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Considering these data were from a single institution, we performed an internal validation using data randomized from the same study by bootstrap and an external validation in a community ED of similar volume. Data analyses showed consistent results indicating the reliability of using the SONET tool to determine ED overcrowding status. As mentioned above, we realize that the study results may be skewed by virtue of population selection. Therefore, an even larger multicenter study among similar ED environments is required to achieve extensive external validation. At present, there remains no gold standard tool capable of defining ED overcrowding. Sole reliance on perceptions of different healthcare providers may be overly subjective. However, a previous study tested the interrater and intrarater variability of healthcare providers' perceptions and results demonstrated a moderate to good agreement across study participants [13]. The SONET tool was derived based on the average level of perceptions of ED overcrowding by the same group of healthcare providers which should therefore minimize the bias of individual subjective judgments. Our incomplete data was relatively higher than we initially estimated (18.3% versus 10%) which resulted in a relatively smaller sample size (206 time points). This is based on the calculated sample size anticipated to reach a 99% significance level. However, it does provide sufficient data to obtain a 95% significance level for statistical analysis. In addition, our realized result of a 60.19% ED overcrowding level was very close to the calculated Delphi estimation of 60%. A similar sample size produced similar results when analyzing the data from the external validation study. Finally, using the SONET score to determine overcrowding status might only apply to similar setting EDs because perceptions of overcrowding might vary among different healthcare providers working in different ED environments. This tool might not be suitable for a relatively low volume ED setting. 5. Conclusion Overall, our study outcomes indicate SONET might be a better tool to determine overcrowding in an ED setting of extremely high volume. This scoring system is intended to differentiate only severely overcrowded, overcrowded, and not overcrowded statuses. In addition, ED overcrowding can negatively affect patient care operations and often produces poor patient perceptions of standardized care delivery. Supplementary Material The supplementary material includes the checklist Proteasome inhibitor detail of using SQUIRE guideline for this manuscript publication. SQUIRE refers to as Standard for Quality Improvement Reporting Excellence. Seventeen items that required by SQUIRE guideline were reported in this paper and listed in detail in the supplementary material. Click here to view.