‘Crisis’ is a word I see in our pre-hospital and inter-hospital world rather frequently these days. There’s no staff. There are no beds. People are tired. And believe me. I get it. I’m right there with you. If it weren’t for the team I have at work, who refuses to take “no” in terms of progress and moving forward, I’d probably have left EMS and run off to live to my ‘ran off to the circus’ dream of taking an apprenticeship from a master Sushi chef somewhere. Spending years making rice seems therapeutic sometimes. But that’s not in the cards. So, thinking about fixing what we have, the system we work in, and the networks of other systems we interact with at our agencies and hospitals is where I’m at.
Emergency Department wait times seem to be a significant issue currently. It’s not a new issue, and no, you cannot blame COVID. EMS crews holding the wall is nothing new. I see news articles from all the major EMS news outlets to local papers covering this issue. Wait times to unload patients are up, affecting getting trucks back on the street to run waiting for 911 and IFT calls. To further compound the issue, moving patients from smaller facilities to more extensive facilities due to lack of staffing, combined with floors with full beds, adds to the weight of the issue. Locally, our closest ICU and Cath Lab are about an hour and a half away in good weather, but they are routinely full in their ICU and thus will not take a patient needing to go to the lab. Honestly, we’ve had some bad outcomes because of it.
One of the more telling articles I’ve read on EMS1 mentions Volusia County EMS. It seems like the wait times to get units to turn over their patients to the ED nursing staff was taking so long the EMS agency hired a nurse to work in the ED to take EMS patients. The article says the estimated cost for this five-day-a-week position is $92,000. The money is coming from a federal relief package… so instead of that money going into the EMS system for wages, benefits, equipment, or trucks on the street, it’s filling a role that the hospital should be paying for, and the county’s EMS agency budget (Moore, 2021).
“While leaders may wish to blame our current failings on COVID-19, this data draws a clear line between poor outcomes and the systematic under-resourcing and underfunding of our service,” Mr. Kastelan said.-Chris Kasetlan, NSW Paramedic Association.
Regardless of where you’re working, pre-hospital, or in the ED taking the patients, I think it’s important to realize we’re all on the same team here. We might not know where we need to start, but there needs to be a systematic approach to fix the issue. It has to come from a Systems Thinking perspective, or I feel like it will fail without stakeholder buy-in. Hospitals have spent years trying to win the accolades of pre-hospital providers with snacks and the best lounge possible. Anyone who’s been around for as long as a takes for that last tuna sandwich left in that s lounge at 3 am on a Saturday to look good to eat because you haven’t seen food in 12 hours also knows that things like hospital-divert do not work. And once everyone is on divert, we’re back to square one. It’s dividing by zero, and that doesn’t benefit anyone. EMS agencies have to face the hard facts; they need to have a system-wide conversation and implement measurable solutions immediately. Emergency Departments need to do the same and take ownership of the issue if they haven’t done so. They need to execute creative, effective, timely, and measurable solutions as part of the pre-hospital system. Silos won’t fix anything here.
“These are taxpayer resources that are being used right now to staff hospitals,” Saylors said. “This is nothing short of criminal.”- Sacramento Assistant Fire Chief Eric Saylors
What We Seem To Know
Finding the fix, based on what I’ve been able to research, is the problem. It indeed looks like the problem is well-researched and well-understood. There is a plethora of information and data talking about the situation and identifying variables that cause ED delays for patients and pre-hospital crews. In 2014, the California Association published a 122-page report on the issue, helping cement the fact COVID isn’t to blame for the problem (Yeulet, 2014). Yes. 2014, and the vast majority of articles I see are from LA and Sacramento. The 2014 article just really showed a lot of metrics talked about ED throughput but didn’t seem to propose any tangible solutions, in my opinion. You can review it here: https://emsa.ca.gov/wp-content/uploads/sites/71/2017/07/Toolkit-Reduce-Amb-Patient.pdf.
The ‘new normal,’ looks like it’s a rough go for providers and patients right now. And it looks like a lot of parked ambulances. It’s an issue worldwide. I’ve seen plenty of media coverage of ambulance wait time issues from the NHS in the UK. Australia is having its issues, too, where New South Wales seems to be hit rather hard with wait times and a paramedic shortage. It’s been a problem, it’s been ignored, and now it’s worse than ever. It is that clear-cut.
“It’s turned into a parking lot,” said Medic Ambulance Operations Manager Eric Paulson. “Hospitals are impacted to the point where they’re using ambulances as free labor.”-Eric Paulson
Solutions?
I will be the first to say that I’m presenting one side of the issue here. The hospitals have valid things they are dealing with. I support the concept of nurse-staffing ratios, which is one of the cited staffing problems, as addressed by California’s Nursing Association (Taxin, 2022). There’s some talk about nursing burnout too, which, again, matters, but that’s a siloed answer. Burnout is everywhere.
It does look like the issue has been elevated to the State level in California, and hopefully, some solutions will be the result of this meeting. Some of the solutions include:
- Develop new regulations as current EMS regulations were established more than 40 years ago.
- Fine hospitals anytime they hold an ambulance for longer than 20 minutes.
- Ask hospitals to hire their own EMTs to care for patients once they’re dropped off.
- Ask hospitals to pay EMS services for their wait times anytime they are held over.
Those aren’t bad ideas. I think there are other solutions, too. Mobile Integrated Health/Community Paramedicine has been successful in terms of keeping people out of the hospital or redirecting them to more appropriate acute medical care beyond that of the Emergency Department. Austin Travis EMS seems to be having success with the use of a PA in the field to handle lower-level calls, like other systems. The NHS with London’s Ambulance Service has a unique solution, where they built a separate EMS receiving area to help the flow in the ED. This program has saved 2,800 hours of wait time for ambulances (Communications and Engagement, 2022). That’s a solid chunk of time.
At this point, you may be saying, “Nick, you’ve got a lot of complaints here; what are you and your system doing to help in the system you work in?” That’s a fair question, and I’m glad you asked it. We were most affected by not being able to transfer patients, or if we could, it was much further away than our usual destinations. I had cornered my Chief and insisted we do something. It’s a problem – Let’s get after it. We came up with an initial meeting including ourselves, our Medical Director, one of the other lead ER physicians, and the nursing director from the ED. The approach was to break down silos, hear and understand everyone’s experience and position, and seek to define and analyze quantitative data (patient acuity, frequencies, etc.) with qualitative experiences and move towards a solution. Everyone had an equal seat at the table to discuss what they were experiencing and their interactions with the other departments involved. It was not about pointing fingers but facing the hard facts. It’s been wildly successful. Our next step is to bring the hospitalists, surgeons, and acute care nursing team to understand their experiences. So far, we hypothesize that we may find a way to keep more patients in our system with some likely changes. It is action research at its core, and it’s incredible to be involved with it.
Every single one of us can start a conversation. We all can collect good data, which you do every time you run a call, so document the best times and why there were delays when you have them. Engage your leadership, engage your local government. EMS providers, alongside hospital personnel, can find a solution to this. It has to be systematic, inclusive, and understanding of every stakeholder’s wants and needs, but it can be done.
Communications and Engagement. (2022). New Ambulance Receiving Centre gives paramedics back 2,800 hours on the road | Latest news | BHR Hospitals. Barking, Havering and Redbridge University Hospitals. https://www.bhrhospitals.nhs.uk/news/new-ambulance-receiving-centre-gives-paramedics-back-2800-hours-on-the-road-3418?fbclid=IwAR1Tknp2MwOgWT8-D0DMqpjBltR4tVsa5tXBEJT5q_cxGBcrDbbG6n2bw34
Moore, M. H. (2021, December 20). Volusia EMS hires nurse to stay at ED to speed up patient transfers. The Daytona Beach New-Journal. https://www.ems1.com/staffing/articles/volusia-ems-hires-nurse-to-stay-at-ed-to-speed-up-patient-transfers-OAat7MCZjhQYr3Bc/
Taxin, A. (2022). Ambulances wait hours with patients at California hospitals | AP News. AP NEWS. https://apnews.com/article/coronavirus-pandemic-health-lifestyle-business-california-c8906d6154daf3185d39fdee2d3a7f55?utm_source=Sailthru&utm_medium=email&utm_campaign=Newsletter Weekly Roundup%3A Healthcare Dive%3A Daily Dive 01-22-2022&utm_term=Healthca
Yeulet, C. (2014). Building Strategies for California Hospitals and Local Emergency Services Agencies Toolkit to Reduce Ambulance Patient Offload Delays in the Emergency Department. www.calhospital.org/publications