Background: Emergency department (ED) overcrowding remains a critical challenge, leading to delays in patient care and increased operational strain. Current hospital management strategies often rely on reactive decision-making, addressing congestion only after it occurs. However, effective patient flow management requires early identification of overcrowding risks to allow timely interventions. Machine learning (ML)–based predictive modeling offers a solution by forecasting key patient flow measures, such as waiting count, enabling proactive resource allocation and improved hospital efficiency. Objective: The aim of this study is to develop ML models that predict ED waiting room occupancy (waiting count) at 2 temporal resolutions. The first approach is the hourly prediction model, which estimates the waiting count exactly 6 hours ahead at each prediction time (eg, a 1 PM prediction forecasts 7 PM). The second approach is the daily prediction model, which forecasts the average waiting count for the next 24-hour period (eg, a 5 PM prediction estimates the following day’s average). These predictive tools support resource allocation and help mitigate overcrowding by enabling proactive interventions before congestion occurs. Methods: Data from a partner hospital’s ED in the southeastern United States were used, integrating internal and external sources. Eleven different ML algorithms, ranging from traditional approaches to deep learning architectures, were systematically trained and evaluated on both hourly and daily predictions to determine the models that achieved the lowest prediction error. Experiments optimized feature combinations, and the best models were tested under high patient volume and across different hours to assess temporal accuracy. Results: The best hourly prediction performance was achieved by time series vision transformer plus (TSiTPlus) with a mean absolute error (MAE) of 4.19 and a mean squared error (MSE) of 29.36. The overall hourly waiting count had a mean of 18.11 and a SD (σ) of 9.77. Prediction accuracy varied by time of day, with the lowest MAE at 11 PM (2.45) and the highest at 8 PM (5.45). Extreme case analysis at (mean + 1σ), (mean + 2σ), and (mean + 3σ) resulted in MAEs of 6.16, 10.16, and 15.59, respectively. For daily predictions, an explainable convolutional neural network plus (XCMPlus) achieved the best results with an MAE of 2.00 and a MSE of 6.64. The daily waiting count had a mean of 18.11 and a SD of 4.51. Both models outperformed traditional forecasting approaches across multiple evaluation metrics. Conclusions: The proposed prediction models effectively forecast ED waiting count at both hourly and daily intervals. The results demonstrate the value of integrating diverse data sources and applying advanced modeling techniques to support proactive resource allocation decisions. The implementation of these forecasting tools within hospital management systems has the potential to improve patient flow and reduce overcrowding in emergency care settings. The code is available in our GitHub repository.

Objectives: This study analyzes factors influencing Emergency Department (ED) overcrowding by examining the impacts of operational, environmental, and external variables, including weather conditions and football games. Materials and Methods: This retrospective observational study analyzed emergency department (ED) tracking and hospital census data from a southeastern U.S. academic medical center covering 2019–2023. These data were merged with corresponding weather, football event, and federal holiday data. The dependent variable was the hourly waiting count in the ED, our operational measure of overcrowding. Seven regression models were developed to assess different predictors across various timestamps. Results: Weather conditions were significantly correlated with increased ED waiting count in the Baseline Model, while federal holidays and weekends were consistently correlated with reduced waiting counts. Boarding count was positively correlated with ED waiting count when concurrent, but boarding counts 3 h and 6 h before showed significant negative correlations. Hospital census showed a negative correlation in the Baseline Model but shifted to a positive effect in other models, reflecting its time-dependent influence on ED operations. Football games 12 h before significantly correlated with increased waiting counts, while games 12 and 24 h after had no significant effects. Discussion: While existing research typically focuses on limited variables and narrow timeframes, the temporal relationships between operational and non-operational factors affecting ED overcrowding remain understudied, particularly the delayed impacts of external events and environmental conditions. Conclusions: This study emphasizes the importance of incorporating both operational and non-operational factors to understand ED patient flow. Identifying robust predictors such as weather conditions, federal holidays, boarding count, and hospital census can inform dynamic resource allocation strategies to mitigate ED overcrowding effectively.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Emergency department (ED) overcrowding remains a critical challenge, leading to delays in patient care and increased operational strain. Current hospital management strategies often rely on reactive decision-making, addressing congestion only after it occurs. However, effective patient flow management requires early identification of overcrowding risks to allow timely interventions. Machine learning (ML)–based predictive modeling offers a solution by forecasting key patient flow measures, such as waiting count, enabling proactive resource allocation and improved hospital efficiency. Objective: The aim of this study is to develop ML models that predict ED waiting room occupancy (waiting count) at 2 temporal resolutions. The first approach is the hourly prediction model, which estimates the waiting count exactly 6 hours ahead at each prediction time (eg, a 1 PM prediction forecasts 7 PM). The second approach is the daily prediction model, which forecasts the average waiting count for the next 24-hour period (eg, a 5 PM prediction estimates the following day’s average). These predictive tools support resource allocation and help mitigate overcrowding by enabling proactive interventions before congestion occurs. Methods: Data from a partner hospital’s ED in the southeastern United States were used, integrating internal and external sources. Eleven different ML algorithms, ranging from traditional approaches to deep learning architectures, were systematically trained and evaluated on both hourly and daily predictions to determine the models that achieved the lowest prediction error. Experiments optimized feature combinations, and the best models were tested under high patient volume and across different hours to assess temporal accuracy. Results: The best hourly prediction performance was achieved by time series vision transformer plus (TSiTPlus) with a mean absolute error (MAE) of 4.19 and a mean squared error (MSE) of 29.36. The overall hourly waiting count had a mean of 18.11 and a SD (σ) of 9.77. Prediction accuracy varied by time of day, with the lowest MAE at 11 PM (2.45) and the highest at 8 PM (5.45). Extreme case analysis at (mean + 1σ), (mean + 2σ), and (mean + 3σ) resulted in MAEs of 6.16, 10.16, and 15.59, respectively. For daily predictions, an explainable convolutional neural network plus (XCMPlus) achieved the best results with an MAE of 2.00 and a MSE of 6.64. The daily waiting count had a mean of 18.11 and a SD of 4.51. Both models outperformed traditional forecasting approaches across multiple evaluation metrics. Conclusions: The proposed prediction models effectively forecast ED waiting count at both hourly and daily intervals. The results demonstrate the value of integrating diverse data sources and applying advanced modeling techniques to support proactive resource allocation decisions. The implementation of these forecasting tools within hospital management systems has the potential to improve patient flow and reduce overcrowding in emergency care settings. The code is available in our GitHub repository. Trial Registration: