title: The Robustness and Effectiveness of the Triage System at Times of Overcrowding and the Extra Costs due to Inappropriate Use of Emergency Departments.
abstract: BACKGROUND
  Overcrowding is one of the most harmful problems for Emergency Department (ED) management and the correct estimation of time resource absorption by each type of patient plays a strategic role in dealing with overcrowding and correctly programming ED activity.
  
  
  OBJECTIVE
  We aimed to investigate how overcrowding may affect urgent patients' waiting times (i.e., the robustness of the triage patient priority system) and to evaluate the extra costs due to inappropriate use of EDs.
  
  
  METHODS
  Data referring to 54,254 patients who accessed the ED of a major Italian hospital in 2011 were analyzed to study patient flows and overcrowding. To define an average per-patient cost, according to the severity of his or her health condition, the 2010 profit and loss account of the aforementioned hospital was studied and the time devoted by physicians to each type of patient was estimated by means of a self-reported survey.
  
  
  RESULTS
  Empirical findings confirm a positive correlation between overcrowding and the time a patient has to wait before receiving treatment. This effect is relevant only for non-urgent patients who are responsible for the overcrowding itself. However, urgent patients' waiting times do not increase in the presence of overcrowding, confirming that the triage priority system is robust against the overcrowding situation. The analysis estimates, using 2010 data, that the actual per patient cost incurred by the hospital when treating white-coded patients is, on average, 36.54 euros; a green code costs 93.17, yellow 170.62, and red 227.62. It emerges that 4% of all the personnel costs are attributable to white color-code assistance, 67% to green codes, 23% to yellow codes, and the remaining 6% to red codes.
  
  
  CONCLUSIONS
  The implementation of effective policies intended to improve both efficiency and quality in providing emergency health services has to deal with the systemic problem of inappropriate use of EDs. Policy-makers should be aware of the fact that there is a considerable portion of ED demand for assistance that is inappropriate and that oversizing EDs with respect to the true, appropriate, urgent patients' demands, could bring about a further and undesirable rise in inappropriate assistance demands and, therefore, an increase in ED costs that are not consistent with their objectives.
authors: E. O. Ospedali Galliera, Genoa, Italy. paolo.cremonesi@galliera.it.
authors: Paolo
authors: P
authors: Cremonesi
authors: Department of Economics, University of Genoa, Via Vivaldi 5, 16126, Genoa, Italy. edibella@economia.unige.it.
authors: Enrico
authors: E
authors: di Bella
authors: Department of Economics, University of Genoa, Via Vivaldi 5, 16126, Genoa, Italy. montefiori@unige.it.
authors: Marcello
authors: M
authors: Montefiori
authors: Department of Economics, University of Genoa, Via Vivaldi 5, 16126, Genoa, Italy. persico@economia.unige.it.
authors: Luca
authors: L
authors: Persico
mesh_terms: D003441:Crowding; D017598:Efficiency, Organizational; D004636:Emergency Service, Hospital / Q000191:economics* / Q000458:organization & administration / Q000706:statistics & numerical data; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006300:Health Services Misuse / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D007558:Italy; D008297:Male; D015233:Models, Statistical; D014218:Triage / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data