Emergency Department (ED) overcrowding significantly impacts patient care, increasing wait times and delaying treatment. This study evaluates a quality improvement project involving the implementation of an early nursing care protocol designed to optimize patient management during overcrowding by enabling nurses to initiate blood tests during triage.

In our high-volume urban ED in Northern Italy, recurrent overcrowding particularly affected patients with non-urgent triage codes, resulting in prolonged door-to-treatment times and decreased patient satisfaction. Nurses were underutilized in early diagnostic workflows.

The study assessed the effectiveness of a protocol involving a predefined set of blood tests performed during the post-triage waiting period under overcrowding conditions in adult patients presenting with chest or abdominal pain and a triage level 2 to 5 at the ED of Santa Croce e Carle Hospital in Cuneo, Italy, from January 1, 2024, to June 20, 2024. The primary outcome was the reduction in ED treatment time and length-of-stay (LOS) during overcrowding among patients managed with the protocol.

The intervention consisted of nurse-initiated blood draws using predefined criteria and an electronic lab test panel. The protocol was activated only during predefined periods of severe ED crowding, based on local operational thresholds.

3,857 patients were included, with 38% undergoing early blood testing due to overcrowding; patients in the early testing group (i.e. patients managed during overcrowding) experienced a significantly longer waiting time (142 min vs. 48 min, p < 0.001). However, their treatment time was significantly shorter (132 min vs. 162 min, p < 0.001), resulting in a less pronounced increase in total ED LOS. Subgroup analyses confirmed consistent reductions in treatment time across different triage levels and presenting symptoms.

Early nursing-led blood testing during ED overcrowding enhances efficiency by reducing treatment times, enabling earlier clinical decision-making, and improving patient monitoring. Despite increased total ED LOS due to overcrowding, this increase appears to be lower than what the prolonged waiting time due to overcrowding itself might have suggested. This quality improvement initiative highlights the potential for advanced nursing roles to optimize emergency care delivery. Further research should assess patient satisfaction and cost-effectiveness.