title: The inaccuracy of determining overcrowding status by using the national ED overcrowding study tool.
abstract: BACKGROUND
  Emergency department (ED) crowding has become more common, and perceptions of crowding vary among different health care providers. The National Emergency Department Overcrowding Study (NEDOCS) tool is the most commonly used tool to estimate ED crowding but still uncertain of its reliability in different ED settings.
  
  
  OBJECTIVE
  The objectives of this study are to determine the accuracy of using the NEDOCS tool to evaluate overcrowding in an extremely high-volume ED and assess the reliability and consistency of different providers' perceptions of ED crowding.
  
  
  METHODS
  This was a 2-phase study. In phase 1, ED crowding was determined by the NEDOCS tool. The ED length of stay and number of patients who left without being seen were analyzed. In phase 2, a survey of simulated ED census scenarios was completed by different providers. The interrater and intrarater agreements of ED crowding were tested.
  
  
  RESULTS
  In phase 1, the subject ED was determined to be overcrowded more than 75% of the time in which nearly 50% was rated as severely overcrowded by the NEDOCS tool. No statistically significant difference was found in terms of the average length of stay and the number of left without being seen patients under different crowding categories. In phase 2, 88 surveys were completed. A moderate level of agreement between health care providers was reached (κ = 0.5402, P < .0001). Test-retest reliability among providers was high (r = 0.8833, P = .0007). The strength of agreement between study groups and the NEDOCS was weak (κ = 0.3695, P < .001).
  
  
  CONCLUSIONS
  Using the NEDOCS tool to determine ED crowding might be inaccurate in an extremely high-volume ED setting.
authors.affiliation: Department of Emergency Medicine, Integrative Emergency Services Physician Group, John Peter Smith Health Network, 1500 S Main St, Fort Worth, TX 76104. Electronic address: hwang01@jpshealth.org.
authors.forename: Hao
authors.initials: H
authors.lastname: Wang
authors.affiliation: Department of Emergency Medicine, Integrative Emergency Services Physician Group, John Peter Smith Health Network, 1500 S Main St, Fort Worth, TX 76104.
authors.forename: Richard D
authors.initials: RD
authors.lastname: Robinson
authors.affiliation: Department of Emergency Medicine, Integrative Emergency Services Physician Group, John Peter Smith Health Network, 1500 S Main St, Fort Worth, TX 76104.
authors.forename: Kellie
authors.initials: K
authors.lastname: Bunch
authors.affiliation: Department of Emergency Medicine, Integrative Emergency Services Physician Group, John Peter Smith Health Network, 1500 S Main St, Fort Worth, TX 76104.
authors.forename: Charles A
authors.initials: CA
authors.lastname: Huggins
authors.affiliation: Department of Emergency Medicine, Integrative Emergency Services Physician Group, John Peter Smith Health Network, 1500 S Main St, Fort Worth, TX 76104.
authors.forename: Katherine
authors.initials: K
authors.lastname: Watson
authors.affiliation: Department of Emergency Medicine, Integrative Emergency Services Physician Group, John Peter Smith Health Network, 1500 S Main St, Fort Worth, TX 76104.
authors.forename: Rani D
authors.initials: RD
authors.lastname: Jayswal
authors.affiliation: Department of Emergency Medicine, Integrative Emergency Services Physician Group, John Peter Smith Health Network, 1500 S Main St, Fort Worth, TX 76104.
authors.forename: Noah C
authors.initials: NC
authors.lastname: White
authors.affiliation: Department of Emergency Medicine, Integrative Emergency Services Physician Group, John Peter Smith Health Network, 1500 S Main St, Fort Worth, TX 76104.
authors.forename: Brett
authors.initials: B
authors.lastname: Banks
authors.affiliation: Department of Emergency Medicine, Integrative Emergency Services Physician Group, John Peter Smith Health Network, 1500 S Main St, Fort Worth, TX 76104.
authors.forename: Nestor R
authors.initials: NR
authors.lastname: Zenarosa
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003441:Crowding; D004635:Emergency Medicine; D016529:Emergency Nursing; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data*; D006786:Hospitals, Urban / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015203:Reproducibility of Results; D062606:Tertiary Care Centers