Hospital-wide interventions to reduce emergency department overcrowding: Data-driven strategies and clinical governance at an Italian teaching hospital

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Background Emergency Department (ED) overcrowding is a global systemic challenge driven by an imbalance between healthcare demand and resource availability. This study evaluates a multifaceted, organization-wide intervention at an Italian teaching hospital by focusing on throughput and output factors. Methods A quasi-experimental, pre-post design analysed 100% of the available population data (N = 199354 visits) from 2019 to 2024. A “Digital Twin” simulation identified boarding as the primary bottleneck, consuming 47% of medical resources. Interventions included a “Discharge Decalogue,” digitalization of community care pathways (ADI/CAVS), and nursing protocols. Statistical significance for patient satisfaction (N = 1840) was assessed via t-tests (95% CI). Results Despite a 23.6% increase in total ED volume and a 37.8% surge in high-complexity presentations (Red Codes), interventions optimized outflow. The ALOS for complex discharges decreased for both CAVS (−24.6%) and ADI (−22.6%). Throughput protocols reduced chest pain response times by 27.7%. Satisfaction scores improved accordingly, particularly within the information domain (p < 0.001; 95/% CI [0.22, 0.38]). While overall waiting times fell by 17.8%, boarding times increased: this was driven by clinical complexity and a deliberate institutional policy to mitigate medical boarding within surgical units. This strategic prioritization was maintained to preserve elective surgical capacity. Conclusions A systems-based approach prioritizing output optimization and hospital-territory integration demonstrates superior efficacy compared to traditional input-reduction strategies. This data-driven model provides a scalable framework to strengthen clinical governance and enhance patient experience within resource-constrained environments.