The ever-increasing problem of hospital overcrowding continues to hinder EMS crews’ ability to promptly transfer care in hospital EDs.
In 2005, the U.S. Metropolitan Municipalities’ EMS Medical Directors Consortium released a collective statement addressing this issue by analyzing underlying causes and providing recommendations for reducing this daily burden on EMS systems.1
Over the past decade it has only gotten worse. This article is a brief summary of that statement, which is as relevant today as ever.
Response intervals have traditionally been a key component in EMS system design and are often under scrutiny from external parties, such as city and county officials and the media. However, the time spent by EMS crews waiting for hospital providers to take over care of a patient was not often recognized as a problem.
Prolonged wait times in EDs are occurring with both increasing frequency and duration. These prolonged waits can often exceed one hour with the ambulance crew “out-of-service” and unable to respond to other emergency calls for protracted periods.
Hospital overcrowding creates a log-jam in EDs. That is, admitted patients “board” in the ED due to lack of available inpatient beds.
Admitted boarding patients place a large burden on emergency medicine providers as they are usually the sickest patients. Additionally, annual ED visits have increased despite an overall decrease in the number of EDs nationwide.
Well-intentioned efforts to reduce ED overcrowding have often fallen short. Ambulance diversion practices often simply shift the burden to other EDs which results in overcrowding at other facilities.
Ambulance diversion, which is usually considered by the EMS community to be a courtesy, may be viewed by hospital personnel as a mandate that must be followed. These differing expectations often result in tension between EMS and hospital providers.
When personnel arrive with a patient at an overcrowded facility they’re often unable to off-load their patient due to the unavailability of an ED stretcher. Patients remain “parked” on the EMS cot in the hospital’s ED for prolonged periods of time.
Unable to transfer care, EMS providers often feel inadequate in a system in which they were trained to provide swift care.
Patient “parking” also has potential legal ramifications.
Once a patient presents to an ED, the hospital is obligated to examine and treat any emergency medical condition according to the Emergency Medical Treatment and Labor Act (EMTALA).
Refusal to accept responsibility for the patient or delaying patient care could be a violation of federal law. Therefore, hospitals should have policies to immediately receive and assume care of patients presenting to their EDs.
Although elimination of overcrowded EDs isn’t likely without major changes in our healthcare delivery system, the authors recommend measures that can be taken by individual stakeholders to reduce the burden.
From the EMS side, overutilization of the 9-1-1 system can be addressed. Efforts can include screening calls for patients who don’t require an emergency response and finding alternative methods of transport other than an ambulance to appropriate healthcare facilities for patients to access non-emergency healthcare.
However, both methods aren’t without risk and can be challenging to implement. Receiving buy-in for these policies at the community level is essential. Efforts to advertise alternative non-9-1-1 numbers have historically had the opposite of the intended effect, resulting in an increase in 9-1-1 calls.
From the hospital side, administrators should constantly monitor patient throughput and bed utilization to maximize patient movement for ED decompression. Specific strategies include observation units, acute care clinics and 24-hour discharges.
Overflow patients can even be managed on hospital floors rather than in the ED.
In the ED, overcrowding plans must be developed and include procedures for retrieving additional stretchers when none are available.
A culture should be instilled in ED staff that optimizes EMT and paramedic turnaround and makes transferring care of their patients a priority. Transfer of patients to ED staff should always occur in less than 10 minutes.
Efforts to improve transfer of care intervals should always start with diplomatic discussion among all local and regional stakeholders. At the community level, ongoing dialogue toward mutual solutions should occur among government officials, EMS administrators and hospital leaders.
Finally, these strategies and their effect on turnaround time should be continuously monitored, sometimes by state and federal regulatory agencies.
EMS agencies must have a strategy for dealing with patient parking issues. The authors of the 2005 paper suggested an action matrix with escalating actions for EMS agencies to take depending on the scale of the problem. They are summarized as follows:
- EMS leadership should meet with ED leadership to discuss the problem of overcrowding and patient parking.
- If unsuccessful, EMS should meet with hospital administration
- If still unsuccessful, city and county officials should be involved.
- If all else fails, EMS should inform ED nursing and physicians that, after 10 minutes of waiting, the patient is being left on spare EMS-provided stretchers.1
The problem of overcrowding is one shared by EMS, the hospital and the community at large. Therefore, strategies for reducing this burden must involve all of these players.
Although a true solution likely involves national health care policy changes, there are many local initiatives that can be undertaken by EMS, the ED, hospital systems and communities to decrease saturated systems.
Prehospital personnel should not wait more than 10 minutes to transfer care to hospital providers and EMS systems must have action plans ready when this unfortunate situation arises.
1. Eckstein M, Isaacs SM, Slovis CM, et al. Facilitating EMS turnaround intervals at hospitals in the face of receiving facility overcrowding. Prehosp Emerg Care. 2005;9(3):267—275.