Emergency Medical Services
The effect of emergency department crowding on paramedic ambulance availability☆

https://doi.org/10.1016/S0196-0644(03)00747-9Get rights and content

Abstract

Study objective

We determine the effect of emergency department (ED) crowding on paramedic ambulance availability.

Methods

This was a prospective longitudinal study from April 2001 through March 2002 in Los Angeles, CA. All incidents in which a Los Angeles Fire Department ambulance was out of service for more than 15 minutes while waiting to transfer a patient because of the lack of open ED beds were captured and analyzed. Data included the total time each ambulance was out of service and the hospital where paramedics were waiting for an open gurney. Analysis was performed to determine weekly and seasonal variations and preponderance at various hospitals.

Results

There were a total of 21,240 incidents in which ambulances were out of service while waiting to transfer their patients to an open ED gurney, which accounted for 1 of every 8 transports. Of these, 8.4% were in excess of 1 hour. The median waiting time per incident was 27 minutes, with an interquartile range of 20 to 40. There was a statistically significant difference in the monthly number of out-of-service incidents during the study (P<.0001), with the highest levels during the winter (January through March).

Conclusion

ED crowding has resulted in delays for paramedics waiting to transfer patients. This decrease in ambulance availability may have a significant effect on emergency medical services systems' abilities to provide timely response.

Introduction

Emergency department (ED) crowding and diminishing inpatient capacity have received a great deal of attention in the medical literature and the lay press as a nationwide problem.1, 2, 3, 4, 5 When paramedics transport a patient to a crowded ED, they are often confronted with the unavailability of an empty ED gurney. The paramedics must wait in the ED with their patient on the ambulance stretcher until an ED gurney becomes available. These waits can vary from only a few minutes to several hours. During this time, the paramedic ambulance is out of service to respond to additional calls. When multiple ambulances are out of service, there is a potentially significant negative effect on the ability to provide emergency medical services (EMS) to the community.

Capsule Summary

What is already known on this topic

Although anecdotally emergency department (ED) crowding is believed to affect ambulance usage and ability, this has not been well documented in large systems.

What question this study addressed

How often paramedic ambulances in Los Angeles were out of service for 15 minutes or more while waiting for an open gurney for an emergency medical services (EMS) patient who had arrived in the ED.

What this study adds to our knowledge

In 1 year, there were 21,240 such delays; 12.5% of all transports. The frequency of delay varied markedly by hospital. The median delay was 27 minutes, and 8% of the delays were 1 hour or longer.

How this might change clinical practice

In this metropolitan area, delayed transfer of EMS patients to ED care due to crowding was frequent and took a sizable proportion of EMS units out of service at any given time.

This study describes the effect of ED crowding on paramedic ambulance availability. Causes of the problem and strategies to mitigate this issue are discussed.

Section snippets

Materials and methods

The Los Angeles Fire Department provides EMS for the 3.8 million residents of the nation's second-largest city.6 It has 67 advanced life support ambulances and 31 basic life support ambulances that responded to approximately 270,000 EMS calls in 2002, of which 172,981 (64%) resulted in patient transport to area hospitals. Of these transports, 131,000 (75%) are transported by advanced life support ambulances (staffed by 2 firefighter/paramedics). The remainder of patients are transported by

Results

During the 12-month study period, there were a total of 21,240 incidents in which ambulances were out of service while waiting in excess of 15 minutes to transfer their patients to an open ED gurney. During the same period, there were 172,981 patients transported to area hospitals by Los Angeles Fire Department ambulances. The monthly number of out-of-service incidents per 100 transports ranged from a low of 9.7 in October 2001 to a high of 17.6 in February 2002 (Figure 1), which translates to

Discussion

A recent study from California EDs found that patients waited an average of almost 1 hour before being treated by a physician.9 Our data show that similar delays now exist for paramedics to transfer care of their patients, having to wait for an open ED gurney.

Although hospitals accounting for the longest periods of out-of-service time were concentrated in some of the most densely populated areas of the city, transfer of care delays occurred across all areas of Los Angeles, which demonstrates

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Author contributions: ME designed the study, collected the data, and wrote the bulk of the manuscript. LSC performed the statistical analyses and wrote the pertinent sections of the Materials and Methods section and the Results section. ME takes responsibility for the paper as a whole.

The authors report this study did not receive any outside funding or support.

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