The day finally came when emergency medical transportation across one stretch of California was brought to a near-halt — in a hospital corridor. At least that's the way it felt to Dan Lynch, the director of Fresno County's Emergency Medical Services, who oversees EMS in that part of California's central valley.
This past January, on two different shifts, ambulance staff were essentially stranded in “wall time” for more than three hours at Fresno's Community Regional Medical Center. Wall time for patients and ambulance staff is nothing new. Stuck on a gurney, with an EMT or paramedic beside them, such patients frequently had to wait “along the wall” for emergency care, along with the EMS personnel who brought them. But on this particular occasion, time dragged on, keeping the two ambulances out of commission for a combined total of more than six hours.
Mr. Lynch and the county EMS system filed a complaint with the California Department of Public Health Licensing and Certification Program against the medical center where this occurred, and then compliance increased dramatically. Though he is quick to point out that this isn't a universal solution to what is now becoming a nationwide problem for ambulance services, it seems that this squeaky wheel strategy is bringing relief and not just to Fresno County. News of the complaint traveled like one of state's infamous wildfires, and EMS in other counties began publicly chronicling similar frustrations. (California Healthline, March 10, 2014; http://bit.ly/1fy84mr.)
“This isn't just a Fresno issue,” Mr. Lynch pointed out. “It is happening in other parts of California ... San Bernardino, Riverside, Ventura. It's all over.”
All over the world, in fact. Wherever there is a well-developed emergency response system — the United Kingdom, Australia, Canada — wall time, or ramping, as it is sometimes called, has become an issue. It's been the subject of distressed blogging in Melbourne, intense research in Canada, and extensive news coverage in Great Britain. California public health officials are working on an approach they hope will provide a toolkit for other EMS systems, perhaps even those in other countries.
Working in tandem, the California Hospital Association and the state's Emergency Medical Services Authority are attacking the problem in a three-pronged way: surveying EMS and hospital systems to determine best-practice approaches, establishing definitions of terms such as what constitutes wall time, and determining the relevant legal and regulatory standards, including staffing ratios that might affect the time ambulances are out of service.
“It's necessary to have all the partners involved to solve the problem,” explained BJ Bartleson, the vice president of nursing and clinical services for the California Hospital Association. The collaborative effort, which has involved 50 stakeholders across the state, began last year, and a draft is currently being written with a target release date of this summer, she said.
The complication of “ambulance patient delay,” as it is being called, is obviously exacerbated at peak times, like flu season, Ms. Bartleson said. Still, it occurs only in “pockets,” in some EMS systems but not others, she added. The trend seems to extend in opposite directions, affecting large, tertiary care centers and smaller but essential hospitals in remote or underserved areas that are, in terms of health care, “the only game in town,” Ms. Bartleson said.
Still, some states seem to be having much more of a problem than others. Florida rivals California for high frequency of ambulance patient delays, but other parts of the country don't seem nearly as affected, she said. The Northeast, for instance, seems to have relatively fewer such incidents, with the exception of major cities, such as the District of Columbia. “I have not seen a major problem like occurred in Fresno,” said J. Curtis Varone, an attorney in Exeter, RI, who writes an online legal column pertaining to firefighter and EMS issues. (www.firelawblog.com.) In his state, “it's not common although there is an inevitable delay at hospitals,” he noted.
Part of the reason for such ambulance delays stems from a rising tide of medical calls across the country, as shown by the number of fire departments that now typically answer at least three times more medical calls than fires, prompting one fire chief to request reassignment of firefighters to ambulances rather than trucks. (Los Angeles Times, April 16, 2013; http://lat.ms/Saj8MC.)
Fire trucks often have to be sent instead of ambulances in counties and cities that combine EMS and fire departments into one agency, and 911 calls have risen so much that in metropolitan areas from Lexington, KY, to Cincinnati, OH, the fire department is almost as likely to answer a medical call as the ambulance system. (Lexington Herald-Leader, Feb. 15, 2014; http://bit.ly/1rFCaVg.)
Widespread concern over EMS performance and ways to measure it spurred U.S. legislators to address the issue in a bill, “The Field EMS Quality, Innovation and Cost Effectiveness Improvements Act of 2013–2014,” which has more than two dozen Congressional sponsors. (http://1.usa.gov/1fQeCYm.)
No one has suggested trauma patients are being compromised or that those who need urgent attention aren't getting it. “It's the patients who fall in between, between the ones who need immediate care, like trauma patients, and those who aren't as sick, who can sit in the waiting room,” Mr. Lynch said. Those in-between conditions can range from abdominal pain to a broken leg, he said. The EMT, paramedic, or both stay with the patient to provide care in the hallway, he added.
Usually, wall time waits occur when boarding in the emergency department is at or over capacity, he noted. Ambulance companies can be fined by state or regional agencies for slow response times. That isn't the only concern, however, because the problem also can pit first responders against the hospital they serve. The safety net that constitutes emergency medicine ought to function like a team, he said.
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