Ambulance Diversion and Offload Delay ED Crowding and the EMS …€¦ · Diversion and Transport...

Am

bula

nce

Div

ersi

on

and

Offl

oad

Del

ay

ED C

row

ding

and

the

EMS

Syst

em

Der

ek R

. Coo

ney,

MD

, FF/

NR

EM

T-P,

FA

CE

PA

ssoc

iate

Pro

fess

or o

f Em

erge

ncy

Med

icin

eS

UN

Y U

psta

te M

edic

al U

nive

rsity

Syr

acus

e, N

ew Y

ork

Dec

lara

tion

•I h

ave

no fi

nanc

ial c

onfli

cts

to re

port.

•I a

m a

mem

ber o

f the

Boa

rd o

f Dire

ctor

s of

the

Nat

iona

l A

ssoc

iatio

n of

EM

S P

hysi

cian

s.

•I a

m a

Med

ical

Dire

ctor

of a

num

ber o

f EM

S a

genc

ies.

•Li

ke e

very

one

else

, I a

m a

pot

entia

l pat

ient

.

Obj

ectiv

es

•D

escr

ibe

wha

t am

bula

nce

dive

rsio

n an

d of

fload

are

and

ho

w th

ey d

iffer

•D

escr

ibe

the

liter

atur

e on

div

ersi

on a

nd o

ffloa

d de

lay

•D

iscu

ss th

e re

latio

nshi

p be

twee

n th

e tw

o

•D

iscu

ss th

e em

ergi

ng im

porta

nce

of A

OD

as

a be

nchm

ark

for E

D q

ualit

y

•D

iscu

ss p

oten

tial s

trate

gies

to d

ecre

asin

g A

OD

Def

initi

ons

Am

bula

nce

dive

rsio

n: re

dire

ctin

g or

lim

iting

des

tinat

ion

of a

n am

bula

nce

carry

ing

a pa

tient

to a

hos

pita

l as

its

dest

inat

ion

Am

bula

nce

offlo

ad d

elay

: th

e tim

e be

twee

n ar

rival

of

an a

mbu

lanc

e, a

nd th

e tim

e th

at th

e pa

tient

is b

oth

(1)

off t

he s

tretc

her a

nd (2

) EM

S re

port

has

been

giv

en

His

toric

al P

rosp

ectiv

e

•A

mbu

lanc

e di

vers

ion

used

to d

ecom

pres

s cr

owde

d E

D b

y di

rect

ing

ambu

lanc

es to

an

ED

with

less

pat

ient

vol

ume

at

the

time

•Fi

rst p

aper

des

crib

ing

succ

ess

was

pub

lishe

d in

199

0 –

Lago

eR

J, J

astre

msk

iMS

. Rel

ievi

ng o

verc

row

ded

emer

genc

y de

partm

ents

thro

ugh

ambu

lanc

e di

vers

ion.

Hos

pita

l Top

ics.

19

90; 6

8 (3

): 23

.•

Mor

e re

cent

ly, d

iver

sion

site

d as

cau

se o

f pat

ient

har

m a

nd

EM

S S

yste

m d

ysfu

nctio

n–

CO

BR

A / E

MTA

LA

DIV

ERSI

ON

LIT

ERAT

UR

E

Am

bula

nce

Div

ersi

on

Lago

eR

J, J

astre

msk

iMS

. Rel

ievi

ng o

verc

row

ded

emer

genc

y de

partm

ents

thro

ugh

ambu

lanc

e di

vers

ion.

H

ospi

tal T

opic

s. 1

990;

68

(3):

23.

–Fi

rst p

aper

to d

escr

ibe

phen

omen

on o

f div

ersi

ons

–U

sed

as a

nov

el w

ay to

dec

ompr

ess

ED

–O

rigin

ally

des

crib

ed fo

r pat

ient

s w

ith

rela

tivel

y m

inor

in

jurie

s.–

ten

adm

itted

pat

ient

s w

ere

awai

ting

inpa

tient

bed

s or

al

l inp

atie

nt m

onito

rs w

ere

in u

se–

3/4

hosp

itals

on

dive

rsio

n -s

end

to o

utly

ing

hosp

itals

–Li

mite

d ef

fect

-la

stin

g on

ly 4

mon

ths

Am

bula

nce

Div

ersi

on

Whi

le a

mbu

lanc

e di

vers

ion

may

dec

ompr

ess

the

ED

, the

re is

con

cern

that

div

ersi

on m

ay

also

cau

se h

arm

.

Am

bula

nce

Div

ersi

onN

eely

KW

, Nor

ton

RL,

You

ng G

P. T

he e

ffect

of h

ospi

tal

reso

urce

una

vaila

bilit

y an

d am

bula

nce

dive

rsio

ns o

n th

e E

MS

sy

stem

. Pre

hosp

italD

isas

ter M

edic

ine.

199

4; 9

(3):

172-

7.–

Five

mon

th p

rosp

ectiv

e st

udy

–91

1 di

vers

ions

com

pare

d to

5%

rand

om s

ampl

e of

non

-di

vers

ions

–M

ean

trans

port

time

non-

dive

rted

11.5

min

vs.

16.

5 m

in (p

<

0.00

2)–

Dis

tanc

e to

inte

nded

des

tinat

ion

1.3

to 4

.6 m

iles

furth

er fo

r di

verte

d–

Sug

gest

ed w

as re

late

d to

una

vaila

bilit

y of

spe

cial

ty s

ervi

ces

–R

ecom

men

ded

rese

arch

into

out

com

e di

ffere

nces

Am

bula

nce

Div

ersi

onS

loan

EP,

et a

l. th

e ef

fect

of u

rban

trau

ma

syst

em h

ospi

tal b

ypas

s on

pr

ehos

pita

ltra

nspo

rt tim

es a

nd le

vel 1

trau

ma

patie

nt s

urvi

val.

Ann

als

of E

M. 1

989;

18

(11)

: 114

6-50

.

–S

tudi

ed in

fluen

ce o

f hos

pita

l byp

ass

on p

reho

spita

ltim

es a

nd

patie

nt s

urvi

val

–D

irect

tran

spor

t pat

ient

s (n

= 6

6) v

s. th

ose

that

requ

ired

bypa

ss (n

= 1

37)

–Tr

avel

tim

e in

byp

ass

grou

p 3

min

long

er (p

< 0

.05)

–N

o di

ffere

nce

in s

urvi

val 8

6% v

s. 8

5%–

Add

ition

al 3

min

add

ed o

nly

5% to

tota

l tra

nspo

rt tim

e

Am

bula

nce

Div

ersi

on

Red

elm

eier

, et a

l. N

o pl

ace

to u

nloa

d: a

pre

limin

ary

anal

ysis

of

the

prev

alen

ce, r

isk

fact

ors,

and

con

sequ

ence

s of

am

bula

nce

dive

rsio

n. A

nnal

s of

EM

. 199

4; 2

3 (1

): 43

-7.

–O

bser

vatio

nal c

ohor

t stu

dy o

ver a

4 y

ear p

erio

d–

153,

167

tota

l tra

nspo

rts; 5

% d

iver

ted

–Lo

nger

tran

spor

t tim

e 13

.3 m

in (±

7.5)

vs

11.6

min

(±

6.9)

; p <

0.0

05–

No

diffe

renc

e in

rate

of t

rans

port

asso

ciat

ed d

eath

Am

bula

nce

Div

ersi

on

Stil

l a c

once

rn th

at d

iver

sion

is h

arm

ful

and

redu

ctio

n is

favo

rabl

e...

Am

bula

nce

Div

ersi

on

Lago

eR

J, e

t al.

Red

ucin

g am

bula

nce

dive

rsio

n: a

mul

tihos

pita

l ap

proa

ch. P

reho

spita

lEm

erge

ncy

Car

e. 2

003;

7 (1

): 99

-108

–R

etro

spec

tive

revi

ew o

f pro

cedu

res

for r

educ

ing

dive

rsio

n •

syst

em-w

ide

exch

ange

of i

nfor

mat

ion

on d

iver

sion

sta

tus

•ho

spita

l com

mitm

ent t

o pr

ovid

ing

reso

urce

s ne

eded

to re

duce

di

vers

ion

•in

divi

dual

hos

pita

ls s

pot c

heck

ing

by m

anag

emen

t lev

el

pers

onne

l–

Bet

wee

n 20

00 a

nd 2

001

hour

s on

div

ersi

on w

ere

redu

ced

by 3

3.3%

–P

revi

ous

pape

r (20

02) b

y La

goe,

Hun

t, et

al.

show

ed

51%

tim

e on

div

ersi

on

Am

bula

nce

Div

ersi

on

Vilk

eG

M, e

t al.

Com

mun

ity tr

ial t

o de

crea

se a

mbu

lanc

e di

vers

ion

hour

s: th

e S

an D

iego

Cou

nty

patie

nt d

estin

atio

n tri

al.

Ann

EM

. 200

4; 4

4 (4

): 29

5-30

3.–

Ret

rosp

ectiv

e st

udy

post

impl

emen

tatio

n of

a d

iver

sion

pro

toco

l–

Pre

-tria

l 12

mon

ths

/ Tria

l 3 m

onth

s / P

ost-t

rial 9

mon

ths

–A

utho

rizat

ion

of d

iver

sion

requ

ired

ED

atte

ndin

g an

d ch

arge

nu

rse.

Afte

r 3 h

ours

then

aut

horiz

atio

n by

hos

pita

l adm

inis

trato

r–

Out

com

es: n

umbe

r of p

atie

nts

trans

porte

d by

am

bula

nce;

nu

mbe

r of p

atie

nts

take

n to

ano

ther

ED

due

to d

iver

sion

; nu

mbe

r of h

ours

on

dive

rsio

n•

Dec

reas

ed h

ours

on

dive

rsio

n–

Pre

-tria

l = 4

,007

/ D

urin

g tri

al =

1,0

79 /

Pos

t-tria

l = 1

,774

•D

ecre

ased

num

ber o

f pat

ient

s di

verte

d –

Pre

-tria

l = 1

320

/ Dur

ing

trial

= 3

22 /

Pos

t-tria

l = 4

99–

75%

redu

ctio

n of

div

ersi

on a

way

from

requ

este

d E

D

Am

bula

nce

Div

ersi

on

•W

hat d

o w

e kn

ow s

o fa

r??

–A

mbu

lanc

e di

vers

ion

may

dec

ompr

ess

an

over

whe

lmed

ED

in th

e sy

stem

–A

mbu

lanc

e di

vers

ion

may

incr

ease

tra

nspo

rt tim

es

–P

olic

ies

to d

ecre

ase

dive

rsio

n ho

urs

have

be

en e

ffect

ive

Div

ersi

on a

nd T

rans

port

Tim

e

Silk

aPA

, et a

l. D

iver

sion

of A

LS a

mbu

lanc

es.

Pre

hosp

itale

mer

genc

y ca

re. 2

001;

5 (1

): 23

-8.

–R

etro

spec

tive

stud

y du

ring

cons

ecut

ive

3 m

onth

s

–ca

se m

atch

ed c

ontro

ls o

f pat

ient

s no

t div

erte

d w

ere

com

pare

d to

div

erte

d pa

tient

s

–2,

534

ALS

runs

: 147

(5.8

%) d

iver

ted;

123

ana

lyze

d

–M

ost c

omm

on re

ason

s fo

r div

ersi

on

•P

atie

nt re

ques

t = 6

9

•E

D s

atur

atio

n =

45

–N

on-p

atie

nt re

ques

t div

ersi

ons

vs. N

on-d

iver

ted

•To

tal p

re-h

ospi

tal i

nter

val

–33

.35

min

(95%

CI 3

1.14

-35

.55)

vs.

33.

43 m

in (9

5% C

I 32.

13 -

34.7

0)

Div

ersi

on a

nd T

rans

port

Tim

e

Sch

ullM

J, e

t al.

Em

erge

ncy

depa

rtmen

t ove

rcro

wdi

ng a

nd

ambu

lanc

e tra

nspo

rt de

lays

for p

atie

nts

with

che

st p

ain.

Can

M

ed J

. 200

3; 1

68 (3

): 27

7-83

.–

Ana

lysi

s of

two

4 m

onth

per

iods

in 1

997

and

1999

that

cor

rela

ted

with

low

and

hig

h ED

by

pass

–Ty

pes

of b

ypas

s

•N

orm

al -

i.e. n

o by

pass

•R

edire

ct -

Acc

ept o

nly

criti

cal c

are

•C

ritic

al c

are

bypa

ss -

cann

ot a

ccep

t crit

ical

car

e

•G

ridlo

ck -

all h

ospi

tals

in q

uadr

ant o

n by

pass

–To

tal p

reho

spita

lint

erva

l

•44

.8 m

in v

s. 4

6.2

min

; cha

nge

of 1

.4 m

in; p

= 0

.2

Div

ersi

on a

nd T

rans

port

Tim

eS

chul

lMJ,

et a

l. E

mer

genc

y de

partm

ent g

ridlo

ck a

nd o

ut-

of-h

ospi

tal d

elay

s fo

r car

diac

pat

ient

s. A

cad

EM

. 200

3;

10 (7

): 70

9-16

.–

Ret

rosp

ectiv

e da

ta o

n co

nsec

utiv

e am

bula

nce

patie

nts

with

che

st p

ain

–11

,400

pat

ient

s ov

er 2

yea

r per

iod

–S

tudy

of o

ut-o

f-hos

pita

l int

erva

ls fo

r pat

ient

s tra

nspo

rted

on d

ays

with

gr

idlo

ck v

s. d

ays

with

out g

ridlo

ck

–M

ain

outc

ome

stud

ied:

90%

tran

spor

t int

erva

l fro

m s

cene

to h

ospi

tal

–4,

223

(37%

) of p

atie

nts

trans

porte

d on

day

with

grid

lock

–R

esul

ts

•Tr

ansp

ort i

nter

val

–17

.4 m

in (9

5% C

I 16.

8 -1

7.8)

vs.

15.

5 (9

5%C

I 15.

3 -1

5.9)

•E

very

hou

r of g

ridlo

ck in

crea

sed

trans

port

by 0

.2 m

in

•A

ll ot

her f

orm

s of

div

ersi

on n

ot a

ssoc

iate

d w

ith lo

nger

inte

rval

s

Div

ersi

on a

nd T

rans

port

Tim

e

Car

ter A

JE, G

riers

on R

. The

impa

ct o

f am

bula

nce

dive

rsio

n on

EM

S re

sour

ce a

vaila

bilit

y. P

reho

spita

lem

erge

ncy

care

. 200

7; 1

1 (4

): 42

1-26

–R

etro

spec

tive

stud

y of

per

iods

on

dive

rsio

n vs

. per

iods

of

f div

ersi

on–

Onl

y on

e ho

spita

l in

syst

em o

n di

vers

ion

at a

tim

e–

Div

ersi

on c

an la

st u

p to

1 h

our w

ith e

xten

sion

gra

nted

by

heal

th d

epar

tmen

t–

Res

ults

-N

o di

ffere

nce

in:

Res

pons

e tim

e O

n-sc

ene

time

Tran

spor

t tim

e H

ospi

tal t

urna

roun

d tim

eO

ut-o

f-ser

vice

tim

e

Div

ersi

on a

nd T

rans

port

Tim

e

So w

hat?

–A

mbu

lanc

e di

vers

ion

in a

nd o

f its

elf m

ay

NO

T in

crea

se tr

ansp

ort t

ime

–If

ther

e is

an

incr

ease

in tr

ansp

ort t

ime

it is

no

min

al

Div

ersi

on

•P

ham

JC

, et a

l. T

he e

ffect

s of

am

bula

nce

dive

rsio

n:

a co

mpr

ehen

sive

revi

ew. A

cad

EM

. 200

6; 1

3 (1

1):

1220

-27.

–S

yste

mat

ic re

view

and

met

a-an

alys

is o

f am

bula

nce

dive

rsio

n lit

erat

ure

–P

auci

ty o

f stu

dies

on

the

effe

cts

of A

D–

No

adeq

uate

stu

dies

on

the

effe

ct o

f AD

on

ED

cr

owdi

ng, o

r mor

bidi

ty/m

orta

lity

Div

ersi

on

Say

it is

nt s

o...

dive

rsio

n ha

s to

be

evil!

NA

EM

SP

Pos

ition

Sta

tem

ent

Glu

shak

C, e

t al.

Am

bula

nce

dive

rsio

n -p

ositi

on p

aper

. P

reho

spita

lem

erge

ncy

care

. 199

7; 1

(2):

100-

3.–

Div

ersi

on m

ay h

ave

nega

tive

impa

ct o

n pa

tient

car

e an

d E

MS

sys

tem

–N

eces

sary

that

EM

S s

yste

ms

take

mea

sure

s to

avo

id

dive

rsio

n w

hich

may

resu

lt in

...•

Una

ccep

tabl

y pr

olon

ged

trans

port

times

•P

rolo

nged

out

of h

ospi

tal c

are

whe

n de

finiti

ve c

are

need

ed

for u

nsta

ble

patie

nts

•In

appr

opria

te a

ttem

pts

by fi

eld

pers

onne

l to

pred

ict

reso

urce

s ne

eded

•D

elay

s in

or l

ack

of a

mbu

lanc

e av

aila

bilit

y to

com

mun

ity

beca

use

of d

iver

sion

to d

ista

nt h

ospi

tals

Div

ersi

on –

Clin

ical

Effe

ctMostly

unim

pressiv

e,bu

t…

Shen

YC,H

siaRY.A

ssociatio

nbetw

eenam

bulancediversionan

dsurvivalam

ongpa

tientsw

ithacutemyocardialinfarction.JAMA.

2011

Jun15

;305

(23):244

07

•expo

sure

to<6,6

to<12,and

12ho

urso

fdiversio

n•

<12ho

urso

fdiversio

n=no

diffe

rence

•>12or

moreho

urso

fdiversio

nwas

associated

with

higher

30daymortality392patie

nts[19

%]vs5

45patie

nts[15

%]

–higher

90daymortality(537

patie

nts[26

%]vs7

62patie

nts[22

%])

–higher

9mon

thmortality(680

patie

nts[33

%]vs9

80patie

nts[28

%])

–higher

1year

mortality(731

patie

nts[35

%]vs1

034patie

nts[29

%])

Div

ersi

on R

educ

tion

Asa

moa

hO

K, e

t al.

A n

ovel

div

ersi

on p

roto

col d

ram

atic

ally

re

duce

s di

vers

ion

hour

s. A

m J

EM

. 200

8; 2

6 (6

): 67

0-75

–R

etro

spec

tive

stud

y of

a c

ount

ywid

e di

vers

ion

prot

ocol

–H

ospi

tal c

ould

go

on d

iver

t for

1 h

our o

nly

and

then

off

dive

rsio

n fo

r nex

t 8 h

ours

–O

utco

mes

: num

ber o

f hou

rs o

n di

vers

ion

and

drop

off

times

for d

iver

sion

per

iods

co

mpa

red

to n

on-d

iver

sion

per

iods

.

–R

esul

ts

•Pr

otoc

ol d

ecre

ased

div

ersi

on b

y 82

%

•In

crea

sed

unit

time

= 17

8 ho

urs/

mon

th (9

5% C

I 74

-283

)

–(U

nit t

ime

= [9

0% d

rop

off t

ime

-15

min

] X n

o of

tran

spor

ts]/6

0 m

in)

•Al

so, l

ittle

effe

ct o

n E

D o

verc

row

ding

•In

crea

sed

drop

offt

ime

= 1.

66 m

in/m

onth

(95%

CI 0

.33

-2.9

8)

–In

crea

se o

f 32%

Div

ersi

on R

educ

tion

... fo

r eve

ry a

ctio

n th

ere

may

be

unin

tend

ed c

onse

quen

ces.

EM

S S

yste

m•

Wha

t is

the

botto

m li

ne fo

r the

EM

S s

yste

m?

–U

nits

bac

k in

ser

vice

in ti

mel

y m

anne

r

–M

aint

ain

acce

ptab

le re

spon

se ti

mes

–C

over

age

in th

e co

mm

unity

at t

he lo

wes

t cos

t pos

sibl

e

requ

iring

mor

e un

its to

mee

t com

mun

ity n

eeds

=

high

er c

ost t

o th

e co

mm

unity

(ie:

low

er U

HU

)

–H

ighl

ight

ed a

noth

er fa

ctor

-dr

opof

ftim

e(o

ffloa

d de

lay)

AM

BU

LAN

CE

OFF

LOA

D

DEL

AY

Inte

rval

sC

one

DC

, et a

l. A

time-

mot

ion

stud

y of

the

emer

genc

y m

edic

al s

ervi

ces

turn

arou

nd in

terv

al. A

nn E

mer

gM

ed. 1

998

Feb;

31(2

):241

-6

Am

bula

nce

Offl

oad

Del

ay•

Sch

war

tz B

, et a

l. Im

prov

ing

acce

ss to

em

erge

ncy

serv

ices

: a

syst

em c

omm

itmen

t. R

epor

t to

the

Min

istry

of H

ealth

and

Lo

ng-te

rm c

are,

Gov

ernm

ent o

f Ont

ario

, Can

ada.

200

5.–

Com

mitm

ent f

rom

all

stak

ehol

ders

is th

e fu

ndam

enta

l re

quire

men

t for

impr

ovem

ent i

n em

erge

ncy

depa

rtmen

t ov

ercr

owdi

ng a

nd a

mbu

lanc

e of

fload

del

ay.

•C

anno

t foc

us s

olel

y on

the

emer

genc

y de

partm

ent

•E

D o

verc

row

ding

is a

sym

ptom

s of

sys

tem

ic is

sues

; no

the

sour

ce o

f the

pro

blem

–S

take

hold

ers

mus

t be

held

acc

ount

able

–P

rinci

ple

caus

e of

off-

load

tim

e is

lack

of c

apac

ity to

tre

at h

ospi

tal i

n-pa

tient

s–

Sol

utio

n to

pro

blem

mus

t loo

k at

in-p

atie

nt c

apac

ity–

Set

goa

l of 3

0 m

inut

es fo

r offl

oad

Am

bula

nce

Offl

oad

Del

ay•

Cen

ters

for M

edic

are

and

Med

icai

d S

ervi

ces

(CM

S).

EM

TALA

-P

arki

ngof

EM

S P

atie

nts

in H

ospi

tals

. Jul

y 13

, 20

06.

–C

MS

has

rece

ived

repo

rts fr

om E

Ds

conc

erni

ng p

atie

nts

bein

g le

ft on

stre

tche

rs fo

r ext

ende

d pe

riods

of t

ime,

pos

sibl

y in

vi

olat

ion

of E

MTA

LA.

–C

MS

reco

gniz

es th

e st

rain

on

ED

s; h

owev

er th

is p

ract

ice

is n

ot

a so

lutio

n.–

Par

king

patie

nts

in h

ospi

tals

impa

cts

the

abili

ty o

f the

EM

S

pers

onne

l to

prov

ide

emer

genc

y se

rvic

es to

the

com

mun

ity

Am

bula

nce

Offl

oad

Del

ay•

CM

S. E

MTA

LA Is

sues

rela

ted

to e

mer

genc

y tra

nspo

rt se

rvic

es. A

pril

27, 2

007.

[Cla

rific

atio

n of

7/1

3/06

lette

r]–

EM

TALA

resp

onsi

bilit

y of

hos

pita

l beg

ins

whe

n an

in

divi

dual

arri

ves

and

not w

hen

the

hosp

ital

acce

pts

the

indi

vidu

al fr

om th

e gu

rney

–H

ospi

tal h

as a

n ob

ligat

ion

to p

rovi

de a

ppro

pria

te

med

ical

scr

eeni

ng e

xam

and

nec

essa

ry s

tabi

lizat

ion

–Fa

ilure

to m

eet t

hese

requ

irem

ents

con

stitu

tes

a vi

olat

ion

of E

MTA

LA»

But

then

they

wen

t on

to s

ay...

.

Am

bula

nce

Offl

oad

Del

ay–

Not

nec

essa

rily

a vi

olat

ion

if th

e ho

spita

l doe

s no

t im

med

iate

ly a

ssum

e ca

re o

f pat

ient

–It

may

be

reas

onab

le fo

r hos

pita

l to

ask

EM

S

prov

ider

s to

sta

y w

ith p

atie

nt u

ntil

such

tim

e as

the

ED

st

aff i

s ab

le to

car

e fo

r pat

ient

. S

uch

an in

stan

ce w

ould

oc

cur i

n tim

e of

man

agin

g m

ultip

le tr

aum

a pa

tient

s or

ot

her c

ritic

ally

ill p

atie

nts.

–H

owev

er, t

he h

ospi

tal M

US

T tri

age

the

patie

nts

cond

ition

imm

edia

tely

upo

n ar

rival

to e

nsur

e th

at a

n em

erge

nt in

terv

entio

n is

not

requ

ired

and

the

EM

S

prov

ider

s ca

n ca

re fo

r the

pat

ient

.

Am

bula

nce

Offl

oad

Del

ay

Coo

ney

DR

, et a

l. A

mbu

lanc

e di

vers

ion

and

emer

genc

y de

partm

ent o

ffloa

d de

lay:

reso

urce

doc

umen

t for

the

Nat

iona

l A

ssoc

iatio

n of

EM

S P

hysi

cian

s po

sitio

n st

atem

ent.

Pre

hosp

Em

erg

Car

e. 2

011

Oct

-Dec

;15(

4):5

55-6

1

–R

evie

wed

lite

ratu

re a

nd n

oted

lack

of d

ata

supp

ortin

g sp

ecifi

c ne

ed to

use

or l

ose

conc

ept o

f div

ersi

on–

Not

ed p

ossi

ble

sign

ifica

nt p

atie

nt c

are

impa

ct o

f offl

oad

dela

y–

Sup

porte

d N

AE

MS

P po

sitio

n–

Rec

omm

ende

d A

OD

be

track

ed b

y E

M a

nd E

MS

adm

inis

trato

rs

Am

bula

nce

Offl

oad

Del

ayC

oone

y D

R, e

t al.

Eva

luat

ion

of a

mbu

lanc

e of

fload

del

ay a

t a u

nive

rsity

ho

spita

l em

erge

ncy

depa

rtmen

t. In

tJ E

mer

gM

ed. 2

013

May

10

;6(1

):15

–O

ffloa

d de

lay

was

ass

ocia

ted

with

NE

DO

CS

sco

re

Am

bula

nce

Offl

oad

Del

ay

SU

NY

Ups

tate

unp

ublis

hed

data

•A

12-m

onth

con

veni

ence

sam

ple

of 1

892

•A

OD

rang

ed fr

om 0

min

. to

122

min

. with

a m

ean

of 1

4.01

min

. (S

D±1

4.2)

. •

Mea

n A

OD

for p

edia

tric

patie

nts

(10.

77 m

in.)

was

less

than

adu

lts

(14.

92 m

in.)

(p<0

.001

). •

NE

DO

CS

gro

ups

(p<0

.001

): –

1=9.

18 m

in.

–2=

12.7

2 m

in.

–3=

18.1

4 m

in.

–4=

20.6

2 m

in.

•E

SI w

as e

valu

ated

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leve

l 3 w

as th

e lo

nges

t mea

n

Am

bula

nce

Offl

oad

Del

ay

Hos

pita

ls a

nd E

MS

Sys

tem

, Lee

Cou

nty,

Flo

rida

–S

ix S

igm

a P

roje

ct 2

007

•Id

entif

ied

offlo

ad d

elay

as

a pr

oble

m•

Est

imat

ed c

ost o

f AO

D a

t $35

0,00

0/yr

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oal o

f 15

min

90%

of t

he ti

me

and

30 m

in 1

00%

•Th

ree

inte

rven

tions

–Tr

ansp

orta

tion

Des

tinat

ion

Coo

rdin

ator

con

tact

prio

r to

trans

port

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MS

yste

ms

upda

te b

y ho

spita

ls–

ED

nur

se fi

ndin

g be

d sp

ace

prio

r to

EM

S a

rriv

al

Am

bula

nce

Offl

oad

Del

ay

Hos

pita

ls a

nd E

MS

Sys

tem

, Lee

Cou

nty,

Fl

orid

a –

Six

Sig

ma

Pro

ject

200

7

13.2

1883

657

44.2

05101520253035404550

Feb-

07Fe

b-M

ar 2

006

Time In Minutes

Mon

th

Aver

age

Offl

oad

Tim

es In

Sea

son

2006

& 2

007

Am

bula

nce

Offl

oad

Del

ayH

ospi

tals

and

EM

S S

yste

m, L

ee C

ount

y, F

lorid

a –

Six

S

igm

a P

roje

ct 2

007

•R

esul

ts:

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ilot p

rove

d a

stat

istic

ally

sig

nific

ant r

educ

tion

in th

e av

erag

e of

f-lo

ad ti

mes

for L

ee M

emor

ial H

ospi

tal

–A

decr

ease

in th

e va

riatio

n (r

ange

)

AD

/AO

D a

nd C

row

ding

Han

del D

A, a

t al.

Varia

tions

in c

row

ding

and

am

bula

nce

dive

rsio

n in

ni

ne e

mer

genc

y de

partm

ents

. Aca

dE

mer

gM

ed. 2

011

Sep

;18(

9):9

41-6

AD

/AO

D a

nd C

row

ding

McL

eod

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t al.

Mat

chin

g ca

paci

ty to

dem

and:

a re

gion

al d

ashb

oard

re

duce

s am

bula

nce

avoi

danc

e an

d im

prov

es a

cces

sibi

lity

of re

ceiv

ing

hosp

itals

. Aca

dE

mer

gM

ed. 2

010

Dec

;17(

12):1

383-

9

AD

/AO

D a

nd C

row

ding

McL

eod

B, e

t al.

Mat

chin

g ca

paci

ty to

dem

and:

a re

gion

al d

ashb

oard

redu

ces

ambu

lanc

e av

oida

nce

and

impr

oves

acc

essi

bilit

y of

rece

ivin

g ho

spita

ls. A

cad

Em

erg

Med

. 201

0 D

ec;1

7(12

):138

3-9

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/AO

D a

nd C

row

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McL

eod

B, e

t al.

Mat

chin

g ca

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ty to

dem

and:

a re

gion

al d

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oard

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ces

ambu

lanc

e av

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nce

and

impr

oves

acc

essi

bilit

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ivin

g ho

spita

ls. A

cad

Em

erg

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. 201

0 D

ec;1

7(12

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3-9

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D a

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urke

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l. T

he e

ffect

of

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lanc

e di

vers

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on

emer

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ent l

engt

h of

sta

y an

d am

bula

nce

turn

arou

nd

time.

Ann

Em

erg

Med

. 201

3 M

ar;6

1(3)

:303

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.e1 .

–B

efor

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d af

ter d

iver

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ban

•A

mbu

lanc

e Tu

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chan

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ot s

ame

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ffloa

d

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OS

for p

atie

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ange

d as

wel

l

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Big

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ture

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Ds

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conc

erne

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row

ding

is

unsa

fe

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MS

sys

tem

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crit

ical

par

t of t

he s

afet

y ne

t ne

ed to

get

uni

ts b

ack

in s

ervi

ce a

s qu

ickl

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pos

sibl

e

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ropo

ffde

lay

the

criti

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acto

r in

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ng u

nits

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k in

se

rvic

e (re

st o

f Tur

n-A

roun

d-Ti

me

can

be c

ontro

lled)

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MS

pro

vide

rs s

houl

d no

t be

held

up

at h

ospi

tals

car

ing

for

patie

nts

•E

MTA

LA v

iola

tion

for h

ospi

tal t

o no

t acc

ept p

atie

nt

Pos

ition

Sta

tem

ent

Pos

ition

Sta

tem

ent:

Am

bula

nce

Div

ersi

on a

nd E

mer

genc

y D

epar

tmen

t Offl

oad

Del

ay

The

Nat

iona

l Ass

ocia

tion

of E

MS

Phy

sici

ans®

bel

ieve

s th

at:

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MS

sys

tem

s, a

nd th

eir p

atie

nts,

are

sig

nific

antly

impa

cted

by

emer

genc

y de

partm

ent (

ED

) cro

wdi

ng.

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espi

te p

revi

ous

stat

emen

ts, n

o da

ta s

uppo

rt th

at th

ere

is d

irect

pat

ient

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m

from

org

aniz

ed s

yste

ms

of a

mbu

lanc

e di

vers

ion

in a

mod

ern

EM

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yste

m. I

n ad

ditio

n, a

mbu

lanc

e di

vers

ion

has

not b

een

show

n to

impr

ove

ED

pat

ient

th

roug

hput

.•

Pro

toco

ls d

esig

ned

to li

mit

dive

rsio

n m

ay le

ad to

an

incr

ease

in E

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ffloa

d de

lay,

the

inte

rval

bet

wee

n ho

spita

l arri

val a

nd tr

ansf

er o

f the

pat

ient

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ambu

lanc

e st

retc

her a

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ssum

ptio

n of

car

e by

ED

sta

ff.

•E

D a

nd h

ospi

tal l

eade

rshi

p sh

ould

wor

k w

ith th

e E

MS

age

ncie

s an

d sy

stem

le

ader

ship

to li

mit

the

time

that

am

bula

nces

are

out

of s

ervi

ce d

ue to

di

vers

ion

or o

ffloa

d de

lay.

•

Ove

rall

impr

ovem

ent o

f ED

cro

wdi

ng b

y ho

spita

l thr

ough

put i

nitia

tives

will

likel

y de

crea

se b

oth

ED

offl

oad

dela

y an

d ho

urs

on d

iver

sion

.•

Sur

veilla

nce

and

com

mun

icat

ion

of E

D o

ffloa

d de

lay,

div

ersi

on s

tatu

s an

d ot

her f

acto

rs re

late

d to

ED

cro

wdi

ng s

houl

d be

em

ploy

ed th

roug

hout

the

EM

S s

yste

m.

•R

egul

ar re

view

of b

ench

mar

ks s

houl

d be

use

d to

gui

de lo

cal s

yste

m a

nd

inst

itutio

nal i

nitia

tives

.•

Reg

ulat

ors,

acc

redi

ting

bodi

es, a

nd q

ualit

y im

prov

emen

t org

aniz

atio

ns

shou

ld tr

ack

ED

cro

wdi

ng b

ench

mar

ks.

AO

D: a

Qua

lity

Mar

ker

•A

mbu

lanc

e of

fload

del

ay re

pres

ents

a

dela

y in

pat

ient

car

e•

In s

ome

stat

es E

MS

pro

vide

rs a

re

not a

llow

ed to

car

e fo

r pat

ient

s in

side

the

hosp

ital

•P

atie

nt s

atis

fact

ion

and

priv

acy

at

risk

durin

g A

OD

•E

MTA

LA in

opp

ositi

on to

AO

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AO

D w

ill b

e fo

rwar

ded

to J

CA

HO

an

d D

NV

AO

D: a

Qua

lity

Mar

ker

•W

here

to s

et th

e ba

r?–

Est

ablis

hing

a b

asel

ine

–E

valu

atin

g th

e ris

k–

Con

side

ring

a go

al•

Avai

labl

e da

ta s

ugge

sts

–<1

5 m

inut

e id

eal (

90%

of t

he ti

me)

= h

igh

qual

ity–

>60

min

ute

= re

porta

ble

inci

dent

Futu

re S

tudy

•Id

entif

y ris

k fa

ctor

s re

late

d to

incr

ease

d A

OD

–N

ED

OC

S s

corin

g (E

D C

row

ding

)–

???

Oth

er fa

ctor

s•

Pat

ient

spe

cific

•S

taffi

ng s

peci

fic•

Faci

lity

spec

ific

Futu

re S

tudy

•Q

uant

ify e

ffect

s on

EM

S S

yste

m–

UH

U–

Res

pons

e tim

es–

Pro

vide

r sat

isfa

ctio

n / a

ttriti

on

Futu

re S

tudy

•E

valu

ate

the

cost

of A

OD

–E

MS

Sys

tem

–U

HU

dec

line

–E

D/h

ospi

tal –

cost

of i

nter

vent

ions

–P

atie

nts

•m

orbi

dity

/mor

talit

y•

patie

nt s

atis

fact

ion

Futu

re S

trate

gies

•Id

entif

y in

terv

entio

ns–

Offl

oad

nurs

e/pr

ovid

er (C

anad

a)–

Pre

hosp

itald

ashb

oard

of s

yste

m h

ospi

tals

–E

D b

ed a

ssig

nmen

t pio

rto

arriv

al–

NE

DO

CS

sco

re tr

igge

rs th

roug

hput

resp

onse

–A

mbu

lanc

e D

iver

sion

•B

ased

on

NE

DO

CS

sco

re o

r AO

D•

Lim

itatio

ns–

Tim

e lim

its?

–Ty

pe o

f pat

ient

s?–

Bui

lt-in

reas

sess

men

t trig

gers

AD

off

–H

ospi

tal t

hrou

ghpu

t ini

tiativ

es•

Gen

eral

impr

ovem

ent i

n pe

rform

ance

Than

ks…

Key

Poi

nts

•A

mbu

lanc

e di

vers

ion

may

be

a us

eful

tool

if u

tiliz

ed

judi

cial

ly a

nd in

con

text

with

hos

pita

l thr

ough

put

adva

ncem

ent

•A

mbu

lanc

e of

fload

del

ay is

an

evol

ving

mar

ker o

f ED

pa

tient

car

e qu

ality

•A

OD

and

AD

are

inte

r-rel

ated

and

hos

pita

l thr

ough

put i

s a

key

caus

ativ

e fa

ctor

•A

OD

repr

esen

ts a

real

and

pot

entia

l del

ay in

pat

ient

car

e–

In th

e E

D–

In th

e pr

ehos

pita

lenv

ironm

ent

•Fu

rther

stu

dy is

nee

ded

QU

ESTI

ON

S?EM

AIL

IN

FO@

UR

GEN

TMAT

TER

S.O

RG