مدیریت گروه اورژانس در لاتزیو، ایتالیا  Emergency Department Management in Lazio, Italy

1. Introduction The Department of Epidemiology of the Regional Health Service of Lazio, Italy (DEP-Lazio in the following), a regional center for Health monitoring and management, is currently involved in a project that aims at defining optimal allocation policies of patients to regional hospital network facilities. The reorganization of health centers in order to deliver services in an effective way by taking into account economic sustainability is a topic of increasing importance for Regional Health Services in Italy. In recent years several inputs have been given, through financial laws, to reorganize hospitals infrastructure in order to increase efficiency. Reorganization policies can be considered, from a strategic point of view, as composed by two main decision elements: the definition of the subset of hospital facilities that should be active within the regional territory and the allocation of demand of services to active facilities. Because the reorganization of a regional health system in terms of facility location and service allocation is a task of great complexity regional managers decided to start by focusing their attention on emergency departments (ED). Indeed, EDs are a crucial access point to hospital network facilities and as a consequence their management is a critical factor in order to improve system effectiveness and effi- ciency. In Italy it is possible to state that the role of EDs is even more important than in other European countries because, in addition to real emergency and urgency services, they have to face a set of demands that should instead be managed by Primary care units or by General Practitioners. This is due to historical reasons associated with the development of the system and, recently, to the increase of (often illegal) immigration. The 2013–2015 operational programs of the Lazio region require the activation of new clinical care pathways for emergencies, with a special priority for life-threatening diseases, such as acute coronary syndrome, stroke and trauma. For these situations, a timely medical intervention, performed in facilities with the necessary equipment, can save the patient’s life and significantly improve the prognosis. For example, with respect to patients suffering from ST Elevation Myocardial Infarction (STEMI),it is suggested to perform a percutaneous coronary intervention (PCI) in hospitals with high volume of activity, equipped with catheterization laboratory and highly qualified teams. Moreover, according to clinical guidelines, it is strongly recommended to perform PCI within 90 min from the onset of the early symptoms. Therefore, it is essential that STEMI patients can immediately be transferred to a specialized hospital. Unfortunately, preliminary analyses showed that the current emergency networks are not able to provide an appropriate and timely healthcare assistance to all residents, especially in areas far from the city of Rome, generally characterized by a lower socioeconomic status. Emergency department characteristics. An emergency department can be defined as an health facility that is dedicated to the management of emergency and urgency treatments, that is to say to that spontaneous or traumatic pathological conditions that need to be treated within a short period of time. Emergency activities are, for their own nature, nonelective and patients can reach ED facilities both by their own (walk-ins) or with the support of an emergency vehicle. Due to the impossibility of planning patients arrival, EDs have to provide an initial treatment for a wide number of diseases some of which can be life-threatening. Because the set of patients that ask for treatments is heterogeneous from the pathological point of view, the admission of patients is driven by a priority-based policy. The stochastic nature of arrival times and of pathological conditions can have a strong impact on workload and as a consequence on patient waiting times and quality of care. It is then fundamental that the priority assignment is properly managed in order to meet patients’ needs according to their critical condition. The process of assigning priorities to patients is defined as triage and it is usually coded at a regional or national level. Triage is a set of procedures that ensure, in the best possible way, that patients with a more critical condition are admitted before the others. The priority level is usually represented by a color code (white, green, yellow and red) that defines the increasing need of care. For each patient the priority is usually defined just after the arrival by a dedicated operator. The definition of triage procedures is then fundamental to guarantee an immediate care for the patient, to identify the priority level and the medical area that may treat him and, ranking lower priority patients, to reduce waiting times. Triage activities can directly address the patient to the most appropriate hospital ward in case of complex treatments, for less serious ones the patient can be directly treated by emergency department physicians and discharged. It is then important for health managers to plan EDs so as to meet a set of objectives that can be in some cases conflicting. At first it is fundamental to guarantee quality of care that is composed by treatment timeliness, according to the patient health condition, and appropriateness, according to the patient pathological condition. On the other hand the cost sustained to provide services has to be reduced as much as possible by taking into account a minimum standard of care. Paper contribution. As already discussed, triage is currently the first activity that is performed when a patient reaches the ED. This means that ED triage is only in charge of determining the care pathway within the hospital structure. In other words, the possibility that a better quality of care and/or a shorter waiting time could have been reached if the patient would have been sent to another ED is not considered.