Overcrowding in Italian Emergency Department: the survey of “Settimana Nazionale del Pronto Soccorso 2017” SIMEU

Paola Caporaletti MD, Margherita Maragno MD, Matteo Cosi, Ombretta Cutuli MD, Stella Ingrassia MD, Antonella Cocorocchio CPSI, Lucia Orlando Settembrini MD, Valeria Donati MD, Mario Guarino MD, Maria Pia Ruggieri MD

Paola Caporaletti MeCAU, AOU Policlinico Consorziale, Bari
Margherita Maragno MeCAU, P.O. Madonna Delle Grazie, Matera
Matteo Cosi Pronto Soccorso EAS IRCCS Policlinico San Matteo, Pavia
Ombretta Cutuli MeCAU Ospedale Policlinico San Martino, Genova
Stella Ingrassia UOC Pronto Soccorso e Medicina d’Urgenza, IRCCS Fondazione Ca’Granda Ospedale Maggiore Policlinico, Milano
Antonia Cocorocchio CPSI UOC PS/BREVE OSSERVAZIONE AO San Giovanni Addolorata, Roma
Lucia Orlando Settembrini UO di Accettazione e P.S. dell’Az. Ospedaliera Pugliese – Ciaccio, Catanzaro
Valeria Donati DEA Arezzo
Mario Guarino UOSD MeCAU C.T.O. AORN dei Colli, Napoli
Maria Pia Ruggieri UOC PS/BREVE OSSERVAZIONE AO San Giovanni Addolorata, Roma


EDs overcrowding is a well known problem, but to the date few data are available.  This survey by the Italian Society of Emergency Medicine shows the real life of EDs and the point to work to improve the overcrowding management. 
Solutions adopted in few regions correlated to organizational problems  (bed lacking, bed management), which partly cause the overcrowding effects on Italian EDs are discussed.
Key words: overcrowding, Emergency Department, Settimana Nazionale del Pronto Soccorso, Simeu
Emergency Department (ED) overcrowding is associated with decreased patient safety, increased 10-day in-patient mortality rates, it causes boarding and leads to staff burning out. (1,2,3,4)
In the past SIMEU (the Italian Society of Emergency Medicine) proposed some organizational models of Emergency Departments and asserted that this problem must be taken into account by the entire hospital and by the out of hospital system.
The event “Settimana Nazionale del Pronto Soccorso 2017 – Simeu” is dedicated to it.
In 2015 Simeu published a Policy Statement about “Overcrowding of Emergency Departement” showing some in-hospital solutions.(5) The paper stressed mostly the use of a validated tool to measure overcrowding (6) and the activation of the short observation unit, OBI (Osservazione Breve Intensiva), for the diagnostic and therapeutic management of patients that can be discharged in 24-36 hours. The paper identified the key role of the Bed Manager who administrates beds available and the patient flow in the hospital. Specific pathways for patients who need a long term hospitalization or are affected by chronic diseases increase the in-patient bed availability for patients with acute illnesses. Two years after this publication, SIMEU wanted to see if and which of the proposed solutions were adopted Italian Emergency Departments.

Materials and Methods

From 1st March to 30th April 2017, through the Regional Simeu Presidents network and with the coordination of national working group of “Settimana Nazionale del Pronto Soccorso”, 219 structures, 54 First Aids, 111 1stlevel EDs and 54 2ndlevel EDs, in all the 20 Italian regions have been censored (corresponding to the 33% of Italian Emergency Department); during the 2016  10.072.924 patients were admitted in all the hospitals. (fig.1)

Figure 1



The figure of the Bed Manager is present  only in 30% of the hospitals (50% in 2nd level EDs, 28% in 1st level EDs and 13% in First Aids). The Holding area exists in the 21% of the ED (33% in 2nd EDs, 17% in 1st EDs and 15% First Aid): in 82% of hospitals this area is managed by emergency physicians, in 11% by other medical figures, in 9% by both.  Only 2nd ED holding area is provided with dedicated nurses.
98 hospitals out of 219 (45%) know about how many beds are available real-time  (2ndED 43%, 1stED 48%, First Aid 41%) and only 24% of EDs have beds dedicated every day. 
For 80% of the interviwees the number of hospitalizations required is perceived as superior to the beds allocated. 
56% of EDs know guidelines about overcrowding provided by their Regional Department of Health; 47% hospitals have an “Overcrowding Management Plan” (2ndED 54%, 1stED 51%, First Aid 33%) but that is actually applied only in 39% of cases (2ndED 43%, 1stED 43%, First Aid 26%).
The OBI are present in 84% of EDs and 78% of them are part of the ED’s organization structure, while 5% of the the OBIs are organized in a different way. (fig. 2)
Figure 2
Post triage nursing paths are present in 67% of the structures (2ndED 78%, 1stED 74%, First Aid 43%), 35% of the structures performs only post triage labs examination.
Fast Track is present in 49% of the cases (2nd ED 63%, 1st ED 53%, First Aid 28%). 
Specific pathways for patients who need a long term hospitalization or are affected by chronic diseases exist only in 8% of the cases. (fig. 3)


Only 22% of hospitals use a validated shared tool to manage overcrowding; the overcrowding level is known by the ED operators in 58% of cases and by the patients in 43% of cases. (fig. 4)


Data show that OBI units are consolidated as an integral part of the Italian ED organizational model, as has been promoted for years by SIMEU.
The Holding Area, an hospitalization waiting area, where  patients are assisted by medical and nursing staff and continue theirtherapeutic and diagnostic courseshould not exist in an ideal model of ED, but instead it exists in 21% of the interviwees EDs. These patients are managed in the  EDs from hours to days  by emergency physicians and nurses, and this is an inappropriate activity for ED,  which not only causes  discomfort for the patient  but also subtracts professional resources for managing patients who have access to the ED.
The low percentage of knowledge of real time bed availability, the absences of beds reserved for EDs and the rare presence of the Bed Manager figure, makes managing admissions even more complicated  cause a reduction of time to be spent on clinical activities. A better organization of this aspect is essential to optimize and improve the care of patients admitted to the emergency departments. The survey shows that in most Italian regions (15 out of 20), the Regional Health Departments provided indications to formulate Overcrowding Management Plans, but unfortunately only in few cases these are realized and frequently they aren’t applied. 
The nurse figure plays an important role in the 1st and 2nd level EDs: Fast Track and the activation of nursing care pathways are crucial in the management of patients who are admitted to the EDs, they can shorten the process times and help in the management of crowding. The small number of structures (17 in total) that can use rapid pathways for chronic patients suggests that integration between hospital and home care is still lacking.
Over the years, the importance of using a validated instrument to control overcrowding has been emphasized,but at the moment it is in use only in few structures and it is therefore difficult to compare the different realities. The improvement of its use is a goal for the emergency community.


The organizational management of emergency departmentshas evolved and continuously evolves to meet ever-more complex health needs. Solutions to ED overcrowding are underused. This survey carried out on the Italian territory, shows the current unsatisfactory organization of EDs and identifies several points on which to work at institutional and corporate levels in order to better cope with the problem of overcrowding in the emergency departments.


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