{"id":3097,"date":"2024-06-26T18:39:36","date_gmt":"2024-06-26T16:39:36","guid":{"rendered":"https:\/\/www.rivistaeco.com\/?p=3097"},"modified":"2024-06-26T18:39:36","modified_gmt":"2024-06-26T16:39:36","slug":"all-the-ills-of-the-emergency-room","status":"publish","type":"post","link":"https:\/\/www.rivistaeco.com\/en\/2024\/06\/26\/all-the-ills-of-the-emergency-room\/","title":{"rendered":"All the Ills of the Emergency Room"},"content":{"rendered":"

An efficient emergency room is crucial for citizens\u2019 health. Too often, however, the emergency department is used for minor and non-urgent conditions or chronic issues. To curb this trend, strengthening local healthcare is necessary. In Italy, the opportunity comes from the National Recovery and Resilience Plan (PNRR).<\/span><\/i><\/p>\n

During the challenging months of the pandemic, the importance of efficient hospital emergency rooms able to ensure a robust connection with community-based care became clear to all. That period also highlighted the vulnerabilities of emergency care in the face of very complex and hard-to-manage demand. For at least two decades, operators and scholars have pointed out such difficulties in many countries, emphasising two issues: overcrowding in emergency departments and the difficulty in recruiting and retaining specialised personnel due to heavy workloads and relatively unattractive economic prospects. Here, we will focus on the first aspect.<\/span><\/p>\n

Why Emergency Rooms Are Overcrowded<\/b><\/h3>\n

Overcrowding in emergency rooms can have many negative consequences. First, it lowers the quality of care, as delays in patient intake can jeopardise prioritisation and timely treatment. Scientific literature also highlights the higher incidence of medical errors related to workload overload, low patient satisfaction levels, and higher costs associated with inappropriate hospital use.\u00a0<\/span><\/p>\n

Overcrowding stems from multiple causes that must be identified so that effective responses can be designed. The first cause is incoming flows greater than what the facilities have the capacity for. The second is about internal organisation: if the setup is poor, it hinders proper prioritisation of treatments and lengthens response times in the most urgent cases. The third factor concerns exit from the emergency room: patients who have already received necessary treatments remain in the emergency room, waiting to be admitted to the hospital or discharged \u2013 a phenomenon called \u201cboarding.\u201d This phase can be particularly critical for the most vulnerable patients.\u00a0<\/span><\/p>\n

A large body of evidence suggests that a significant portion of emergency room visits could be avoided. Although there is no universally accepted definition for what constitutes an \u201cavoidable\u201d emergency visit, most studies estimate that 10% to 30% of total visits are inappropriate because, due to lower severity and urgency, patients could have found an equally effective response outside the emergency room. The overuse of emergency services disrupts the relationship between hospital and community care, causing discontinuity in care and worsening the quality of general medical care. Added to this are the financial costs of improperly using specialised facilities for minor issues, and increasing the use of more complex diagnostic tools, sometimes for preventive reasons.<\/span><\/p>\n

Attempts to Tackle the Problem<\/b><\/h3>\n

Various actions have been taken to address emergency room overcrowding. First, programmes to strengthen local healthcare responses to less serious emergencies have been studied, to ensure that local needs are better met. Public and professional awareness campaigns and technological solutions such as call centres, appointment apps, and telemedicine are also being implemented.\u00a0<\/span><\/p>\n

In Spain and Portugal, for example, there is strong involvement of family doctors and community nursing staff, thanks to improved local setups where the doctor works with a nurse and multidisciplinary teams in managing chronic diseases. In England, family doctors\u2019 office hours have been extended to 12 or 24 hours a day, supported by multidisciplinary staff and the increased use of telemedicine. There are also many urgent care centres for minor injuries or non-urgent needs: Spanish primary care centres operate 24 hours a day. In England, numerous centres \u2013 predominantly open for 12 hours a day \u2013 can be accessed without an appointment, while patients who go to the emergency room on the advice of the National Health Service\u2019s 111 telephone operator receive a specific time slot for clinical evaluation to reduce overcrowding. Analysing the types of patients who frequently make inappropriate use of the emergency room has also led to the design of specific local pathways, such as for people dealing with drug addiction or homelessness. Although results are mixed, strengthening local services appears to be effective in alleviating congestion.\u00a0<\/span><\/p>\n

Structural factors in emergency rooms are also being addressed to improve patient pathways. Protocols for triage have been established to better manage patients based on the severity of their illness or injury. Times have been set for diagnoses, protocols optimised to reduce waiting times and improve operational efficiency, and emergency-room networks reorganised by complexity levels of the emergency. Sometimes these have been accompanied by an increase in dedicated human and financial resources.\u00a0<\/span><\/p>\n

Regarding the emergency-room exit phase, problems often arise from the unavailability of beds in destination departments; when it comes to people from vulnerable sectors of society, the difficulty lies in referring patients to community structures. For such cases, efforts are being made to strengthen intra-hospital pathways, optimise bed availability, and involve community services in caring for the most vulnerable patients who have been discharged. Studies report overall positive results of these developments, although whether such efforts can make a significant impact often depends heavily on the initial conditions.<\/span><\/p>\n

The Situation in Italy<\/b><\/h3>\n

In Italy, combatting emergency room congestion relies on a variety of strategies. Regarding internal factors, in 2019, the Conference of Regions and Autonomous Provinces approved national guidelines to regulate \u201cintensive short observation\u201d (for patients requiring a few hours of observation), standardise the nursing triage system, and define a plan for managing emergency room overcrowding. For healthcare companies, adopting the plan is a requirement for institutional accreditation and can be included in their performance indicators. The guidelines also envision establishing a staff position to facilitate emergency admissions and introducing the operational role of an emergency manager. Approval of the plans was delayed by the pandemic, but many regions are now moving in this direction, and healthcare companies are overhauling their internal operational processes.\u00a0<\/span><\/p>\n

However, solving the problems of frequent emergency room visits for non-urgent or minor issues and exit from the emergency room is more complex. These issues are worsened by substantial cuts in the number of acute inpatient beds over the last decade and insufficient capacity of post-acute facilities and services to absorb the most socially vulnerable patients. The first figure shows the treatment outcomes for white and green codes (not urgent and low priority), highlighting marked regional differences in the frequency of home discharges and the use of alternative solutions.<\/span><\/p>\n

Outcome of Treatment with White or Green Triage Code at Visit<\/b><\/p>\n

\"\"
Source: Agenas.<\/figcaption><\/figure>\n

The National Recovery and Resilience Plan for Community Healthcare<\/b><\/h3>\n

A recent report from the National Agency for Regional Healthcare Services (Agenas) states that in 2023, our emergency rooms recorded over 18 million visits, a 6% increase compared to the previous year, but less than the 21 million in 2019. Sixty-eight percent of the visits received a white and green triage code on exit, only a small fraction of which required hospital admission. The second figure shows regional differences in visits per 1,000 inhabitants in Italy, distinguished by triage color, revealing a heterogeneous picture in both visit frequency and the proportion of white codes out of the total.<\/span><\/p>\n

Emergency Room Visits per 1,000 Inhabitants (2022)<\/b><\/p>\n

\"\"
Source: Agenas.<\/figcaption><\/figure>\n

Among patients coming to the emergency room \u2013 independently or referred by a family doctor \u2013 on weekdays, holidays, and during daytime hours, and who are discharged to their homes or outpatient structures, white and green visits are considered inappropriate. Agenas estimates that they represent 22% of the total: almost 4 million citizens, predominantly in the 25-to-64 age group, come to the hospital mainly in the morning, between 8 a.m. and 12 p.m., when alternative options were available through community-based health services. The last figure highlights the regional distribution of inappropriate visits out of the total and confirms that in many regions, the share of avoidable visits contributes significantly to the congestion of facilities.<\/span><\/p>\n

To address emergency room overcrowding, community health centres, family and community nurses, continuity care units, the European non-urgent medical care number 116117, and telemedicine \u2013 initiatives central to the National Recovery and Resilience Plan \u2013 will all need to contribute. Meanwhile, community emergency coordination centres should help alleviate exit problems by connecting emergency rooms with community hospitals, post-acute care facilities, and home care services. In Italy, unlike in England and Spain, no outpatient emergency centres are planned. However, at the end of 2023, the Emilia-Romagna region launched urgent care centres as an experiment in applying the same decree to improve the continuity of care in community health centres. Urgent care centres are local structures that provide services previously offered by emergency rooms or first aid points and handle low-criticality and low-complexity emergencies. Preliminary evaluations show a decrease in inappropriate white and green codes and lowered pressure on reference emergency rooms. Such experiments also strengthen public oversight, even as private, paid emergency points emerge in several regions.\u00a0<\/span><\/p>\n

The problem is that the decision of whether to go first to the urgent care centre, first aid point, or emergency room is left to the individual. This means that the success of an emergency healthcare system with multiple entry points ultimately relies on effective public information and outreach. Without that, there is a risk that roles overlap or, worse, that the role of general practitioners is undermined. It would therefore be valuable if the 116117 number were active everywhere and operational all day to help citizens identify the most appropriate service for their needs. The line could offer medical advice, suggest ways to access the most appropriate local services in case the patient has difficulty contacting their family doctor, and transfer urgent cases to 118.\u00a0<\/span><\/p>\n

In the coming years, local healthcare services must be strengthened. The central government\u2019s choice was to set qualitative, structural, technological, and quantitative standards that regions must adhere to. But the detailed relationships to be established locally are not detailed. To limit emergency room inflows, it is crucial to identify the most suitable responses for different types of users in the local area. It will be each region\u2019s job to study the most appropriate solutions for their governance model, keeping in mind that the emergency network is an essential component to fulfill the constitutional mandate of protecting citizens\u2019 health.<\/span><\/p>\n

Total and Inappropriate Emergency Room Visits per 100 Inhabitants<\/b><\/p>\n

\"\"
Source: Agenas elaboration from EMUR flow 2022.<\/figcaption><\/figure>\n

Bio<\/em><\/p>\n

Matteo Lippi Bruni<\/strong> is a professor of public finance at the Department of Economic Sciences at Alma Mater Studiorum University of Bologna.<\/span><\/em><\/p>\n

Cristina Ugolini<\/strong> is a professor of public finance at the Department of Economic Sciences at Alma Mater Studiorum University of Bologna, where she directs the School of Health Policies.<\/span><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

An efficient emergency room is crucial for citizens\u2019 health. Too often, however, the emergency department is used for minor and non-urgent conditions or chronic issues. 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