Stories continue to pour in from across the country about emergency department (ED) wait times, which continue to be a problem for EMS.
Some communities commonly report wait times of up to six hours for ambulances to off-load patients in EDs. This is a major problem for EMS managers because important assets (our ambulances and crews) are unavailable for other calls in the community.
If you were to look at each ambulance as producing one hour of work for each hour in the day and then add up the total number of unnecessary hours that your ambulance was stuck at a hospital trying to off-load a patient, it could be significant. Twenty-four hours of excessive time in the ED among all your ambulances in the course of the day is the equivalent of taking one ambulance off the street.
In essence, when your ambulance and crew are stuck with a patient at a hospital, the crew is basically free labor for the hospital. In some cases, crews are pressed into service wheeling the patient to get an X-ray, an ECG or some other service—all while on their ambulance stretcher.
The main problem is ED physical capacity. Some just aren’t capable of handling a surge in patients, and they don’t have enough beds. A recent study estimates that the total annual visits to the nation’s EDs in a 10-year period increased by about 23% (94.9 million to 116.8 million). This represents an increase that’s nearly double what would be expected from population growth.(1) The study suggested the increase in ED visits was the result of increased enrollments in Medicaid between 1999–2007.
If this study is accurate, just imagine what will happen when the new health-care legislation takes full effect. In March 2011, 40 million people will be added to the health-care system—most being Medicaid patients.
So what can you do as the EMS manager to reduce wait times?
First, meet with your ED administrators. But don’t go unarmed. Bring data showing the problem that exists and off-load times. Don’t leave the meeting without a commitment from them and some type of solution.
Inefficiencies in the ED are often causing the delay. Sometimes the inefficiencies are in the hospital itself. I know of one hospital that had trouble with the timely cleaning of rooms. When the rooms weren’t cleaned fast enough, patients who would normally have been brought up to the rooms were left to sit on a stretcher down in the ED, thus causing further backup.
Other times the inefficiencies are in the ED itself. The triage process may be slow or poorly managed. Sometimes, the ED staff doesn’t care. They already have enough patients, so why would they want one more?
One nurse told me of other nurses who would call for housekeeping to come and change a sheet on an ED stretcher instead of changing the sheet themselves. The delay was sometimes 20–30 minutes. Point out these deficiencies to hospital administration to help them (and you) solve the problem.
Some hospitals and communities are implementing technological find solutions for these problems. Several commercial software packages monitor ED capacity. Hospitals can then send out advisories showing their status to ambulances. If an ambulance or dispatch center sees a hospital is overloaded, that ambulance can be diverted.
Recently, some hospitals have used their computerized patient management system to make the ED wait times available to the public. Most of these hospitals make it available on a Web site or by texting to a dedicated phone number. A few hospitals have their wait times publicly displayed on a billboard in the community.
Another solution is to triage ambulance patients to the waiting room if their condition doesn’t warrant them being monitored or having to occupy a bed. Of course, the hospital and the ambulance service should have specific guidelines on who can be triaged to the waiting room. I wouldn’t recommend triaging anyone to the waiting room if they’re under 15 years of age or older than 65, but you should consider triaging patients with stable conditions or those for which there was no intervention by the EMS crews, such as starting an IV or giving medication.
The waiting game at the ED is only going to get worse as time goes on. So EMS managers need to be progressive and minimize the times as best as possible to keep their service efficient. JEMS
1. Tang N, Stein J, Hsia RY, et al. Trends and characteristics of U.S. emergency department visits, 1997–2007. JAMA. 2010;304:664–670
This article originally appeared in January 2011 JEMS as “Why Wait?: EMS managers can proactively reduce ED delays”.