LO17: A comparative evaluation of ED crowding metrics and associations with patient mortality

Abstract

Introduction: Over 700 different input, throughput and output metrics have been used to quantify ED crowding. Of these, only ED length-of-stay (ED LOS) has been shown to be associated with mortality. No comparative evaluation of ED crowding metrics has been performed to determine which ones have the strongest association with patient mortality. The objective of this study was to compare the strength of association of common ED input, throughput and output metrics to patient mortality. Methods: Administrative data from five years of ED visits (2011-2014) at three urban EDs were linked to develop a database of over 900,000 ED visits with patient demographics, electronic time stamps for care processes, dispositions and outcomes. The data were randomly divided into three partitions of equal size. Here we report the findings from one partition of 253,938 ED visits. The remaining two data partitions will be used to validate these findings. Commonly-used crowding metrics were quantified and aggregated by day or by shift (0800-1600, 1600-2400, 2400-0800), and the shift-specific metrics assigned to each patient. The primary outcome was 7-day all-cause mortality. Multilevel logistic regression models were developed for 7-day mortality, with selected ED crowding metrics and a common set of confounders as predictors. The strength of association between the crowding metrics and mortality was compared using Akaike’s Information Criterion (AIC) and the Bayesian Information Criterion (BIC): ED crowding metrics with lower AIC and BIC have stronger associations with 7-day mortality. Results: Of 909,000 ED encounters, 124,679 (16.5%) arrived by EMS, 149,233(19.7%) were admitted, and 3,808 patients (0.5%) died within 7 days of ED arrival. Of input metrics, the model with ED wait-time was better (i.e. had a smaller AIC and BIC) than models for daily census, ED occupancy or LWBS proportion for predicting 7-day mortality. Of throughput metrics, the model with mean ED LOS was better than the model for mean MD care time. Of output metrics, the model with daily inpatient hospital occupancy was better than the model with mean boarding time. Conclusion: Based on one data partition, regression models based on the average wait-time, ED LOS and inpatient occupancy best predicted 7-day mortality. These results will be validated in the two other data partitions to confirm the best-performing ED input, throughput and output metrics.