Care accessibility and reasons for non-urgent emergency department visits in South Tyrol (Italy): protocol of the multicentre cross-sectional CARES study

Abstract

Introduction

Emergency departments (EDs) suffer from crowding due to patients with low urgency whose treatment is often inappropriate in many cases. Crowding in the ED may indicate inefficiencies in the primary care infrastructure. According to the literature, it is associated with individual and system-related factors, such as younger age, convenience of visiting the ED and a negative perception of care outside the hospital. However, patients’ motives driving decision-making for non-urgent visits to the ED in this post-pandemic period require further exploration. Therefore, this study aims to describe the proportion of potentially avoidable, non-urgent ED visits and to explore the associations between socio-demographic and clinical characteristics, patients’ motives, and potentially avoidable, non-urgent visits to the ED.

Methods and analysis

This multicentre cross-sectional study will be conducted in the ED of seven public hospitals in the South Tyrolean Health Service in the northern Italian Province of Bolzano-Bozen. A consecutive sample of 1000 adult patients (≥18 years) with clinical conditions that are triaged as ‘non-urgent’ (ie, Manchester Triage System priority level ‘blue’ or ‘green’) and consent to participate in the study will be included. Data will be collected in each ED over two full working weeks (24 hours, weekdays and weekends) between 1 September 2024 and 30 November 2024. For each patient, triage nurses and medical doctors will fill out a data collection sheet, including the triage code, diagnosis at discharge and avoidability of the ED visit. Patients will be surveyed using a structured questionnaire with standardised instruments (eg, the Patient Activation Measure and Mental Health Inventory) and self-developed items (eg, motives for ED visits and previous use of community care services). Data analysis will involve descriptive and inferential analyses (ie, χ² tests) to determine group differences. Multivariate multilevel modelling will be applied to explore the associations between individual, system and cultural factors and potentially avoidable, non-urgent visits.

Ethics and dissemination

Ethical approval for this study was obtained from the Medical Ethics Committee of the South Tyrolean Health Service (Nr. 41-2024). The results will be published in relevant scientific journals and communicated to the public and relevant institutions through dissemination activities, including press releases and stakeholder meetings. The findings will inform recommendations aimed at refining health policies and optimising access to primary and emergency care services.

Registration details

ISRCTN registry (ISRCTN17355506).

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study provides a context-specific analysis of potentially avoidable, non-urgent emergency department (ED) visits in South Tyrol (Italy) across all seven EDs in this region.

• The use of structured patient interviews, standardised triage data and discharge diagnoses coded with the ICPC-2 enhances the internal validity and comparability of the findings.

• As the study exclusively includes patients with non-urgent triage codes (blue or green codes) during the data collection period, findings are not generalisable to urgent or high-acuity cases.

• The cross-sectional nature of the data limits causal inference, and patient self-reporting may be subject to recall or social desirability biases.

Introduction

In recent decades, increasing utilisation of emergency department (ED) services has been consistently observed across developed countries.¹ This often leads to crowding in the ED, which poses an additional risk of morbidity and mortality for patients² and frequently results in emotional exhaustion, job dissatisfaction and turnover among healthcare personnel due to deteriorating working conditions.³ Responsible for crowding are often patients with low urgency (eg, problems with the musculoskeletal system and skin), whose treatment in the ED is considered inappropriate in many cases. For instance, a national French cross-sectional study in 734 EDs found that 13.5%–27.4% of ED visits to the ED were classified as inappropriate.⁴ Of all ED visits, non-urgent attendance represents 14%–40%.4,8 According to major variations in the definition and methodology used to quantify non-urgent ED use, some authors even estimate that non-acute ED attendances constitute up to 90%.^{5 6 9} Thus, in some settings, urgent conditions for which emergency care is intended may represent a minority of ED visits.¹⁰

Several studies have shown that the recent COVID-19 pandemic has significantly reduced the prevalence of urgent ED visits in its early stages,11,13 with a rebound to previous rates during the ongoing pandemic.^{6 14} Although pandemic-related restrictions have come along with the underuse of necessary treatments,¹⁴ the initially drastic reductions in ED visits seem to confirm that some of the reduced ED care may have been avoidable. On the other hand, some studies report a significant increase in non-urgent ED visits during the ongoing crisis compared with pre-pandemic values, which may be attributed to increased levels of anxiety and pandemic-related behavioural changes in the population, but also to reduced face-to-face visits and changed modalities in primary care.^{10 15} In this post-pandemic period, intensified efforts to investigate and efficiently tackle the phenomenon of non-urgent ED utilisation are urgently needed, as its negative consequences are well known and remain a major challenge for healthcare systems: crowding of ED facilities, increased service-related expenditures, impaired efficiency in the treatment of urgent conditions, pressure placed on the staff, long waiting times, which negatively affect the satisfaction of patients and medical service providers,¹⁶ increased length of patients’ stay leading to higher rates of medical errors, risk of iatrogenic harm, reduced patient safety and increased morbidity and mortality.²

The rationale that induces patients to seek an ED for non-urgent health problems instead of primary care services is heterogeneous.¹⁷ This trend may partly be attributable to demographic changes, with an increase in the proportion of older, multimorbid individuals with chronic illnesses and cognitive impairments. Older age has been shown to correlate with more frequent overall use of ED care.¹ However, most findings suggest that non-urgent ED use is inversely associated with older age,^{4 5 18 19} and younger adults tend to bypass lower-acuity settings, such as primary care and directly approach EDs.¹⁶ While the convenience of visiting the ED plays a role, they often seek urgent care because of anxiety about their symptoms and a lack of coping capacity due to various life stressors.²⁰ Uncomfortable symptoms, a perceived need for immediate action and the choice of what they perceive to be the most appropriate healthcare provider drive younger adults’ decisions to visit the ED.²¹ Patient decision delays and subsequent help-seeking behaviours are profoundly affected by their understanding of their symptoms and the seriousness of their condition.²²

Patients often directly access the ED without attempting primary care, which is associated with higher odds of non-urgent ED use compared with patients who are referred by a healthcare professional.²³ Robust primary care systems are the ‘backbone’ of efficient healthcare delivery and are crucial for decreasing the likelihood of non-urgent visits to EDs.²¹ Yet, previous studies showed that only about one-fifth of patients seeking ED were referred by their general practitioners (GPs) or by a specialist, whereas most patients had come on their own initiative.^{24 25} Limited confidence in primary care services, difficulties in accessing or not timely availability of GPs, or dissatisfaction with their own GP have been described as key driving factors.^{5 6 16 17 26 27} In this context, patients’ behavioural changes and personal convenience seem to play a crucial role;^{8 27} for example, a desire to be cured quickly, flexibility of a 24/7 hour healthcare service with no need for appointments and easier access than primary care, assumed higher quality of hospital care, broad availability of secondary services or geographical proximity of the ED, especially in urban locations.^{16 17 28 29} In addition, the perceived urgency of medical problems,^{18 26} presumed need for investigation, health concerns and uncertainty, risk aversion, views of other persons or healthcare professionals, and lack of awareness regarding alternative care options have been described as reasons for non-acute ED approaches.^{16 17 27} In summary, these findings suggest that non-urgent ED visits are a complex problem influenced by individual-related, system-related and culture-related factors.

Study context and research aims

South Tyrol, the Autonomous Province of Bolzano, is part of the Trentino–Alto Adige region in Northern Italy, next to Austria (total population: 534 912), with approximately 70% German-speaking, 25% Italian-speaking and 5% other languages. This multilingual environment poses specific challenges for healthcare delivery, particularly in primary-care settings. There is an urgent need to explore the reasons for non-urgent ED visits in South Tyrol, as the region’s healthcare system is under increasing pressure to meet the growing demand for ED visits. We assume that a significant number of these visits could be managed more appropriately and efficiently in primary care settings, suggesting shortcomings, including accessibility and linguistic and cultural barriers that complicate communication between healthcare providers and patients. Primary care must be accessible and effective for the entire population to ensure that emergency services are reserved for true emergencies. Therefore, the overarching goal of this study is to gain a holistic understanding of the care accessibility and reasons for non-urgent ED visits in South Tyrol, which is crucial for developing, implementing and evaluating strategies to optimise primary care utilisation and reduce inappropriate ED visits. Thus, we aim to improve our understanding of whether inefficiencies in the primary care infrastructure contribute to potentially avoidable ED visits and which individual, system and culture-related factors drive patients’ decision to attend the ED for non-urgent problems.

With this study, we aim (1) To describe the proportion of potentially avoidable, non-urgent ED visits, (2) To describe patients’ motives (eg, individual, system and cultural factors) for attending the ED for non-urgent visits, (3) To compare patients’ socio-demographic and clinical characteristics between potentially avoidable and non-avoidable ED visits as judged by the healthcare personnel and (4) To explore the associations between individual, system and cultural factors and avoidability of non-urgent visits to the ED.

Methods

The ‘Care Accessibility and Reasons for Non-urgent Emergency Department Visits in South Tyrol (CARES) study’ applies a multicentre cross-sectional study design and will be conducted in the EDs of the seven public hospitals of the South Tyrolean Health Service in the northern-Italian Province of Bolzano-Bozen (South Tyrol). The study methodology builds on an observational study conducted in Germany.^{24 30}

Setting

Healthcare provision in South Tyrol

The national public healthcare system in Italy, known as Servizio Sanitario Nazionale, is organised under the Ministry of Health and administered on a devolved regional basis. It provides residents with free or low-cost healthcare services, including access to GPs, treatment at public hospitals (including emergency care), subsidised medicines, laboratory services, ambulance services and specialist care. In the Autonomous Province of Bolzano (South Tyrol), healthcare is managed by the South Tyrolean Health Trust (Südtiroler Sanitätsbetrieb—Azienda Sanitaria dell’Alto Adige), which offers acute care services through seven hospitals (Bolzano-Bozen, Merano-Meran, Silandro-Schlanders, Bressanone-Brixen, Vipiteno-Sterzing, Brunico-Bruneck and San Candido-Innichen) and community care services. Across the four health districts, 288 GPs operate in single or group practices and serve as ‘gatekeepers’, responsible for treating common medical conditions and referring patients to hospitals and other medical services for urgent and specialist treatment.

Triage in the EDs

Since 2013, patients attending South Tyrolean EDs have been triaged according to the Manchester Triage System (MTS) method with the goal of improving the efficiency and effectiveness of managing patient flow.³¹ The MTS is a widely used system that includes 53 flow-chart diagrams for specific complaints. Each flowchart depicts six key discriminators to identify key signs and symptoms to place patients at an appropriate level for their generic acuity or risk.³¹ The five triage priority levels predict how long a patient can safely wait in the ED: red (immediate, no waiting), orange (very urgent, 10 min), yellow (urgent, 60 min), green (normal, 120 min) and blue (non-urgent, 240 min). Recent studies in South Tyrol have investigated the performance of MTS in safely prioritising patients presenting with various symptoms in the ED, including fever, abdominal pain, dyspnoea, non-traumatic headache and transitory loss of consciousness.32,36 The accuracy of the MTS for patient outcomes after triage underscores the benefits and capacities of specialised registered nurses to quickly and accurately distinguish patients in need of urgent (priority level ‘red’ to ‘yellow’) and non-urgent care (priority level ‘green’ and ‘blue’).³⁷ Patients admitted to South Tyrolean EDs receive a triage evaluation from a specialised triage nurse; that is, registered nurses who have at least 2 years of experience in a critical care area, have completed a dedicated 2-day training course, and have received mentoring from clinical expert nurses.

Study sample

We aim to include a consecutive sample of 1000 adult patients (≥18 years) with clinical conditions that are triaged as ‘non-urgent’ (‘blue’) or ‘normal’ (‘green’) according to the MTS,³⁸ are able to communicate in either German or Italian and who consent to participate in the study. Excluded are minor patients (<18 years old), patients with high acuity triaged as ‘immediate’ (‘red’), ‘very urgent’ (‘orange’) or ‘urgent’ (‘yellow’), as well as non-triaged patients requiring immediate or emergency treatment without waiting time and patients triaged with fast track (ie, specialised medical visit). Additionally, patients meeting one or more of the following criteria will also be excluded: (1) Cognitive impairment (eg, patients with any condition that results in impaired decision-making that may affect informed consent, such as patients with dementia or psychiatric conditions), (2) Inability to communicate verbally in German or Italian, (3) Lack of consent (eg, patients who refused to participate or were unable to consent) and (4) Direct referral to another outpatient clinic or department within the hospital.

In 2023, a total of 18.27 million patients accessed EDs in Italy, corresponding to an increase of 6% compared with 2022. The proportion of non-urgent visits (triage code ‘white’ or ‘green’) was 68%, and 22% (3.9 Mio. visits) were considered as inappropriate.³⁹ With 498.8 visits per 1000 inhabitants, South Tyrol had the highest incidence of ED visits in 2023 across Italy, where 80% (399.0 accesses per 1000 inhabitants) were considered non-urgent ED visits. According to national data, South Tyrolean EDs have 212 281 non-urgent visits (18 796 ‘white’ and 193 485 ‘green’ triage codes).³⁹ This high volume suggests a substantial pool of study participants. For our study, hypothesising a prevalence of 80% potentially avoidable, non-urgent ED visits, a level of confidence of 95%, a precision of 5% and non-response or any loss of 50%, a sample size of at least 246, and 493 patients (added for loss).⁴⁰ However, we aim to include a total of 1000 patients to have a more robust sample size for the descriptive and explorative analyses within this observational study. A recent prospective observational single-centre study in one South Tyrolean ED enrolled 2032 patients with priority level blue from MTS over a 6-month period to investigate the rate of hospitalisation.⁴¹ Similarly, a single-centre study in our region observed a total of 2462 emergency visits in a 2-week period, with 72.5% considered non-urgent.⁴² Based on the experiences within these two studies, we deemed it feasible to achieve the target of 1000 evaluable patients within a 2-week study period, with each of the seven EDs contributing to the collective data pool, allowing for comprehensive analysis across the South Tyrolean healthcare setting.

Data collection

As described in figure 1, the study plan is designed in three phases to efficiently collect data while minimising participant burden.

Figure 1. Flow chart of study participation. MTS, Manchester Triage System.

• Screening: during this initial phase, triage nurses will assess all patients presenting to the ED according to the urgency of their symptoms, using the MTS. Those classified as ‘green’ or ‘blue’, indicating non-urgent cases, will be considered eligible for inclusion in the study.

• Enrolment: patients identified as non-urgent in the screening phase and who fulfil all other inclusion criteria will be invited to participate in the study. Enrolment will include obtaining informed consent from participants, explaining the purpose of the study and detailing what their participation entails.

• Assessment: the enrolled participants will be asked to complete a paper questionnaire designed to collect information on their symptoms, self-perceived urgency and motives for attending the ED. Simultaneously, the triage nurse will start completing a paper questionnaire to provide information about the triage (for example, MTS priority level and specific flow chart). At discharge, the medical doctor will fill out the diagnoses, and both the triage nurse and medical doctor will assess the avoidability of the ED visit.

Data collection will include the following two groups of data sources (figure 1). According to their mother tongue, patients included in the study will fill out a paper questionnaire (eg, self-assessment of urgency, motives for use in the ED, non-use of GP and health literacy) in Italian or German. Healthcare personnel (triage nurses, medical doctors) working in the ED will complete a paper-based data collection sheet (eg, date and time of ED visit, clinical and socio-demographic characteristics of patients, triage code and diagnoses at discharge) for each patient with support from the study assistants. Their responses to the questionnaire also capture their professional judgement regarding avoiding ED visits. The variables and measures for both data sources are listed in table 1.

Table 1. Variables, measurements, number of items and data source.

Study variables	Measurements	Number of items	Data source
Patient survey
Current health complaints (eg, type, duration, self-perceived urgency, influence for ED visit)	Single self-developed items	5	Patient
Previous contact with general practitioner (GP) (type of contact, received treatment/recommendation)	Single self-developed items	2	Patient
Reasons for not contacting/visiting GP	Single self-developed items	1	Patient
Reasons for emergency department (ED) visit	Single self-developed items	1	Patient
Diagnosed chronic disease	Single self-developed items	1	Patient
Self-management	Patient Activation Measure (PAM)46	10	Patient
Mental health	Mental Health Inventory (MHI-5) of the Short-Form health survey questionnaire (SF-36)47	5	Patient
GP (number of contacts in the last 12 months, satisfaction, change)	Single self-developed items	3	Patient
Intensity of GP retention	Fragebogen zur Intensität der Hausarztbindung (F-HaBi)48	6	Patient
Socio-demographic characteristics (ie, age, sex, mother tongue, educational level, citizenship, employment status, living situation, distance from home to hospital)	Single self-developed items	8	Patient
Data collection sheet
Admission (Hospital, date, time)	Single self-developed items	3	Triage nurse
Triage (Main/leading symptom, urgency level)	Single self-developed items	2	Triage nurse
Urgency assessment of the ED visit	Single self-developed item	1	Triage nurse, medical doctor
Discharge (date, time, location)	Single self-developed items	3	Triage nurse
Health complaints and diagnoses at discharge	ICPC-2 areas/organ systems and medical diagnoses	1	Medical doctor
Avoidability of ED visit according to triage nurse and attending medical doctor	Single self-developed item	1	Triage nurse, medical doctor

The study will not include observational visits or follow-up assessments as all data will be collected during the ED visit only. The data will be collected over a total period of 98 days in a three-shift system (weekdays and weekends), covering two full working weeks (14 days) in each hospital’s ED. The 2-week data collection period will be arranged for each ED and will take place between 1 September 2024 and 30 November 2024. Data collection, integration and cleaning have been completed, while data analyses and the dissemination of results are still ongoing.

Variables and measures

Primary and secondary outcomes

The primary outcome of the study is potentially avoidable ED visits. There is no universally accepted definition of a potentially preventable ED visit.⁴³ Some studies used a triage-based approach only, some used a resource use approach (eg, patient receipt of any diagnostic test or medication during the ED visit), and some used a postdischarge diagnosis-based approach as measures to define ED visits as potentially preventable,⁴⁴ which have several limitations.⁴⁵ In our study, we define potentially avoidable ED visits as those that are (1) Triaged as non-urgent (ie, priority level ‘blue’ or ‘green’ according to the MTS) and (2) Where the care provided could have been treated safely and effectively in a primary care setting (eg, GP). Accordingly, healthcare professionals in the ED (ie, the triage nurse and the medical doctor in charge of the patient) will independently assess the patient at discharge if the visit is potentially avoidable (1=yes, 2=no), considering the patient’s somatic, mental or social problems in accessing the ED. We will calculate across all seven EDs and for each ED the proportion of potentially avoidable, non-urgent visits with agreement between the triage nurse and the medical doctor in relation to the total number of non-urgent visits (ie, MTS priority level ‘blue’ or ‘green’). The secondary outcome will be patients’ self-reported access to primary care services (ie, contact with or visit to the GP) for the current health problem prior to attending the ED (1=yes, 2=no).

Explanatory variables

The explanatory variables of the study are related to the hypothesised individual, system and cultural factors driving patients’ motivation and decision-making for non-urgent ED visits. These variables were determined based on a literature review as well as our own clinical experience and discussions with medical doctors and triage nurses from the seven EDs participating in this study. Individual factors are related to patients’ current health complaint, including duration (‘6-point Likert scale: from ‘less than 12 hours’ to ‘more than 1 months’), self-perceived urgency (numeric rating scale from 0 to 10) and decision for ED visit (1=own decision, 2=on recommendation), the overall health status (4-point Likert scale: from ‘bad’ to ‘very good’), chronic disease (1=at least one diagnosed chronic disease, 2=no chronic disease), self-management knowledge and skills (total score of the Patient Activation Measure)⁴⁶ and mental health (total score of the 5-item Mental Health Inventory of the Short-Form Health Survey Questionnaire.⁴⁷

System factors include the accessibility and previous use of primary care services, including nine reasons for not contacting/visiting the GP for the current health complaint, number of visits to GP in the last 12 months (1=no visit, 2=one or more visits), overall satisfaction with GP (4-point Likert scale: from ‘not satisfied at all’ to ‘very satisfied’), GP retention (total score of the 6-item ‘intensity of GP retention questionnaire)⁴⁸ and preference to change GP (1=yes, 2=no). Reasons for attending the ED are assessed for accessibility, including day of ED visit (1=weekday, 2=weekend), time of ED visit (1=from 8:00 to 18:00, 2=from 18:00 to 8:00), distance from patients’ home to hospital (4-point Likert scale: from ‘<5 km’ to ‘≥20 km’) and seven preferences for using ED services.

Cultural factors are related to patients’ citizenship (1=Italy, 2=other country), mother tongue (1=German, 2=Italian, 3=Ladin, 4=other language), and language barriers as reasons reported by patients who did not contact or visit the GP (1=yes, 2=no).

Possible confounding variables

Based on our literature review, patients’ socio-demographic characteristics, such as sex (1=male, 2=female), age (in years), educational level (4-point Likert scale: from ‘high school or lower’ to ‘university degree’), employment status (1=dependent or independent working, 2=retired or currently not working), living situation (1=living alone, 2=living with partner or other family members) will be considered as possible confounding variables associated with both the outcome and the explanatory variables.

Data management and analyses

As described in figure 1, for each patient, data will be collected separately from the patient attending the ED and from healthcare personnel (triage nurse and medical doctor). Data collection in the EDs will be supported by study assistants, who will help patients and healthcare personnel fill out the paper-based questionnaire and data collection sheet and perform data entry of pseudonymised data into a secure online database compliant with the EU General Data Protection Regulation (eg, REDCap electronic capture tool). To merge the two databases at the individual patient level, a unique patient ID number composed of the hospital abbreviation, months, date and time of triage (eg, BZ09010800) will be used. Data entry errors will be checked by a member of the research team using a random sample of 10% of patients.

Data analysis initially involves descriptive analyses to check the quality of the data (eg, missing values) and describe the outcome and explanatory and confounding variables (eg, frequencies, range). To determine differences between patient subgroups (eg, potentially avoidable vs non-avoidable ED visits), χ² or Fisher’s exact tests for categorical variables will be used. To explore the associations between individual, system and cultural factors and the primary (ie, potentially avoidable, non-urgent visits) and secondary outcomes (ie, GP visit prior to accessing the ED), we will apply multivariate logistic regression models. Guided by the ‘principle of parsimony’, bivariate analyses will inform the model-building process to identify the most relevant predictors for stepwise fitting of the multivariate logistic regression model. To minimise model complexity, we consider the model fit (eg, Akaike and Bayesian Information Criteria). Due to the natural clustering of the data (patients within seven hospitals’ ED), intraclass correlation coefficients (ICC)(1) for the outcome and explanatory variables at the hospital level will be calculated. If the ICCs are equal to or higher than 0.10, multilevel modelling will be considered. An alpha level of 5% (p≤0.05) is considered the threshold for inferential statistical analyses. Data analysis will be performed using the R Statistical Software package (V.4.3.1⁴⁹ and RStudio V.2023.6.2.561).⁵⁰

Ethical aspects and dissemination

Ethical approval was obtained from the Medical Ethics Committee of the South Tyrolean Health Service (Nr. 41-2024). Eligible patients will be screened by the triage nurses. Study assistants (from Monday to Friday, 8.00 to 17.00) or triage nurses (Saturday and Sunday, 17.00 to 8.00) will provide detailed study information. Written informed consent will be obtained from those willing to participate. Participants may voluntarily withdraw from the study at any time, without affecting subsequent care. Investigators may withdraw subjects from the study for specific reasons such as administrative or safety reasons (eg, aggressive behaviour). Given the observational nature of the study, safety concerns are minimal. Thus, adverse events are not expected because the study does not involve interventions or changes in the standard of care. However, any adverse events observed during the study that are believed to be related to participation, such as aggressive behaviour or emotional distress, will be monitored.

The results will be published in relevant scientific journals and communicated to the public and relevant institutions through dissemination activities, including press releases and stakeholder meetings. The findings will inform recommendations aimed at refining health policies, improving access to primary and emergency care, and enhancing interdisciplinary and interprofessional communication and educational efforts for healthcare professionals to better meet the health needs of the community.

Impact

This study protocol outlines a multicentre cross-sectional study aimed at gaining a better understanding of the individual, system and cultural factors associated with potentially avoidable, non-urgent ED visits in a multilingual region with unique healthcare challenges. As ED utilisation for non-urgent problems continues to be a global concern with implications for healthcare efficiency and costs, our investigation in South Tyrol provides evidence on the individual, systemic and cultural factors driving patients’ behaviour toward non-urgent ED visits. We anticipate that the study findings will contribute to the existing literature by highlighting the role of primary care accessibility, patient self-management skills and the impact of cultural and linguistic diversity on non-urgent ED utilisation. This study will reveal the complexity of the decision-making processes that lead to non-urgent ED visits, thereby offering potential opportunities for targeted interventions. Moreover, gaps in primary care may inadvertently lead patients to the ED. By conducting this study in the specific context of South Tyrol, our findings will be of particular interest to other culturally and linguistically diverse settings, given the increasing mobility of populations and the consequent challenges faced by health systems worldwide.

In addition to informing local health policies, the CARES study will enable improvements in patient education and engagement strategies. By recognising the multiple reasons for non-urgent ED visits, healthcare systems can develop more effective communication and outreach programmes tailored to different patient populations. One of the limitations we anticipate is the cross-sectional nature of this study, which may limit our ability to draw causal inferences. While the validity and reliability of the Manchester Triage Scale are widely recognised, nurses’ triage decisions regarding non-urgent patients (priority levels ‘blue’ or ‘green’) may be subject to error, potentially resulting in overtriage or undertriage.³⁷ Existing inter-rater agreement estimates for the Manchester Triage Scale may not fully capture the multilingual, multi-centre context of South Tyrol, where linguistic nuances and institutional workflows could subtly influence triage consistency. Moreover, it will not be possible to guarantee full blinding between triage nurses’ and medical doctors’ assessment. For clinical/organisational reasons, the triage nurses will be first to provide an assessment of whether a visit is potentially avoidable. Thus, when assessing this, medical doctors may have access to the nurses’ assessment by filling out the data collection sheet. Nevertheless, we consider the risk of bias arising from medical doctors relying on nurses’ judgments to be low. While measures are in place to minimise such influence, it remains possible that doctors’ assessments could be systematically biased if they were aware of nurses’ initial triage judgements. The richness of the collected data will still provide valuable evidence that can inform hypothesis generation for future longitudinal and interventional studies. This CARES study will make a significant contribution to the understanding and management of non-urgent ED visits. It is our expectation that the results will not only inform regional healthcare strategies but also provide evidence for other regions facing similar challenges, ultimately leading to more efficient and patient-centred healthcare.