This is how EMS can be optimized through medical operations coordination centers, healthcare coalitions and PerformanceStat.
The textbook, “Emergency Medical Services Systems Development: Lessons Learned from the United States of America for Developing Countries,”1 describes Emergency Medical Services (EMS) as a comprehensive system designed to coordinate personnel, facilities, and equipment for delivering timely health and safety services to individuals experiencing sudden illness or injury.
At its core, EMS is structured to provide rapid and effective care that minimizes preventable mortality and long-term morbidity. Early identification and treatment of stroke reduces injury and necrosis of the brain, improving functional and cognitive outcomes. Effective management of bleeding, treating hypoxia, and administration of blood reduces end-organ damage (e.g., kidney failure) and complications such as motor, neuronal, and cerebral damage in major trauma patients.
The EMS system encompasses four primary components: facilitating access to emergency care, providing immediate care in the community, ensuring continuity of care en route, and in a hospital-based (any hospital MICU in NJ) or rural service delivery model, continuing to assist with delivering care upon arrival at a healthcare facility.
While the term “EMS” often refers to the ambulance service that responds directly to emergency scenes, stabilizes patients, and transports them to definitive care, the broader “EMS System” includes an integrated network of public safety and healthcare services.
This system comprises prehospital response and transport, definitive and specialty care facilities, community education, prevention efforts, and structured medical oversight. Additionally, it incorporates a framework for emergency access, coordination with collaborative organizations, educational programs, and financial and resource management.
Embedded within the larger Emergency Health Services (EHS) System, EMS is part of a public health model that addresses urgent needs beyond emergency response alone. The EHS System spans disaster response, public health crises, mental health impacts, and community-wide threats such as infectious disease outbreaks. As a crucial subset of public health, EMS contributes both as a safety net and as a key component of the healthcare delivery system.
The primary purpose of an EMS System is to provide around-the-clock, high-quality emergency response to meet the community’s needs. Central to this mission is a focus on providing emergency medical care for victims of sudden illness or severe injury, including those in life-threatening conditions like cardiac or respiratory arrest, diabetic crises, trauma, and other critical states.
To support this, the EMS System should engage in educating the public on how and when to access services and setting clear expectations for care delivery. Where resources allow, EMS may also extend its mission to address a broader array of urgent health needs, enhancing its role within the larger public health and safety landscape.1
In recent years, the role of EMS has expanded far beyond the traditional model of prehospital care and rapid patient transport to emergency departments. EMS plays a critical role as the bridge between the community and the healthcare system, providing high-quality care in situ for patients who do not require the depth and breadth of emergency department services.
EMS is an integral component of the healthcare system, often serving as the initial point of contact for individuals experiencing medical emergencies and increasingly complex health crises. As healthcare delivery systems continue to evolve, EMS’s role as the vital link between community-based responses with hospital and healthcare infrastructure cannot be underestimated.
However, one significant issue that has challenged EMS and healthcare systems nationwide is Ambulance Patient Offload Time (APOT), commonly referred to as hospital turnaround time. This issue, which occurs when EMS crews are delayed in transferring care of their patients to emergency department staff, represents a bottleneck within both the EMS and healthcare systems.
APOT has become a pressing concern, affecting not only the immediate availability of ambulances for new emergencies but also the efficiency and operational sustainability of the healthcare system at large.
The factors contributing to prolonged APOT are complex and multifaceted, often encompassing systemic inefficiencies, resource limitations, and fluctuating demand within the healthcare system. Emergency departments (EDs) are frequently overwhelmed, driven by rising patient volumes, resource limitations, and a lack of inpatient capacity.
Consequently, this strain on ED resources creates a ripple effect, ultimately forcing EMS providers to wait extended periods before they can transfer patient care—a delay that hinders their capacity to respond to other emergencies in the community.
The implications of prolonged APOT are profound. For EMS systems, these delays reduce ambulance availability, impede response times, and strain financial and human resources. Paramedics and EMTs, already operating in high-stress environments, experience additional stress from extended wait times and the challenges of providing ongoing care while they wait.
In the broader healthcare context, delayed patient offloads further exacerbate emergency department crowding, which can lead to a diminished quality of care, increased patient risk, and potentially adverse outcomes.
In this report, we will examine the scope of the APOT issue, exploring contributing factors and the cascading effects on both EMS and healthcare systems. We will also consider potential strategies and innovations that have been proposed to alleviate these delays, ranging from policy interventions to operational changes and technological advancements.
Through this comprehensive analysis, we aim to provide a detailed understanding of APOT and underscore the importance of addressing this challenge to ensure the resilience and effectiveness of our EMS and healthcare systems.
Contributing factors to Ambulance Patient Offload Time (APOT) delays and their cascading effects on EMS and healthcare systems stem from structural inefficiencies, resource shortages, and evolving demand patterns.
Each factor not only prolongs APOT but also reverberates across the entire healthcare and EMS ecosystem, hampering quality of care, operational efficiency, and patient outcomes. Analyzing these causes reveals underlying system vulnerabilities that require a strategic, multifaceted approach to address.
1. Emergency Department Overcrowding and Throughput
At the heart of APOT issues is emergency department (ED) overcrowding. Many hospitals operate with limited inpatient capacity, especially during peak demand hours, often forcing EDs to retain patients longer than intended due to insufficient downstream capacity.
This lack of “throughput,” or the hospital’s ability to move patients efficiently from the ED to inpatient beds, creates a backlog that spills over to EMS. Paramedics may find themselves waiting with patients in hallways, lobbies, or ambulances, unable to transfer them into an already overwhelmed ED. Not only does this increase APOT, but it also impacts the EMS system’s operational efficiency, leading to delays in responding to subsequent emergencies.
A critical analysis suggests that one remedy may lie in addressing upstream bottlenecks through hospital-based solutions like streamlined admissions protocols, for example, in systems that have currently established healthcare information exchanges (HIE) once a patient is entered into an electronic healthcare record by EMS in the field, they could be registered into the destination ED.
Currently, most EMS systems look at HIE’s as a one-way data exchange to find out the admission diagnosis for quality improvement, for example, but it can be utilized effectively by the hospital as well to register patients, dedicated triage/treatment teams where patients who have low-acuity needs are immediately identified, treated and discharged; or improved patient flow management.
For example, discharge planning teams to move patients off the floor quicker, staging patients in a discharge area so that their room can be cleaned and prepped faster for ED admissions, and utilizing teams of environmental services staff more effectively to turn beds around faster. Initiatives such as utilizing observation units,2-4 increasing ED staffing during peak times, utilizing facility and interfacility strike teams, and implementing rapid discharge procedures for appropriate patients could mitigate the impact of ED bottlenecks on APOT.
However, these solutions require significant hospital commitment and resource investment, which are often hindered by financial and logistical constraints (e.g., poor reimbursement to better pay and hire staff, inability to attract people to work in rural areas, contractual or regulatory staffing levels; etc.), particularly for under-resourced or rural healthcare facilities.
Examination of all facets of a hospital’s operations is crucial. Is there a backup caused by the ability to discharge patients from the ED or the floor?5-6 If it is in the ED, what needs to be accomplished to improve ED discharges, fast track low-acuity patients, and a dedicated discharge team are two solutions. If there is a problem on the floor, ask why. Do we need an improved process for discharging patients? Do we have enough environmental service staff and ancillary staff to turn rooms around?
2. Staffing Shortages in Both EMS and ED
Staffing shortages compound the APOT crisis on both ends of the system. Emergency departments nationwide face shortages of physicians, nurses, and support staff, making it difficult to accommodate the growing volume of patients arriving by ambulance.
When understaffed EDs struggle to manage patient flow, the result is longer waiting periods for EMS handoffs. On the EMS side, the increase in call volume coupled with extended APOT means fewer available resources to respond to new calls, leaving EMS agencies stretched thin and their personnel at risk of burnout.
What can be done to improve ED staffing shortages? Cross-training staff from other units to assist with low acuity patients, RNs/LPNs/CNAs from intermediate care units, RNs and LPNs from same-day surgery/outpatient clinics/home care services have the capabilities and capacities to flex up for an hour or two to help manage surges.
Re-imagine staffing, for example, splitting an eight-, ten-, or 12-hour shift in half so that staff members may be utilized during the busiest times of the day. For example, a staff member works 4 hours of an eight-hour shift, has a 4-hour unpaid break, and comes back to finish their final 4 hours. Shifting resources from one facility to another, for example, moving environmental services staff between facilities to improve hospital bed turnaround times.
Addressing these shortages is challenging due to high turnover rates, low compensation in many EMS roles, and lengthy training requirements for healthcare professionals. Solutions could include improving workforce incentives, fostering pathways for career advancement, and securing better funding for EMS and healthcare staffing.
Yet, while such initiatives may attract more professionals to the field in the long term, the immediate impact on APOT remains limited without broader systemic changes to resource allocation and workforce management. We need to overcome certain issues within the profession, where current models of EMS care, especially in the for-profit arena, have led to running services “lean” in order to optimize revenue, with depressed wages and benefits schemas that are sorely lacking when we look at certain parts of the public safety sector the fact that EMS is looked down upon.
EMS is an honorable profession, and regardless of the patch, all members need to be treated with respect. If we begin to elevate the position within the eyes of the public safety sector, we will attract more people who will want to stay.
3. Rising Demand and Population Health Dynamics
An aging population, increasing rates of chronic illness, and a higher volume of behavioral health emergencies drive greater EMS and ED utilization, further straining resources. The rising incidence of chronic conditions like heart disease, diabetes, and respiratory illnesses has led to a surge in 911 calls and subsequent EMS transports, many of which end up in already crowded EDs. Behavioral health cases are particularly problematic, as EDs often lack the necessary resources to triage and manage these patients effectively, resulting in prolonged ED stays and extended APOT.
The solution to this issue may require a shift toward more community-based care models, such as mobile integrated healthcare (MIH) programs or community paramedicine, which can manage non-urgent or chronic cases outside of the hospital setting. Such initiatives, while promising, face barriers such as regulatory limitations, funding challenges, and the need for specialized training (Again, this all sounds good, but the recently implemented large Center for Medicare and Medicaid Services ET3 initiative to demonstrate the utility of MIH and thereby a federal funding stream to sustain it recently fell apart.
Why, and what does that mean for the future of such initiatives?
Additionally, broader population health interventions aimed at preventing chronic disease and reducing behavioral health crises could decrease EMS utilization over time, though these solutions require a significant, coordinated effort between healthcare providers, public health organizations, and policymakers (Are there any initiatives or other ‘significant coordinated efforts’ that might be going on in this regard).
Hospital LACE scores (Length of stay of the index admission; Acuity of the admission: Was this patient admitted through the ED or an elective admission? Comorbidities, incorporating the Charlson Comorbidity Index; Emergency department visits within the last six months), would identify patients most at risk prior to hospital or ED discharge.
This would provide improved focus on those patients wherever they end up post-discharge. Having MIH or EMS providers complete a PEAT scale (Physical Environment Assessment Tool) will help identify patients at the most risk of making a request for EMS in the future. Clinical pathways could be developed to reduce the risk of a 9-1-1 response and EMS transport. In California, one MIH program reduced hospital readmissions by almost 75% by using PEAT scores to help identify high-risk patients.7
4. Insufficient EMS Funding and Reimbursement Structures
The economic structure of EMS funding, particularly fee-for-service reimbursement models, can exacerbate APOT issues. EMS agencies are often compensated only for patient transports, creating a disincentive for alternative treatment or triage options on the scene.
This model limits the ability of EMS to provide non-transport care, even when transporting patients to the ED may not be necessary. As a result, EMS transports more patients to EDs than might be clinically required, increasing ED volume and contributing to APOT.
A transition to value-based reimbursement, in which EMS agencies are compensated for patient outcomes and not merely transport, could incentivize EMS providers to adopt alternative care pathways. Initiatives that reimburse for treat-and-refer programs, telehealth consultations, or transport to non-ED facilities could reduce unnecessary ED visits and ease APOT.
However, the widespread adoption of value-based models is constrained by complex regulatory requirements, varying state policies, and the need for CMS and private insurers to adjust their reimbursement structures. Insurance companies take their lead from CMS, and until CMS allows for EMS to be reimbursed for value-based care as opposed to just paying the cost of transport, insurance companies will continue to be reticent about adopting this payment model.
Cascading Effects on EMS and Healthcare Systems
The ramifications of prolonged APOT extend well beyond the confines of the emergency department and EMS, creating a ripple effect across the healthcare and public safety ecosystems. For EMS, extended APOT results in increased response times, reduced unit availability, and decreased capacity to respond to emergencies. This delay in response not only jeopardizes patient outcomes but also places communities at heightened risk during high-demand periods, such as natural disasters or public health emergencies.
On the healthcare system side, prolonged APOT contributes to ED crowding, adversely affecting care quality and patient satisfaction. Overcrowded EDs are more likely to experience medication errors, longer patient wait times, and strained staff resources, all of which can lead to suboptimal care.
The compounded effect can even result in hospital-acquired complications, increased healthcare costs, and an overall decline in public trust in healthcare systems. Additionally, delayed offloads and ED congestion have negative implications for staff mental health, with both EMS and ED professionals facing heightened stress, frustration, and burnout—factors that exacerbate workforce shortages and turnover, creating a vicious cycle.
Approach to Problem Solving
The problem of APOT is emblematic of broader systemic issues that require a coordinated, multi-level response. Short-term solutions, such as improving ED processes, staffing, and EMS reimbursement models, must be implemented alongside long-term strategies aimed at expanding community-based care, enhancing population health, and shifting funding structures.
Addressing APOT is critical not only for the effective operation of EMS but also for the sustainability of healthcare delivery as a whole. Only through a collaborative effort among EMS agencies, healthcare providers, policymakers, and public health organizations can we begin to mitigate the impact of APOT and ensure that EMS and ED resources are optimized for both current and future needs.
In Part 2 of this article, we will examine potential solutions to this complex issue.
References
1. Holtermann, K. A., & González, A. G. R., Editors, (2003). Emergency medical services systems development: lessons learned from the United States of America for developing countries. Pan American Health Organization.
2. Baugh CW, Venkatesh AK, Bohan JS. Emergency department observation units: A clinical and financial benefit for hospitals. Health Care Manage Rev. 2011 Jan-Mar;36(1):28-37. doi: 10.1097/HMR.0b013e3181f3c035. PMID: 21157228.
3. Claudia Cicchini, M. D., Simone, A., Valeriano, V., Livoli, D., & Pugliese, F. R. Measures of efficiency in the emergency department observation units.
4. Peacock F, Beckley P, Clark C, Disch M, Hewins K, Hunn D, Kontos MC, Levy P, Mace S, Melching KS, Ordonez E, Osborne A, Suri P, Sun B, Wheatley M. Recommendations for the evaluation and management of observation services: a consensus white paper: the Society of Cardiovascular Patient Care. Crit Pathw Cardiol. 2014 Dec;13(4):163-98. doi: 10.1097/HPC.0000000000000033. PMID: 25396295.
5. Hospital-Wide Strategies for Reducing Inpatient Discharge Delays and Boarding By Shari Welch, MD, FACEP | on July 27, 2021 https://www.acepnow.com/article/hospital-wide-strategies-for-reducing-inpatient-discharge-delays-and-boarding/2/
6. Addressing the Emergency Department Crowding Crisis: Is Discharge by Noon Really the Answer? Scott, Brandon S. et al. Joint Commission Journal on Quality and Patient Safety, Volume 49, Issue 4, 179 – 180
7. Coffman, J. M., Blash, L., & Amah, G. (2018). Update of Evaluation of California’s Community Paramedicine Pilot Program. Healthforce Center at UCSF. July.
