Towards a best measure of emergency department crowding: Lessons from current Australasian practice.

OBJECTIVE: Despite extensive literature, how crowding in EDs should be measured is still debated. The present study aimed to describe crowding metrics used in Australasia, what they were used for, the perceived extent and frequency of crowding and the challenges faced when trying to measure crowding.

METHODS: A survey of ED clinical directors was undertaken between December 2014 and July 2015. Free-text responses were categorised and thematically coded. Quantitative data were analysed descriptively and with logistic regression.

RESULTS: There were 113 of 145 responses (78%). Crowding was considered a major problem by 84 of 113 (74%) and not rare by 88 of 111 participants (79%). These constructs were correlated; G = -0.851, P < 0.001. Levels 1-3 EDs were less likely to report crowding as a major problem than Level 4 EDs; odds ratio 0.15 (0.03-0.69), P = 0.02. Sixteen current metrics were identified and categorised into 'time', 'occupancy' and 'workload' metrics. These categories of metric were used differently, and multiple metrics had more uses than single metrics. Previously described complex crowding metrics were infrequently recognised (<20%). Common challenges to measuring crowding were lack of an agreed metric (40%) and lack of buy-in by inpatient teams or hospital management (35%).

CONCLUSION: ED crowding remains a common and important problem in Australasia. Crowding is multifaceted, so a single metric might not capture all important elements of crowding or be relevant to all stakeholders. However, a metric like Access Block, which encompasses elements of time, occupancy and workload and is relevant to stakeholders outside the ED, might hold the most promise.