|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.
EMSA Participates in ‘Operation First On Scene’
EMSA’s response personnel unit staff participated in the Alameda County’s mass casualty incident exercise on March 19, 2016 in Dublin, California. The exercise provided medical reserve corps (MRC) members training on patient triage, injury treatment, bleeding control, wound care, transport and treatment area management.
MRC units are community-based healthcare teams that are locally organized and utilize volunteers to donate their time and expertise to prepare for and respond to emergencies. MRC volunteers include medical and public health professionals, including physicians, nurses, pharmacists, dentists, veterinarians, epidemiologists, interpreters, chaplains, office workers, and legal advisors. There are currently 41 MRC units throughout the state that are composed of some 8,892 volunteers.
Are you interested in volunteering your time and expertise as an MRC member? Contact EMSA’s State MRC Coordinator for details.
California Medical Reserve Corps Volunteer Receives National Recognition
Ms. Yolanda “Lonnie” Cronin, RN was one of two medical reserve corps (MRC) volunteers across the nation to be recognized as an “outstanding MRC responder” by the Division of Civilian Volunteer Medical Reserve Corps (DCVMRC) for her dedicated work as a Contra Costa County’s MRC responder at the Valley Fire which burned over 1,900 structures and over 76,000 acres. Thousands of residents were left homeless and sought out shelter at the Calistoga fair grounds in Napa County, where Ms. Cronin and her fellow MRC unit members provided medical care at a field treatment site.
Ms. Cronin has been a volunteer nurse with the Contra Costa County MRC since 2010. She dedicated over 60 hours responding to the Valley Fire. She was the first to respond and on her first shift, she was the only RN on hand to provide care for more than 600 individuals. In addition to providing medical care to evacuees, Ms. Cronin also performed wellness checks, bathroom and shower assistance, and emotional support to evacuees. She also coordinated staffing shifts to service the evacuees and assisted with the transition of her Contra Costa County MRC unit to the Marin County MRC unit when the field treatment site changed locations.
EMSA is proud to see a California MRC responder honored nationally. Thank you for your volunteerism and concern for your fellow Californians!
Hospital Incident Command System Gets International Adaptations
EMSA’s Hospital Incident Command System (HICS) materials are used nationally and internationally to bring incident command system (ICS) concepts and principles into hospitals and healthcare systems.
HICS is currently being implemented in Kenya, Pakistan, Iran, Taiwan and Turkey. EMSA anticipates Japan, Syria, Afghanistan, Tanzania, India, Tajikistan, and Colombia in South America to implement HICS into their systems in the near future.
The University of Tokyo is in the final reviewing stages for release of The HICS Guidebook, Fifth Edition into Japanese. EMSA was recently contacted by officials from Taiwan, Iran, and South Korea to assist with translating HICS materials into Mandarin, Farsi, and Korean.
EMSA Hosts American College of Surgeons for Trauma System Consultation
In March 2016, EMSA hosted the American College of Surgeons (ACS) for a four day trauma system consultation. Using national standards as a rubric, the consultation assessed key areas of California’s trauma systems. The review process involved ACS team members asking questions of EMSA staff, trauma system stakeholders and reviewing responses contained in a previously submitted questionnaire.
On the final day of their visit, the ACS team provided the following key recommendations:
- Create an injury report template and coordinate with the California Department of Public Health (CDPH) epidemiological center.
- Revise regulations to be less permissive in certain areas and consistent with the state trauma system plan.
- Provide for minimum operational standards based on size and resource capabilities delineated by the local EMS agencies (LEMSAs).
- Establish basic quality and activity reporting standards for the LEMSAs.
- Better define the structure and charge of the trauma regions to solidify their role in the state trauma system.
- Roll out a media campaign and use any opportunities to educate the public on the state trauma system.
- Seek stable and sustainable funding to support state system planning, oversight, and evaluation.
- Work with local agencies to report on cost and value of the system emphasizing the importance of maintaining readiness.
- Ensure uniform criteria for trauma center designation by the LEMSAs.
- Exercise the authority to collect data from all acute care facilities receiving trauma patients.
- Adopt the draft state performance improvement and patient safety plan.
- Monitor performance measures, especially timeliness to care and address trends in deviation of care.
- Utilize CEMSIS data for reports.
A final report will be provided to EMSA in the coming months, and in conjunction with California Health and Human Services Agency (CHHS), final recommendations and strategies will be evaluated to further enhance the quality of care made available to all of California’s residents and visitors.
Visit EMSA’s trauma website for additional information.
Dare to Prepare Day Coming to Sacramento
This family friendly event will help you prepare for any emergency or disaster. Walk away with great tips, learning tools, check lists, “make a plan” options, freebies, and more.
The event will include an earthquake simulator, equipment displays, food trucks, presentations, run-hide-fight class, exhibits, show & tell, give-aways & chances to win prizes.
Visit the Dare to Prepare Day website for details.