|Director’s Message: Howard Backer, MD, MPH, FACEP
Ambulance Patient Off-load Delay (Wall Time)Most EMS providers are intimately familiar with “wall time.” It is also known as ambulance wait time, EMS patient parking or ambulance patient off-load delay. It is the interval between arrival of an ambulance patient at the ED until the EMS and ED personnel transfer the patient to an ED gurney and the ED staff assume responsibility for the patient. It does not include time when the crew may be stationed at the hospital or remain in the ED after the unit is available for the next call.Although widespread in California, the problem is not uniform or consistent. Specific medical centers or regions are disproportionately impacted. Many health care systems and acute care EDs have never routinely had a problem, or they have resolved it. In a study involving 200 cities (including California cities), the national average wait time for handing off ambulance patients has doubled since 2006, from 20 minutes to over 45 minutes, resulting in a loss of nearly five million hours of EMS system productivity. A 2004 study from Los Angeles revealed 21,240 incidents (one out of every eight transports) in a one-year period when EMS providers were out of service for more than 15 minutes waiting to transfer a patient to the ED staff; 8.4% of incidents were greater than one hour and the maximum wait time was 6.75 hours. Some urban areas in California report ambulance wait times to transfer care in the ED not uncommonly reaching two to four hours. In reality, few EMS systems measure the extent of the problem.This problem is not unique to California. Other states including New York, Massachusetts, Nevada, Pennsylvania and West Virginia have documented and addressed this issue. Recent reports from Canada, United Kingdom and Australia indicates that this issue is international.
Ambulance off-load delays are not an isolated issue. Research and expert opinion connect patient off-load delay to ED crowding, ambulance diversion, and ED patient boarding with obstructions in hospital throughput. Many additional factors contribute to decreased patient throughput, including nurse-patient ratios, increasing patient complexity, lack of hospital beds, and increased psychiatric holds due to fewer mental health community resources, among others. The final common endpoint is that ED beds are full, including admitted patients, and the ED cannot free gurneys and staff to accept new patients arriving by EMS.
Impact on EMS System
When prehospital providers wait with the patient on their gurney unable to transfer the patient to a hospital gurney and to transfer care to the ED staff, it creates issues of patient safety for both the patient arriving in the ED and others in the community who may need EMS stabilization and transport. The ambulance unit and staff that are delayed in the ED are effectively out of service, decreasing advanced life support coverage in the community, which can increase response time for subsequent critical cases, including cardiac arrest and major trauma. The compilation of these additional non-productive unit-hours are costly to the company and to the community, since readiness accounts for a large portion of cost for EMS ambulance coverage in a community, and ambulance contracts mandate maximal response times to critical calls.
In 2012, Riverside and San Bernardino counties logged approximately 20,535 total delay hours, accounting to $3 million in lost unit hours during that year (not counting potential lost revenue). In 2012, Sacramento Metro Fire Department accumulated 17,345 hours of delays in patient off-load time at one hospital with an estimated system cost of $2.6 million. In 2015, Riverside County logged approximately 29,354 total hours in patient off-load delays. In 2015, Alameda County EMS providers accumulated 5,388 hours of patient off-load delays with an estimated system cost of $1,043,224.
Efforts to Address Off-load Delays
A collaborative effort between the California Hospital Association (CHA), EMSA, and the EMS Administrators’ Association (EMSAAC) was initiated in 2013 to address this issue. The initiative convened stakeholders to provide focus on the problem, develop consistent metrics, explore successful and promising approaches to improve the problem, and determine how to disseminate and institute solutions between medical systems and jurisdictions with problematic delays.
The effort was supported by the development and distribution of a white paper and manual to support a quality improvement initiative for hospitals. A follow-up meeting in 2015 indicated that there had been some successes, but the problem was unchanged in many jurisdictions.
AB 1223 (O’Donnell, Chapter 379, Statutes of 2015)
The on-going frustration over the impact of patient delays on EMS systems led to legislation. AB 1223 mandates that EMSA develop a statewide standard methodology for the calculation and reporting by a local EMS agency (LEMSA) of ambulance patient off-load time. It also authorizes a LEMSA to adopt policies and procedures relating to ambulance patient off-load time. The bill does not mandate an end to off-load delays or institute a penalty for delays, but it does require an important fist step, which is to create a uniform measure that will support collection of comparable data. Currently, only about six LEMSAs collect data on the delays, and only Contra Costa, Riverside, Inland Counties EMS Agency, Alameda, and San Joaquin counties make data available on their websites.
Measurement specifications were developed through input from a stakeholder group. The time interval for ambulance patient off-load time begins when the ambulance stops at the site of unloading at the hospital ED. The statute says the ending time is when “the patient is transferred to the ED gurney or other location AND the ED assumes the responsibility for the patient.” The assumption is that transfer of care has occurred when the patient is transferred from the EMS gurney to an ED gurney, chair or sent to the waiting room. In some EMS systems, the CAD automatically documents these time stamps. In others, the medics will initiate the time stamps in their ePCR. NEMSIS 3 compliant data systems have data fields for these times.
The target goal is to have patient transfer occur within 20 minutes in the ED 90% of the time. Even when this is impossible due to volume or other circumstances, the transfer time should not exceed one hour. To a large extent, how this problem is managed in the future will depend on the data collected by EMS providers. Measuring a problem is the first step toward focusing attention and finding a solution.