Measuring emergency department crowding: comparing the NEDOCS and Fenice crowding scores against staff perception

This study assesses the feasibility of collecting real-time perceptions of emergency department (ED) crowding from different professional roles and compares the recorded perceptions with two crowding indicators: the NEDOCS and the recently proposed Fenice score. We conducted a prospective observational study in an Italian university hospital. ED staff received two SMS questionnaires daily, assessing perceived crowding and workload pressure on 0-10 scales. Simultaneously, the NEDOCS and Fenice scores were recorded every 15 min. Spearman correlations, regression models, and generalized additive models were used to assess associations. Among 49 staff members, 830 valid on-shift responses were collected (response rate: 62.6%). Perceived crowding was generally high (median: 7; Q1-Q3: 5-9) and varied significantly by role (p-value < 0.001), with healthcare assistants and boarding nurses perceiving the ED as more crowded and process management nurses perceiving it as less crowded. The Fenice and NEDOCS scores correlated strongly with perceived crowding (ρ: 0.71 and 0.69; p value = 0.06) and moderately with workload pressure (ρ < 0.60). The Fenice score explained slightly more variance in perceived crowding (R²: 0.65 vs. 0.59). While the correlation between the two scores in the study ED was high (ρ: 0.85), a wide range of correlation coefficients emerged in a cohort of 83 Italian EDs (average ρ: 0.80; min-max: 0.24-0.99; Q1-Q3: 0.73-0.93). Real-time monitoring of ED staff perceptions is feasible and informative. Both the NEDOCS and Fenice scores correlate well with staff perception, but the simplicity and fully automatable implementation of the Fenice score make it a promising alternative to be evaluated in future studies.