Why is there so much talk about ambulance offload delays? A look into the process, challenges, and solutions (a 🧵). 
While not a new problem, there has been increased conversation on ambulance offload delays as we weather this latest COVID surge. Systems all over the world are struggling to get ambulances back in service in a timely manner after transporting pts to the hospital.
@NEMSISTAC nationwide data shows offload times (elapsed time from the arrival of an ambulance with a pt to the ED until the ambulance is back in service) have increased and spiked at various times in 2020 & 2021 (red + purple lines) compared to 2018 & 2019 (blue + green lines).
What typically happens when an ambulance transports a patient to the hospital? EMS crews facilitate the pt in getting registered, give a report to the RN, and then wait with the pt on their stretcher until directed to a room (can be minutes to hours).
ED delays put incredible strain on EMS systems. When ambulances are tied up at the hospital, fewer units are available to respond to other calls + are dispatched from greater distances. Crews have little to no downtime, unable to return to the base or rest up for the next call.
The EDs are in a tough position, too. They have to balance limited beds, nursing staff, and other resources among patients coming in both as walk-ins and by EMS. Due to COVID, ED room turnover is slower from PPE procedure, enhanced disinfection, lack of fam present to give hist.
But the problem is larger than just the ED. When the hospital census nears capacity, ED admits begin to accumulate from prolonged “boarding,” thus filling the ED to capacity as well. This great article summarizes causes of ED crowding at various levels: bit.ly/3JOgGWn
From a patient centered care perspective, ED bed delays and crowding are a cause for serious concern. Pts are less likely to be closely monitored and may decompensate during the delay, experience is poor, and pts are exposed to the gen pop w/o privacy, physical distancing.
From a legal perspective, hospitals can ask EMS to stay with a pt, but once a pt is on the hospital’s property, the hospital bears the legal responsibility for the pt, and EMS sticking around is purely voluntary (but common practice) bit.ly/3F2ReJb @pwwemslaw
So now, what can we do about it? Unfortunately, the problem will never be resolved without comprehensive emergency care reform. Let’s take a look though at some of the levers that have been implemented/proposed (lower hanging fruit).
Ambulance diversion, a controversial strategy for temp. relief, allows EDs to request incoming ambos transport to other facilities. However, most believe the practice does little if anything to reduce crowding and may have (-) fx on pt care bit.ly/3n4ADOW
“Direct to Triage” protocols empower EMS to place stable, low acuity pts in the ED waiting room. By doing so, EMS stretchers don’t become tied up and units can return to service much faster. These protocols are somewhat newer and have not been implemented universally.
Some systems have hired their own RNs to assume care from the EMS crew & wait w/ the pt in the ambo triage area. EMS then picks up a new stretcher + returns to service. Problem here is the added handoff (an already weak point in hc) + just shifts waiting. bit.ly/3GnaJxH
A more promising option is EMS transport to alternate destinations (now reimbursed by @CMSinnovates under #ET3). Some pts can receive appropriate care at UC, PCPs, sobering cntr, etc. Systems (inc. @MedStarEMSInfo, @REMSAHealth) have proven success w/ high satisfaction + safety.
Along with alt destinations, ET3 covers the use of nurse-triage lines. These consultations can prevent a trip to the ED and instead provide pt with home care instructions or referrals to other points of care n.pr/3q6qFi7
COVID has also sped up conversations on the incorporation of #telemedicine into EMS care. #FICEMS has created a resource doc that provides info to #EMS orgs looking to meet the healthcare needs of their pts & communities through telemedicine: bit.ly/3F6cDB6
Lastly, we need mass messaging re. appropriate 911/em care use. Ie. messages that say don't call 911 for things such as COVID tests. Some depts have started, but need assistance with adopting public health proven language and strategies. bit.ly/3JNPas2
What is your system doing to address ambulance offload delays and ED crowding? What mitigation actions do you think will yield the greatest results? #EMS #ambulance #EmergencyMedicine #PublicHealth #COVID19
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