Emergency Department overcrowding represents a growing challenge for healthcare systems, with significant consequences for quality of care, patient safety, and hospital organizational efficiency. Among the main determinants of this phenomenon is boarding, which is widely recognized in the literature as a major challenge within hospital output processes. Boarding is defined as the time during which patients requiring hospital admission remain in the Emergency Department while awaiting transfer to an inpatient ward. In light of these challenges, the overall aim of this thesis was to identify and analyse organizational strategies aimed at reducing boarding times in emergency departments. The study was divided into two main phases. The first phase consisted of a Scoping Review of the literature, aimed at identifying and analysing the main organizational strategies adopted internationally to reduce boarding times in emergency departments, as well as identifying interventions potentially transferable to the local context. The review highlighted that the most effective interventions are generally embedded within complex organizational models based on integration among Emergency Departments, inpatient wards, community-based services, Bed Management, hospital administration, and the wider hospital network. The second phase initially focused on the potential implementation, at the “Infermi” Hospital in Rimini, of one of the interventions identified in the literature. However, due to organizational, financial, and time constraints that prevented the introduction of new models in the short term, the study was subsequently refocused on the analysis of an organizational strategy already in place at the hospital, namely the “Early Boarding” project. This study therefore aimed to describe the intervention and to analyse adherence to the model, annual trends in boarding times in relation to hospital admissions and Emergency Department visits, and the safety of the process. The project involves the early admission of clinically stable patients (MEWS ≤ 3), through transfer to the inpatient ward and immediate nursing care, without the need for a medical assessment to be performed at the time of transfer. The results showed limited but stable adherence to the model during the observation period, with an annual rate of early admissions ranging from 5.12% to 5.59% of total admissions in the participating departments. Analysis of boarding times revealed an overall increase compared with the period preceding the implementation of the project, with no clear reversal of this trend following its introduction. During the same period, Emergency Department visits increased from 85.369 to approximately 101.000 (+18.3%), while the annual number of hospital admissions remained generally stable, ranging from 9.125 to 9.315 cases per year. With regard to process safety, the analysis of 132 medical records from 2025 identified no adverse events attributable to the implementation of the project during the period between transfer to the inpatient ward and the first medical assessment. The experience analysed suggests that “Early Boarding” is a safe and practically applicable organizational strategy that may support hospital patient-flow management while enhancing the nursing role in continuity of care and in the management of admission pathways. However, the findings indicate that, when implemented as a standalone measure, this intervention is not sufficient to reduce boarding times. Its integration within broader and more comprehensive organizational strategies is therefore necessary.
Il fenomeno del sovraffollamento (overcrowding) nei Pronto Soccorso rappresenta una criticità crescente per i sistemi sanitari, con importanti ripercussioni sulla qualità dell’assistenza, sulla sicurezza dei pazienti e sull’efficienza organizzativa delle strutture ospedaliere. Tra i principali determinanti del fenomeno vi è il boarding, riconosciuto in letteratura come una delle principali criticità dei processi di output e definito come il tempo di permanenza in Pronto Soccorso dei pazienti destinati al ricovero, in attesa di trasferimento presso un reparto di degenza. Alla luce di tali criticità, l’obiettivo generale della presente tesi è quello di individuare ed analizzare le strategie organizzative di output finalizzate alla riduzione dei tempi di boarding in Pronto Soccorso. Il lavoro è stato articolato in due fasi principali. La prima fase ha previsto la conduzione di una Scoping Review della letteratura, con lo scopo di identificare ed analizzare le principali strategie organizzative adottate a livello internazionale per la riduzione dei tempi di boarding in Pronto Soccorso, al fine di individuare interventi potenzialmente trasferibili al contesto locale. La revisione ha evidenziato come gli interventi maggiormente efficaci siano generalmente inseriti all’interno di modelli organizzativi complessi, basati sull’integrazione tra Pronto Soccorso, reparti di degenza, servizi territoriali, Bed Management, Direzione Aziendale e rete ospedaliera. La seconda fase, inizialmente orientata alla possibile implementazione nel contesto dell’Ospedale “Infermi” di Rimini di uno degli interventi individuati in letteratura, è stata successivamente riorientata verso l’analisi di una strategia organizzativa già attiva nel contesto aziendale (“Early Boarding”), in considerazione di vincoli organizzativi, economici e temporali che non hanno consentito l’introduzione di nuovi modelli nel breve periodo. Il presente studio si propone pertanto di descrivere tale intervento e di analizzarne il grado di adesione, l’andamento annuale dei tempi di boarding in relazione al numero di ricoveri ed accessi in Pronto Soccorso, nonché la sicurezza del modello. Il progetto prevede l’anticipazione del ricovero dei pazienti clinicamente stabili (MEWS≤3) mediante trasferimento precoce nel reparto di degenza ed immediata presa in carico infermieristica, senza la necessità che la valutazione medica avvenga contestualmente al trasferimento. I risultati hanno evidenziato un’adesione limitata ma stabile al modello nel periodo osservato, con una quota annuale di ricoveri anticipati compresa tra il 5,12% e il 5,59% del totale dei ricoveri nelle Unità Operative coinvolte. L’analisi dei tempi di boarding ha evidenziato un aumento complessivo rispetto al periodo precedente all’introduzione del progetto, senza mostrare una chiara inversione di tendenza successivamente alla sua attivazione. Nel medesimo periodo, gli accessi al Pronto Soccorso sono aumentati da 85.369 a circa 101.000 (+18,3%), mentre il numero annuale dei ricoveri è rimasto complessivamente stabile, variando tra 9.125 e 9.315 casi annui. Per quanto riguarda la sicurezza del percorso, dall’analisi di 132 cartelle cliniche relative all’anno 2025 non sono emersi eventi avversi attribuibili all’applicazione del progetto. L’esperienza analizzata suggerisce come l’“Early Boarding” rappresenti una strategia organizzativa sicura e concretamente applicabile, potenzialmente utile a supportare la gestione dei flussi ospedalieri, valorizzando al contempo il ruolo infermieristico nella continuità assistenziale e nel governo dei percorsi di ricovero. Tuttavia, i risultati ottenuti indicano che tale intervento, se adottato come misura isolata, non è sufficiente a determinare una riduzione dei tempi di boarding, rendendo necessario il suo inserimento all’interno di strategie organizzative più ampie ed integrate.
Strategie per la riduzione dei tempi di boarding in Pronto Soccorso: evidenze dalla letteratura ed analisi del progetto riminese “Early Boarding”
BETTI, JESSICA
2025/2026
Abstract
Emergency Department overcrowding represents a growing challenge for healthcare systems, with significant consequences for quality of care, patient safety, and hospital organizational efficiency. Among the main determinants of this phenomenon is boarding, which is widely recognized in the literature as a major challenge within hospital output processes. Boarding is defined as the time during which patients requiring hospital admission remain in the Emergency Department while awaiting transfer to an inpatient ward. In light of these challenges, the overall aim of this thesis was to identify and analyse organizational strategies aimed at reducing boarding times in emergency departments. The study was divided into two main phases. The first phase consisted of a Scoping Review of the literature, aimed at identifying and analysing the main organizational strategies adopted internationally to reduce boarding times in emergency departments, as well as identifying interventions potentially transferable to the local context. The review highlighted that the most effective interventions are generally embedded within complex organizational models based on integration among Emergency Departments, inpatient wards, community-based services, Bed Management, hospital administration, and the wider hospital network. The second phase initially focused on the potential implementation, at the “Infermi” Hospital in Rimini, of one of the interventions identified in the literature. However, due to organizational, financial, and time constraints that prevented the introduction of new models in the short term, the study was subsequently refocused on the analysis of an organizational strategy already in place at the hospital, namely the “Early Boarding” project. This study therefore aimed to describe the intervention and to analyse adherence to the model, annual trends in boarding times in relation to hospital admissions and Emergency Department visits, and the safety of the process. The project involves the early admission of clinically stable patients (MEWS ≤ 3), through transfer to the inpatient ward and immediate nursing care, without the need for a medical assessment to be performed at the time of transfer. The results showed limited but stable adherence to the model during the observation period, with an annual rate of early admissions ranging from 5.12% to 5.59% of total admissions in the participating departments. Analysis of boarding times revealed an overall increase compared with the period preceding the implementation of the project, with no clear reversal of this trend following its introduction. During the same period, Emergency Department visits increased from 85.369 to approximately 101.000 (+18.3%), while the annual number of hospital admissions remained generally stable, ranging from 9.125 to 9.315 cases per year. With regard to process safety, the analysis of 132 medical records from 2025 identified no adverse events attributable to the implementation of the project during the period between transfer to the inpatient ward and the first medical assessment. The experience analysed suggests that “Early Boarding” is a safe and practically applicable organizational strategy that may support hospital patient-flow management while enhancing the nursing role in continuity of care and in the management of admission pathways. However, the findings indicate that, when implemented as a standalone measure, this intervention is not sufficient to reduce boarding times. Its integration within broader and more comprehensive organizational strategies is therefore necessary.| File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12075/27126