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Bed Delays Keep EMSA Medics at Hospitals

On any single day, 20 percent of the EMSA paramedics needed to respond to emergencies in Tulsa could be stranded waiting in a hospital emergency room instead. The state Medical Control Board is gathering data on a growing problem known as "bed delay," which keeps ambulance crews tied up at hospital emergency rooms because no beds are available for the patient they have transported.

A snapshot of data showed that in some cases, half a dozen ambulances out of about 30 normally on the streets of Tulsa were stranded at hospitals for more than an hour due to bed delays, said Dr. Jeffrey Goodloe, medical director of the Medical Control Board.

The 11-physician member Medical Control Board establishes clinical standards of care for first responders working for EMSA and fire departments comprising the EMS system for Tulsa, Oklahoma City and surrounding cities. The Emergency Medical Services Authority is a government agency that oversees a contractor providing ambulance service to more than 1.1 million people.

Goodloe, an emergency room physician who teaches at OU's School of Community Medicine, discussed the problem of bed delays with EMSA's board of trustees last week and said comprehensive data is being gathered to address the issue. Goodloe said the bed delays are more common in Tulsa than Oklahoma City.

"Sometimes we have five or six crews literally lined up in the hallway with patients on stretchers." He said in some cities, paramedics bring a sack lunch to the hospital so they can eat while waiting for a bed to open for their patients. "Our ambulances are being held hostage at hospitals with over an hour's time. This is not," Goodloe said, pausing for emphasis, "this is not the fault of nurses and physicians in the emergency department. This is a bed-flow problem, getting the sickest of the sick out of the emergency department to the services where they need to go. "If you want to know how bad this can get, our colleagues in Los Angeles are looking at a six- to eight-hour wait."

'Delivery time' Rising
Goodloe said in one case, a patient in Tulsa had a heart attack while waiting for a hospital bed with an EMSA crew. He said the patient survived and likely received more immediate care due to the situation.

According to a recent article in the journal of the National Association of EMS Physicians, patient "delivery time" has grown dramatically in recent years. The journal article defined delivery time as the number of minutes between an ambulance crew's arrival at the hospital with a patient and transfer of the patient to care of hospital staff. One study found delivery time grew from a median of just under 13 minutes in 2002 to almost 37 minutes in 2007. The causes of bed delays are numerous and vary from hospital to hospital.

Some of the causes include a shortage of hospital beds, nursing staff shortages, patients with increasingly complex illnesses, patients who use the emergency room for primary care or minor issues and a shortage of services such as X-rays. If increasing delivery times are not addressed, patient health could suffer, the article notes.

Goodloe said EMSA will record data on all situations in which an ambulance crew waits more than 15 minutes to transfer care of a patient to hospital staff. He said the data will be shared with hospitals and used to begin a discussion in the medical community about how to limit bed delays. While hospitals in some cities have been fined to discourage bed delays, Goodloe said he believes the issue can be addressed with communication and teamwork. "If we don't try to engineer something, I'm afraid I'm going to be back here talking about two hours" of bed delay, he told the EMSA board.

Managing Admissions
Goodloe said charge nurses and others in emergency departments recognize the problem, which can be exacerbated by hospitals that avoid diverting ambulances during peak hours. So-called "divert status" can be a public relations problem for hospitals, so instead they continue accepting patients into overloaded emergency departments. "The thing that can easily be misunderstood about this is that blame often is assigned to the very people who are working hardest to fix it," Goodloe said.

Peter Aran, senior vice president and chief medical officer of St. Francis Health System, said: "With over 90,000 patients coming into the St. Francis Trauma Emergency Center annually, the hospital has implemented quality improvement measures and is collaborating with EMSA to best manage emergency room admissions.

"In 2014, St. Francis will open a new Trauma Emergency Center and 150-bed patient tower to help meet the growing need for health-care services in the community," Aran said. Cheena Pazzo, a spokeswoman for St. John Medical Center, said the hospital estimates its average time of receiving and registering patients from EMSA to the emergency department (ED) to be within 15 minutes. "Upon receiving notice from EMSA on a patient's estimated time of arrival, the ED staff begins preparations to receive and register the patient," Pazzo said.

EMSA board members said they support the efforts of Goodloe and the rest of the Medical Control Board to find a solution. Trustee Phil Lakin said while paramedics are waiting with a patient at a hospital, a sicker patient elsewhere could be waiting for transfer. EMSA can request "mutual aid" from first responders in the area if no ambulances are available. Trustee Joe Hodges, president of St. Anthony Hospital, said, "These aren't easy problems to solve." "I don't want anybody to think, 'Oh well, just make the hospital administrator write a check and it's done.'"



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