Inappropriate Emergency Department “Code White” visits. Experience within the ASL Latina, Center-South regional hospitals

The main causes of overcrowding in the Italian emergency departments (ED) are attributable to several factors including: the increasing lack of confidence in the General Practitioners, excessively long waiting times for specialist outpatient services and diagnostic tests, the increase size of the population not included in the National Health Service, the organizational evolution of ED as a genuine unit of diagnosis and treatment, and the closure of small hospitals with the consequent reduction in the number of available EDs.
The triage system in the EDs of the Italian hospitals has improved, and is now basing the order of entry of patients who come to the facility on the severity of the clinical conditions, giving priority to the need of care, and not according to the order of arrival, even though in the past this was done informally.
However, there is an issue concerning the cost and efficiency of the system because of the crowding of ED, not always due to the needs of the patients. The scenario in which we are addressing the most interesting developments is the management of the improper access of non-urgent or low complexity care cases.
The improper visits heavily influence the ED activities, increasing the average waiting times, and failing to ensure proper distribution of human, structural and economic resources. Moreover, a high influx of people will involve not only the ED, but also influence many other units (laboratory tests, radiology, consultation services, and administrative units).
This research was carried out to see if improper visits to the ED of regional hospital constituted an overcrowding factor that caused difficulties in the delivery of care.
Our analysis has focused on the work of the emergency rooms of the ASL Latina, Center-South region hospitals. The table shows data broken down by the color codes assigned in the years 2006 and 2007.

TYPE YEAR RED YELLOW GREEN WHITE TOTAL
ED A.Fiorini 2006 245 6289 20761 3167 30391
Terracina 2007 208 6309 16491 4512 27524
D.E.A. Dono 2006 355 6074 26435 2100 34944
Formia Svizzero 2007 422 6357 23910 3658 34347
ED Don Liegro 2006 31 1296 13245 5648 20220
Gaeta 2007 10 1037 11160 4468 16675

The area and the districts are not homogeneous and therefore we wanted to focus on the activity of an emergency room of a restricted and homogenous area as that heads up to the Terracina A. Fiorini hospital, that has no Obstetric services, but that in the past four years has had a significant increase of activity due to the inclusion of operational units of the University of Rome "Sapienza".
The users go to the hospital mainly for medical, surgical and orthopedic emergencies. Triage with a dedicated operator, is carried out continuously over 24 hours.
In 2006 there were on average 83 visits per day, and about 77 in 2007.
The data indicate that the greater percentage of the visits is represented by green codes in both years.
Codes Red and Yellow are virtually super imposable in the two years; in 2006 there were more code Green, while in 2007 there were more code White. (Fig.1)

Figure 1 Visits to ED Hospital A. Fiorini Terracina in 2006 and 2007.

The percentage distribution of the codes is similar in both years under review. The sum of green and white codes represents about 80% of the visits to the ED; the Code Yellow about 20% and the Code Red less than 1%. However, even the percentages of Codes White have increased in 2007 more than in 2006. (Fig. 2).

Fig 2. Percentage breakdown of visit codes

Patients who truly needed care at ED (Codes Red and Yellow) were about 7000 per annum (20% of total) with a daily average of 20 visits.
Certainly some of the improper visits were due to opportunistic causes, like immediately obtain a benefit (x-rays, ultrasounds, laboratory tests ...) that the waiting lists would have delayed. The organizational model of regional medicine does not always ensure adequate response to the needs of citizens. The emergency room often becomes for the citizens a point of reference for the services that should be provided by other social assistance structures.
The exponential growth in demands to the emergency rooms in recent years has been addressed mainly in terms of deterrence, by introducing tools such as participation in expenditure for minor cases. The application of Triage, however, did not solve the problem of overcrowding and of improper and avoidable visits. Finally, the final arrangements for the General Practice have introduced new elements, such as forms of association designed to induce a greater assumption of issues now dealt with in the emergency room; nonetheless, the phenomenon of excessive influx has not been fully resolved.
It is necessary to reorganize the emergency services and, at the same time, the regional healthcare, through diverse and highly flexible organizational models with further development of multi-professional integrations, adaptable to different regional contexts: metropolitan, urban and suburban.