed likely to stay for less than 24 hours. Additionally, patients admitted to ECOWs remain under the care of emergency and acute care practitioners who routinely review patients on a more frequent basis than the traditional daily inpatient ward review, thus allowing for the high turnover that is necessary to maintain streamlined EC unit flow.