A decalogue for saving Italian emergency departments

The COVID-19 pandemic severely impacted Italian Emergency Departments (EDs), leading to drastic staff reductions, chronic overcrowding, widespread burnout, and an exodus of healthcare providers. Consequently, the ED system faces collapse due to relentless overloading. The authors propose a radical decalogue of provocations to drive structural reform and spark scientific debate on the future of emergency care. The core objective is to restore the ED’s mission by strictly limiting access to acute, time-dependent conditions. This requires diverting non-urgent visits to a genuinely operational territorial network, creating distinct, non-ED managed flows for non-acute or destabilized chronic patients. To reach this aim, a single, national, scientifically validated triage system is essential to reliably distinguish between ED-acute patients and those who belong in alternative settings. To address staff retention, the Decalogue demands increased pay, reduced weekly working hours, optimized night work, and structured work diversification between pre-hospital and intermediate care units to make the profession sustainable. Furthermore, the ED must be restored as the hospital's strategic core, with the emergency physician as team leader. Simultaneously, boarding must end by mandating the transfer of stabilized patients out of the ED. System-wide, the network should be rationalized by concentrating resources in equipped referral centers. Finally, the Decalogue calls for legal protection for emergency professionals (with liability resting on healthcare institutions), the establishment of academic chairs in emergency medicine assigned to emergency physicians, and mandatory research for residents. The authors contend that only bold, radical choices can safeguard the ED system and the entire healthcare infrastructure. 

1. Oskvarek JJ, Zocchi MS, Black BS, et al. Emergency department volume, severity, and crowding since the onset of the coronavirus disease 2019 pandemic. Ann Emerg Med 2023;82:650-60. DOI: https://doi.org/10.1016/j.annemergmed.2023.07.024

2. Coen D, Casagranda I, Cavazza M, et al. Facing the emergency department crisis in italy. Emerg Care J 2021;17:10331. DOI: https://doi.org/10.4081/ecj.2021.10331

3. Zaboli A, Brigo F, Sibilio S, et al. The impact of COVID-19 pandemic on the urgency of patients admitted to the emergency department. Int Emerg Nurs 2022;65:101229. DOI: https://doi.org/10.1016/j.ienj.2022.101229

4. Green MA, McKee M, Katikireddi SV. Remote general practitioner consultations during COVID-19. Lancet Digit Health 2022;4:e7. DOI: https://doi.org/10.1016/S2589-7500(21)00279-X

5. Sise RG, Calvo RY, Spain DA, et al. The epidemiology of trauma-related mortality in the United States from 2002 to 2010. J Trauma Acute Care Surg 2014;76:913-9; discussion 920. DOI: https://doi.org/10.1097/TA.0000000000000169

6. van Breugel JMM, Niemeyer MJS, Houwert RM, et al. Global changes in mortality rates in polytrauma patients admitted to the ICU-a systematic review. World J Emerg Surg 2020;15:55. DOI: https://doi.org/10.1186/s13017-020-00330-3

7. Hardy BM, King KL, Enninghorst N, Balogh ZJ. Trends in polytrauma incidence among major trauma admissions. Eur J Trauma Emerg Surg 2024;50:623-6. DOI: https://doi.org/10.1007/s00068-022-02200-w

8. Fischer-Rosinský A, Slagman A, Legg D, et al. Frequency, demographics, diagnoses and consultation patterns associated with low-acuity attendances in German emergency departments: a retrospective routine healthcare data analysis from the INDEED project. BMJ Open 2024;14:e084986. DOI: https://doi.org/10.1136/bmjopen-2024-084986

9. Dinh MM, Berendsen Russell S, Bein KJ, et al. Statewide retrospective study of low acuity emergency presentations in New South Wales, Australia: who, what, where and why? BMJ Open 2016;6:e010964. DOI: https://doi.org/10.1136/bmjopen-2015-010964

10. Berkowitz DA, Brown K, Morrison S, et al. Improving low-acuity patient flow in a pediatric emergency department: a system redesign. Pediatr Qual Saf 2018;3:e122. DOI: https://doi.org/10.1097/pq9.0000000000000122

11. Atenstaedt R, Gregory J, Price-Jones C, et al. Why do patients with nonurgent conditions present to the Emergency Department despite the availability of alternative services? Eur J Emerg Med 2015;22:370-3. DOI: https://doi.org/10.1097/MEJ.0000000000000224

12. di Bella E, Gandullia L, Leporatti L, et al. Frequent use of emergency departments and chronic conditions in ageing societies: a retrospective analysis based in Italy. Popul Health Metr 2020;18:29. DOI: https://doi.org/10.1186/s12963-020-00237-w

13. Chiu YM, Dufour I, Courteau J, et al. Profiles of frequent emergency department users with chronic conditions: a latent class analysis. BMJ Open 2022;12:e055297. DOI: https://doi.org/10.1136/bmjopen-2021-055297

14. Zaboli A, Turcato G, Brigiari G, et al. Emergency departments in contemporary healthcare: are they still for emergencies? An analysis of over 1 million attendances. Healthcare (Basel) 2024;12:2426. DOI: https://doi.org/10.3390/healthcare12232426

15. NHS Improvement. NHS England; 2018. Ambulatory Emergency Care Network. Ambulatory Emergency Care Guide. Same Day Emergency Care: Clinical Definition, Patient Selection and Metrics. [cited 2024 Feb 7]. Available from: https://www.england.nhs.uk/wp-content/uploads/2021/05/aec-same-day-emergency-care-clinical-definition-patient-selection-metrics.pdf

16. NHS England. NHS England; 2015. Transforming urgent and emergency care services in England. [cited 2024 Feb 7]. Available from: www.england.nhs.uk/wp-content/uploads/2015/06/trans-uec.pdf .

17. NHS Improvement. NHS England; 2018. Ambulatory emergency care network. ambulatory emergency care guide. same day emergency care: clinical definition, patient selection and metrics. [cited 2024 Feb 7]. Available from: https://www.england.nhs.uk/wp-content/uploads/2021/05/aec-same-day-emergency-care-clinical-definition-patient-selection-metrics.pdf.

18. NHS England. NHS England; 2015. Transforming urgent and emergency care services in England. [cited 2024 Feb 7]. Available from: www.england.nhs.uk/wp-content/uploads/2015/06/trans-uec.pdf .

19. Derlet RW, Nishio DA. Refusing care to patients who present to an emergency department. Ann Emerg Med 1990;19:262-7. DOI: https://doi.org/10.1016/S0196-0644(05)82041-4

20. Derlet RW, Nishio D, Cole LM, Silva J Jr. Triage of patients out of the emergency department: three-year experience. Am J Emerg Med 1992 May;10:195-9. DOI: https://doi.org/10.1016/0735-6757(92)90207-E

21. Derlet RW, Kinser D, Ray L, Hamilton B, McKenzie J. Prospective identification and triage of nonemergency patients out of an emergency department: a 5-year study. Ann Emerg Med 1995;25:215-23. DOI: https://doi.org/10.1016/S0196-0644(95)70327-6

22. Kuensting LL. "Triaging out" children with minor illnesses from an emergency department by a triage nurse: where do they go? J Emerg Nurs 1995;21:102-8. DOI: https://doi.org/10.1016/S0099-1767(05)80007-8

23. Diesburg-Stanwood A, Scott J, Oman K, Whitehill C. Nonemergent ED patients referred to community resources after medical screening examination: characteristics, medical condition after 72 hours, and use of follow-up services. J Emerg Nurs 2004;30:312-7. DOI: https://doi.org/10.1016/j.jen.2004.04.001

24. Morin C, Choukroun J, Callahan JC. Safety and efficiency of a redirection procedure toward an out of hours general practice before admission to an emergency department, an observational study. BMC Emerg Med 2018;18:26. DOI: https://doi.org/10.1186/s12873-018-0173-6

25. Kirkland SW, Soleimani A, Rowe BH, Newton AS. A systematic review examining the impact of redirecting low-acuity patients seeking emergency department care: is the juice worth the squeeze? Emerg Med J 2019;36:97-106. DOI: https://doi.org/10.1136/emermed-2017-207045

26. Morreel S, Philips H, De Graeve D, et al. Triaging and referring in adjacent general and emergency departments (the TRIAGE trial): A cluster randomised controlled trial. PLoS One 2021;16:e0258561. DOI: https://doi.org/10.1371/journal.pone.0258561

27. Ylä-mattila J, Koivistoinen T, Siippainen H, et al. The outcome of ''non-urgent'' patients diverted by triage at an emergency department. Signa Vitae 2023;19:91-6.

28. Déglise A, Guechi Y, Le Terrier C, et al. SAFEty assessment of a REdirection process after TRIage (SAFE RETRI) by a triage nurse in an emergency department: a monocentric cohort study. Swiss Med Wkly 2024;154:4030. DOI: https://doi.org/10.57187/s.4030

29. Feral-Pierssens AL, Gaboury I, Carbonnier C, Breton M. Redirection of low-acuity emergency department patients to nearby medical clinics using an electronic medical support system: effects on emergency department performance indicators. BMC Emerg Med 2024;24:166. DOI: https://doi.org/10.1186/s12873-024-01080-0

30. Zachariasse JM, van der Hagen V, Seiger N, et al. Performance of triage systems in emergency care: a systematic review and meta-analysis. BMJ Open 2019;9:e026471. DOI: https://doi.org/10.1136/bmjopen-2018-026471

31. Hinson JS, Martinez DA, Cabral S, et al. Triage performance in emergency medicine: a systematic review. Ann Emerg Med 2019;74:140-52. DOI: https://doi.org/10.1016/j.annemergmed.2018.09.022

32. Zaboli A, Brigo F, Cipriano A, et al. Assessing triage efficiency in Italy: a comparative study using simulated cases among nurses. Intern Emerg Med 2025;20:1167-76. DOI: https://doi.org/10.1007/s11739-024-03735-z

33. Roussel M, Teissandier D, Yordanov Y, et al. Overnight stay in the emergency department and mortality in older patients. JAMA Intern Med 2023;183:1378-85. DOI: https://doi.org/10.1001/jamainternmed.2023.5961

34. Mohr NM, Wessman BT, Bassin B, et al. Boarding of critically ill patients in the emergency department. Crit Care Med 2020;48:1180-7. DOI: https://doi.org/10.1097/CCM.0000000000004385

35. da Silva Ramos FJ, Freitas FGR, Machado FR. Boarding in the emergency department: challenges and mitigation strategies. Curr Opin Crit Care 2024;30:239-45. DOI: https://doi.org/10.1097/MCC.0000000000001149

36. Organization for Economic Co-operation and Development (OECD) Health at a Glance: Europe 2024. STATE OF HEALTH IN THE EU CYCLE. Available from: https://www.oecd.org/content/dam/oecd/en/publications/reports/2024/11/health-at-a-glance-europe-2024_bb301b77/b3704e14-en.pdf

37. Viccellio A, Santora C, Singer AJ, et al. The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience. Ann Emerg Med 2009;54:487-91. DOI: https://doi.org/10.1016/j.annemergmed.2009.03.005

38. Canetta C, Accordino S, La Boria E, et al. Effects of a medical admission unit on in-hospital patient flow and clinical outcomes. Eur J Intern Med 2024;127:105-11. DOI: https://doi.org/10.1016/j.ejim.2024.05.001

39. Vrangbæk K, Smith Jervelund S. A comprehensive mosaic reform to strengthen primary and chronic care capacity," Updates - European Observatory on Health Systems and Policies, 25-Nov-2024. Accessed: Aug. 26, 2025. Available: https://eurohealthobservatory.who.int/monitors/health-systems-monitor/updates/hspm/denmark-2024/a-comprehensive-mosaic-reform-to-strengthen-primary-and-chronic-care-capacity

40. Healthcare Denmark. Innovative hospital services in Denmark. Triple I Denmark Informs–Inspires–Invites, Mar. 2025. Accessed: Aug. 26, 2025. Available:https://healthcaredenmark.dk/media/5j1dhkti/hospitals2025_onlinepdf.pdf

41. Flojstrup M, Bogh SBB, Bech M, et al. Mortality before and after reconfiguration of the Danish hospital-based emergency healthcare system: a nationwide interrupted time series analysis. BMJ Qual Saf 2023;32:202-13. DOI: https://doi.org/10.1136/bmjqs-2021-013881

42. Pudasaini S, Schenk L, Möckel M, Schneider A. Work-life balance in physicians working in two emergency departments of a university hospital: Results of a qualitative focus group study. PLoS One 2022;17:e0277523. DOI: https://doi.org/10.1371/journal.pone.0277523

43. Ross S, Liu EL, Rose C, et al. Strategies to enhance wellness in emergency medicine residency training programs. Ann Emerg Med 2017;70:891-7. DOI: https://doi.org/10.1016/j.annemergmed.2017.07.007

44. Ben-Itzhak S, Dvash J, Maor M, et al. Sense of meaning as a predictor of burnout in emergency physicians in Israel: a national survey. Clin Exp Emerg Med 2015;2:217-25. DOI: https://doi.org/10.15441/ceem.15.074

45. Bostock F, Mortimore G. Considering the impact of shift working on health. Br J Nurs 2024;33:120-4. DOI: https://doi.org/10.12968/bjon.2024.33.3.120

46. Ugwu LE, Idemudia ES, Onyedibe MC. Decoding the impact of night/day shiftwork on well-being among healthcare workers. Sci Rep 2024;14:10246. DOI: https://doi.org/10.1038/s41598-024-60882-1

47. Batat H, Baniamer AZ, Hamasha AM, et al. The relationship between night shift work, sleep patterns, psychological well-being, and mental health among Jordanian healthcare workers. Arch Environ Occup Health 2024;79:131-41. DOI: https://doi.org/10.1080/19338244.2024.2379826

48. Zaboli A, Brigo F, Brigiari G, Turcato G. Exploring the variability in triage nursing workload: insights from a multicentre observational study. J Adv Nurs 2025;81:4690-7. DOI: https://doi.org/10.1111/jan.16627

49. Turcato G, Zaboli A, Ferretto P, et al. The role of an intermediate care unit in reducing intensive care unit admissions and improving patient outcomes in internal medicine: A quasi-experimental study. Eur J Intern Med 2025;137:45-54. DOI: https://doi.org/10.1016/j.ejim.2025.03.028

50. Throop J, Powell D, Slywka B. A successful sabbatical program to reduce burnout in emergency medicine physicians. NEJM Catalyst 2022;3:0209. DOI: https://doi.org/10.1056/CAT.22.0209

51. Baugh JJ, Takayesu JK, White BA, Raja AS. Beyond the Maslach burnout inventory: addressing emergency medicine burnout with Maslach's full theory. J Am Coll Emerg Physicians Open 2020;1:1044-9. DOI: https://doi.org/10.1002/emp2.12101