Italy's prison overcrowding became world news in early March 2020, when the COVID-19 outbreak sparked riots in prisons across the country, causing the death of 13 inmates. As a crisis narrative, the COVID-19 pandemic made visible the deep, ongoing crisis of Italy's prison system and disclosed new conditions for critical thought on the restorative potential of the penitentiary system. This article first describes the impact of COVID-19 on Adriano Sofri's ‘no prison’ writings, starting from his column in Il Foglio on the prison uprisings in March that followed the announcement of the anti-COVID measures; it subsequently analyses the Italian response to the pandemic from an internal, practitioner-led perspective. By offering both a dialectic and an immanent perspective, it aims to develop new ways of understanding the detention system and enhance the social credibility of the penitentiary system in Italy beyond the constraints of COVID and the emergency logic.

The late eighteenth and early nineteenth century witnessed a dramatic increase in the number of pauper lunatics being admitted to institutions and many mentally-ill paupers found their way into workhouses. The range of options existing for the admission of paupers, who at the time were described as lunatics or insane, included private madhouses, charitable asylums, public asylums as well as workhouses. Legislation relating to transfer from a workhouse to a one of these other institutions was ambiguous and depended on the concept of dangerousness and whether a workhouse inmate was manageable, rather than the nature of their illness. Because demand exceeded the space available because of overcrowding, workhouses and public asylums continually needed to increase provision by means of converting existing facilities or erecting new buildings. Nevertheless, the transfer of patients between asylums was commonplace and extensive. This article will explore the interface between two urban workhouses in the West Midlands of England and their local asylums from the late eighteenth until the end of the nineteenth century. It will demonstrate that, although local circumstances at any one time may have contributed to decisions on transfer, the overriding difficulty in the correct placement of pauper lunatics throughout the time period was institutional overcrowding, mainly driven by the increasing numbers of pauper lunatics.

Introduction: Overcrowding in the Emergency Department (ED) results in delays in care, and increased patient morbidity and mortality. Innovative departmental approaches have the potential to make patient flow through the ED more efficient and reduce overcrowding by improving patient throughput. The Calgary zone ED recently piloted a new physician role, the Emergency Physician Lead (EPL), a senior physician working closely with the charge nurse and consulting services to provide physician leadership, and to troubleshoot flow issues and safety breeches such as EMS offload delays and long emergency inpatient (EIP) stays. The objective of this study was to evaluate the efficacy of the EPL by determining its effect on key metrics of patient flow, and by identifying which specific EPL interventions were most effective at improving patient throughput. Methods: A retrospective cohort design was used to compare Foothills Medical Centre (FMC) ED patients seen by the EPL from March-June 2019 (n = 1343 patients) with a control group from the same period in 2018 (n = 5530). An EMR search was used to collect patient data and generate descriptive statistics, which were compared between groups by Mann-Whitney U-test. Patient handover notes left by the EPL were also collected and analyzed by two independent assessors to develop a list of actions taken by the EPL. Each patient was then coded based on the actions in the handover note, and means for each coded group were compared to control to find correlations between action and changes in key flow metrics. Results: Patients whose care involved the EPL had a 40% shorter average ED length of stay (ELOS) compared to control (515 vs 865 min, p < 0.001). The EPL was especially effective for patients with ELOS above the 90th percentile, with a 58% relative reduction. EPL patients also had lower average times from first contact with the department to first order being placed (79 vs 143 min, p < 0.001), and spent less time as EIPs after being admitted (390 vs 515 mins, p < 0.001). EPL actions aimed at early ordering of investigations or early management showed the largest relative reductions in ELOS, followed by actions related to resolving issues with consulting services (56% and 48% respectively, p < 0.001). Conclusion: The EPL role appears to be associated with improvements in several key metrics of patient flow. Specific EPL actions were correlated with marked decreases in length of stay. The EPL may be an effective strategy to improve patient throughput and combat ED overcrowding.

Introduction: Access block is a pervasive problem, even during times of minimal boarding in the ED, suggesting suboptimal use of ED stretchers can contribute. A tracking board utility was embedded into the electronic health record in Calgary, AB, allowing MDs and RNs to consider patients who could be relocated from a stretcher to a chair. Objectives of this study were to evaluate the feature's impact on total stretcher time (TST) and ED length of stay (LOS) for patients relocated to a chair. We also sought to identify facilitators and barriers to the tool's use amongst ED MDs and RNs. Methods: A retrospective cohort design was used to compare TST between those where the tool was used and not used amongst patients relocated to a chair between September 1 2017 and August 15 2018. Each use of the location tool was time-stamped in an administrative database. Median TST and ED LOS were compared between patients where the tool was used and not used using a Mann-Whitney U Test. A cross sectional convenience sample survey was used to determine facilitators and barriers to the tool's use amongst ED staff. Response proportions were used to report Likert scale questions; thematic analysis was used to code themes. Results: 194882 patients met inclusion criteria. The tool was used 4301 times, with “Ok for Chairs” selected 3914(2%) times and “Not Ok for Chairs” selected 384(0.2%) times; 54462(30%) patients were moved to a chair without the tool's use. Mean age, sex, mode of arrival and triage scores were similar between both groups. Median (IQR) TST amongst patients moved to a chair via the prompt was shorter than when the prompt was not used [142.7 (100.5) mins vs 152.3 (112.3) mins, p < 0.001], resulting in 37574 mins of saved stretcher time. LOS was similar between both groups (p = 0.22). 125 questionnaires were completed by 90 ED nurses and 35 ED MDs. 95% of staff were aware of the tool and 70% agreed/strongly agreed the tool could improve ED flow; however, 38% reported only “sometimes” using the tool. MDs reported the most common barrier was forgetting to use the tool and lack of perceived action in relocating patients. Commonly reported nursing barriers were lack of chair space and increased workload. Conclusion: Despite minimal use of the tracking board utility, triggering was associated with reduced TST amongst ED patients eventually relocated to a chair. To encourage increased use, future versions should prompt staff to select a location.

Introduction: Overcrowding in emergency departments (EDs) is a constant problem. One of the major factors contributing to this situation is the inappropriate ED use by patients with low-acuity problems. In order to reduce overuse, EDs have developed agreements with clinics to reorient low-acuity ambulatory patients toward them. These agreements often leave the burden of decision on the triage personnel as to which patients can be safely redirected. The aim of this study was to evaluate the safety of redirecting patients to nearby medical clinics and to evaluate their satisfaction with this program. Methods: In the ED of a tertiary care facility, a computer-based algorithm allowing triage personnel to reorient patients presenting with one of 52 medical complaints, was implemented in 2016. Our prospective cohort study was composed of reorientation admissible ED patients between March 2017 and August 2017. Patient safety was evaluated with patient follow-up phone interviews one week after their visit to the ED to identify the number of patients who needed to return to a medical facility after their reorientation. Patient satisfaction with the reorientation program was evaluated during the same follow-ups. Results: Of the 980 reoriented patients interviewed, only 57 (5.9%; 95% confidence interval [CI] 4.57.5) had to unexpectedly go back to a health care facility. None of these returns were for severe complications. Over 84% of the reoriented patients were satisfied with their reorientation and 89% say they would use this program again. Having a transportation problem was most common reason mentioned by patients for refusing to be reoriented. Conclusion: Reorientation to medical clinics using a new computer-based algorithm was safe and no case of urgent return was seen during the 6-month study period. In addition, patients who were reoriented to medical clinics were satisfied by their treatment experience.

Introduction: Emergency Department Systems Transformation (EDST) is a bundle of Toyota Production System based interventions implemented in two Canadian tertiary care Emergency Departments (ED) between June 2014 to July 2016. The goals were to improve patient care by increasing value and reducing waste. Longer times to physician initial assessment (PIA), ED length of stays (LOS) and times to inpatient beds are associated with increased patient morbidity and potentially mortality. Some of the 17 primary interventions included computerized physician order entry optimization, staff schedule realignment, physician scorecards and a novel initial assessment process ED access block has limited full implementation of EDST. An interim analysis was conducted to assess impact of interventions implemented to date on flow metrics. Methods: Daily ED visit volumes, boarding at 7am, time to PIA and LOS for non-admitted patients were collected from April 2014 -June 2016. Volume and boarding were compared from first to last quarter using an independent samples median test. Linear regression for each variable versus time was conducted to determine unadjusted relationships. PIA, LOS for non-admitted low acuity (Canadian Triage and Acuity Scale (CTAS) 4,5) and non-admitted high acuity (CTAS 1,2,3) patients were subsequently adjusted for volume and/or boarding to control for these variables using a non-parametric correlation. Results: Overall, median ED boarding decreased at University Hospital (UH) (14.0 vs 6.0, p<0.01) and increased at Victoria Hospital (VH) (17.0 vs 21.0, p<0.01) from first to last quarter. Median ED volume increased significantly at UH from first to last quarter (129.0 vs 142.0, p<0.01) but remained essentially unchanged at VH. 90th percentile LOS for non-admitted low acuity patients significantly decreased at UH (adjusted rs=-0.24, p<0.01) but did not significantly change at VH. For high acuity patients 90th percentile LOS significantly decreased at both hospitals (UH: adjusted rs=-0.23, p<0.01; VH: adjusted rs=-0.21, p<0.01). 90th percentile time to PIA improved slightly but significantly in both EDs (UH: adjusted rs=-0.10, p<0.01; VH: adjusted rs=-0.18, p<0.01). Conclusion: Persistent ED boarding impacted the ability to fully implement the EDST model of care. Partial EDST implementation has resulted in improvement in PIA at both LHSC EDs. At UH where ED boarding decreased, LOS metrics improved significantly even after controlling for boarding.

Introduction: Emergency Department (ED) overcrowding has been shown to delay time sensitive tests and therapies. North American guidelines call for Door-to ECG (DTE) times to be <10min in patients presenting with chest pain as delays have been shown to lead to poorer patient outcomes. We hypothesize that increased ED crowding will increase the DTE times. Methods: This was a retrospective cohort study from July 2015-May 2016 at a single tertiary care Canadian ED (53000 visits per year). Data were extracted from the ED information system (EDIS) which contains an organized record of ED activity for each visit. Our selection criteria screened for patients presenting with complaints that included chest pain, chest heaviness, chest tightness and chest burning. The primary outcome of the study was the association between ED occupancy and DTE time, which was measured using a non-parametric Spearman correlation. Multivariable linear regression models controlling for age and sex were developed for both time in minutes, and the log transformed time in minutes. Results: There were 2479 ECGs done on patients presenting with chest pain that met inclusion criteria. The median DTE time was 55.1 minutes. There was a significant positive association between DTE time and ED occupancy (rho=.133, p<0.001). DTE time increased by 0.64 minutes (or approximately 0.4%) for each additional patient in the ED, p<0.001. Additionally, younger age and female sex were also associated with increased DTE time. Conclusion: Increased ED occupancy was correlated with longer DTE times at a single Canadian ED, even after controlling for age and sex. This study provides an example of the negative consequences of ED overcrowding.

In this contribution the author examines overcrowding, one of the chronic problems that affect the prison system in Peru. First, the topic of the growth of the prison population during a determined period of years is addressed. Then, the author discusses three options for avoiding or controlling overcrowding in prisons: sending fewer people to prison, increasing the release of prisoners, and expanding existing prisons or building new ones. Finally, the article presents alternative measures of limiting freedom other than sending people to prison, and proposes a long-term solution which includes the participation of different sectors of the Peruvian government.

There is a saying: “Justice delayed is justice denied.” The perception of a continuing failure of the Philippine criminal justice system to deliver fast and efficient justice has inevitably led to the erosion of public trust in the government. As a consequence, citizens are laden with anxiety because of unabated criminality and violence in their communities. The type of justice that leads to peace and prosperity continues to be elusive in the Philippines as the worsening scenario of jail congestion continues to manifest its malevolent implications for the human rights of prisoners. It appears that the culprit is an overwhelmed machinery of criminal justice that has not been able to keep pace with growing rates of population, urbanization and criminality. There is also an apparent imbalance in the justice structure where there are too few judges, prosecutors and public defence attorneys to process the cases filed by the numerous law enforcers who file criminal cases. This leads to bottlenecks in criminal justice procedures and has resulted, in not a few instances, in human rights crises in jails. However, emerging developments give some hope to Filipinos.

This article charts the rapid rise in the use of imprisonment in recent decades before considering some of the most pressing issues of concern in the use of imprisonment today. First among these is prison overcrowding, which continues to blight the record of many countries in their treatment of prisoners. To illustrate the potentially dire consequences of overcrowding – a problem common to many other countries and regions – an account is given of a recent visit to a prison in El Salvador. The article then provides an overview of the relevant regional and international standards on the treatment of prisoners, referring also to the role of judicial bodies in ensuring implementation.

Visiting an overcrowded prison is a journey into the private life of each person deprived of his or her freedom, into the community of the detainees and of the staff working in such a place. Using the senses of sight, hearing, smell and touch, combined with empathy and time for observation, helps ICRC delegates to explore vulnerabilities, discover how detainees and staff cope, and grasp the intricate complexity of such a prison system. Beyond what is left of human dignity in these places of detention, when coping mechanisms become survival mechanisms, the suffering shows that overcrowding is wrong. It follows that if overcrowding is “nobody's fault”, it is the responsibility of every individual and every institution of the criminal justice system to create solutions.

Introduction: Emergency department (ED) over-crowding and increased wait times are a growing problem. Many interventions have been proposed to decrease patient length of stay and increase patient flow. Early disposition planning is one method to accomplish this goal. In this study we developed statistical models to predict patient admission based on ED administrative data. The objective of this study was to predict patient admission early in the visit with goal of preparation of the acute care bed and other resources. Methods: Retrospective administrative ED data from the Thunder Bay Regional Health Sciences Centre was obtained for the period May 2014 to April 2015. Data were divided into training and testing groups with 80% of data used to train the statistical models. Logistic regression models were developed using administrative variables (i.e., age, sex, mode of arrival, and triage level). Model accuracy was evaluated using sensitivity, specificity, and area under the curve measures. To predict hourly bed requirements, the probability of admission was summed to calculate a pooled bed requirement estimate. The estimated hourly bed requirement was then compared to the historical hourly demand. Results: The logistic regression models had a sensitivity of 23%, specificity of 97%, and an area under the curve of 0.78. Although, admission prediction for a particular individual was satisfactory, the hourly pooled probabilities showed better results. The predicted hourly bed requirements were close to historical demand for beds when compared. Conclusion: I have shown that the number of acute care beds required on an hourly basis can be predicted using triage administrative data. Early admission bed planning would allow resources to be managed more effectively. In addition, during periods of hospital over capacity, managers would be able to prioritize transfers and discharges based on early estimates of ED demand for beds.

Introduction: Arriving EMS patients often experience offload delay due to a lack of available care spaces. Arrival in an overcrowded ED is the primary cause of offload delay, but patient characteristics may also play a role. Our objective was to describe system and patient level determinants of offload delay. Methods: From July 2013 to June 2016, administrative data was collated from the four Calgary Zone adult EDs. All CTAS level 2 and 3 patients arriving by ambulance were eligible for study. To define patient complexity and illness severity, we captured patient demographic data, living situation (homecare/facility vs. independent), vital signs, complaint category (medical, cardiovascular, mental health/neuro, GI, trauma/MS, other), biochemical parameters (serum Na, K, creatinine, hemoglobin, WBC), patient care needs (IV fluid bolus, IV antibiotics, CT scan, admission) and mortality at 7 and 30 days. Results: 162,002 EMS patients were studied. Of these, 67,785 went to a care space within 15 minutes (minimal offload delay), 53,185 between 15 and 59 minutes (moderate offload delay), and 41,032 at ≥60 minutes (severe offload delay). Vital signs, biochemical and hematologic parameters did not differ between groups. ED site was a strong predictor of offload delay (odds ratio {OR}=1.0, 2.03, 2.14, 3.5 for the 4 EDs), as was arrival on weekday (OR=1.38) or night shift (OR=0.71). After adjusting for site, day and time of arrival, multivariate logistic regression models showed the following associations with offload delays of more than 15 minutes: male sex (OR=0.94), age (OR=1.01 per year of age), dependent living situation (OR=1.15), CTAS 3 acuity (OR=1.27), number of prior ED visits within a year (OR=1.06 per visit), and complaint category: general medical (1.0), cardiovascular (0.90), mental health/neuro (0.90), GI (0.85), trauma/MS (0.61). Odds ratio estimates were precise—all with p<0.001. Offload delay was associated with prolonged time to MD, increased EDLOS and higher LWBS/AMA rates. Delayed patients had similar rates of IV antibiotic use, but lower rates of IV fluid bolus, CT use, admission, and 7-day mortality. Conclusion: The strongest predictor of offload delay is arrival to a crowded ED, but patient factors including female sex, older age, dependent living status and repeat hospital use increase risk. Patients subjected to offload delay also appear to have lesser immediate care needs and lower short-term mortality.

Introduction: Previous studies have shown a link between Emergency Department (ED) overcrowding and worse clinical outcomes, increased risk of in-hospital mortality, higher costs, and longer times to treatment. Prolonged ED Length of Stay (LoS) of admitted patients awaiting a bed on in-patient units has been identified as a major driver of ED overcrowding. The purpose of this study is to provide a descriptive analysis of ED LoS among admitted patients, and determine the impact of prolonged ED LoS on total hospital in-patient length of stay (IP LoS). Methods: We conducted a single-site retrospective study for the period between January 1-December 31, 2015 at a very high volume community hospital. All patients aged ≥18 years admitted from the ED to acute in-patient Medicine units were identified. We carried out overall descriptive analysis (including analysis of day-of-the-week variability) on ED LoS. The mean total IP LoS for those patients with ED LoS<12 hours, 12-24 hours, and ≥24 hours were calculated and analyzed using ANOVA and Tukey HSD tests. Results: A total of 6,961 individuals were admitted to the medical units over the 12-month period. The median and mean ED LoS for admitted patients were 22.9 hrs (IQR: 13.9 hrs- 33.1 hrs) and 25.6 hrs respectively. Using ANOVA, there was a statistically significant difference in means of ED LoS as a function of the day of the week (p<0.0001), with Mondays having the highest mean ED LoS (27.6 hrs), and Fridays having the lowest (23.1 hrs). The mean IP LoS for those with ED LoS<12 hours, 12-24 hours, and ≥24 hours, were 6.8 days, 6.9 days, and 8.5 days respectively, with a statistically significant difference between group means (p<0.0001). Multiple pairwise comparisons of group means showed a statistically significant (p<0.05) difference between mean IP LOS of those with an EDLOS≥24 hours and those with an EDLOS<24 hours. Conclusion: Preliminary results indicate that ED LoS≥24 hours among admitted patients was associated with an increase in total IP LoS.*In the next 1-2 months, we intend to explore the role of other independent variables (age, sex, comorbidity, isolation status, and telemetry) on total ED LoS, and its association with IP LoS.

Introduction: ED and hospital overcrowding cause offload delays that remove EMS crews from service and compromise care delivery to patients. Prolonged ED boarding times are associated with increased hospital LOS and patient mortality, but the impact of offload delays has not been studied. Our objective was to determine whether offload delays are associated with adverse system and patient outcomes. Methods: From July 2013 to June 2016, administrative data was collated from four Calgary adult EDs. All CTAS 2 and 3 EMS arrivals were studied. Those assigned an ED care space within 15 minutes were considered controls while those with delays of ≥60-minutes were considered ‘delayed’. Multivariable logistic regression was used to determine propensity scores, which were used to match delayed patients to nearest neighbor controls. Matching variables for propensity modeling included age, sex, CTAS level, ED site, arrival day and time, living situation (homecare/facility vs. independent), complaint category (medical, cardiovascular, mental health/neuro, GI, trauma/MS, other) and previous ED use (visits within 1 year). The primary outcome was 7-day mortality. Secondary outcomes included hospital LOS and 30-day mortality. Results: A total of 111,743 patients were studied: 70711 controls and 41032 delayed (median time to stretcher of 8 vs. 109 minutes). There was significant baseline covariate imbalance: Delayed patients were more likely to be female, older, have lower CTAS acuity, arrive on weekdays and evenings, to have general medical complaints, and to arrive at the slowest offload site. In the unmatched analysis, delayed patients had lower 7-day mortality (2.1% vs. 2.6%), similar 30-day mortality (3.5% vs. 3.6%), and longer hospital LOS (10.3 vs. 9.8 days). In the propensity-matched analysis (41016 patients per group), covariate balance was substantially improved and outcomes differed slightly. Seven and 30-day mortality were essentially unchanged, but between group differences for hospital LOS disappeared (10.3 vs. 10.2 days). Conclusion: Propensity analysis suggests that EMS patients exposed to offload delays have similar 30-day mortality and slightly lower 7-day mortality than patients who receive timely ED access. While offload delays lead to substandard hallway care, patient dissatisfaction, and remove EMS crews from service, the levels of offload delay studied here were not associated with higher mortality or prolonged hospital LOS.