The Financial Impact of Ambulance Diversions and Patient Elopements

Objectives
Admission process delays and other throughput inefficiencies are a leading cause of emergency department (ED) overcrowding, ambulance diversion, and patient elopements. Hospital capacity constraints reduce the number of treatment beds available to provide revenue-generating patient services. The objective of this study was to develop a practical method for quantifying the revenues that are potentially lost as a result of patient elopements and ambulance diversion.
Methods
Historical data from 62,588 patient visits to the ED of a 450-bed nonprofit community teaching hospital in central Pennsylvania between July 2004 and June 2005 were used to estimate the value of potential patient visits foregone as a result of ambulance diversion and patients leaving the ED without treatment.
Results
The study hospital may have lost $3,881,506 in net revenue as a result of ambulance diversions and patient elopements from the ED during a 12-month period.
Conclusions
Significant revenue may be foregone as a result of throughput delays that prevent the ED from utilizing its existing bed capacity for additional patient visits.     

Ambulance Diversion and Emergency Department Offload Delay: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

The emergency medical services (EMS) system is a component of a larger health care safety net and a key component of an integrated emergency health care system. EMS systems, and their patients, are significantly impacted by emergency department (ED) crowding. While protocols designed to limit ambulance diversion may be effective at limiting time on divert status, without correcting overall hospital throughput these protocols may have a negative effect on ED crowding and the EMS system. Ambulance offload delay, the time it takes to transfer a patient to an ED stretcher and for the ED staff to assume the responsibility of the care of the patient, may have more impact on ambulance turnaround time than ambulance diversion. EMS administrators and medical directors should work with hospital administrators, ED staff, and ED administrators to improve the overall efficiency of the system, focusing on the time it takes to get ambulances back into service, and therefore must monitor and address both ambulance diversions and ambulance offload delay. This paper is the resource document for the National Association of EMS Physicians position statement on ambulance diversion and ED offload time.     

The effects of minimizing ambulance diversion hours on emergency departments

This study explores the effects of minimizing Emergency Department (ED) bypass on individual hospital's ED census, ambulance transports, and admissions. Five hospitals in a geographic area collected data over 3 weeks. The first and third week represented controls, whereas the second week hospitals minimized their usage of bypass. Data collected included hours on bypass, ED census, ambulance runs, hospital admissions, and inter-facility transfers. The total number of hours on bypass for all hospitals for pre-trial, trial, and post-trial weeks were 112.2, 0.3, and 47, respectively. There were several statistical shifts in the proportion of ambulance runs and admissions seen by individual hospitals. Clinically, these shifts in patients were minor and within ED capacity. Hospitals in a given geographic area may successfully reduce the number of hours on bypass with possible minor shifting in the number of ambulance runs and admissions that are within ED capacity.     

Prehospital use of activated charcoal: A pilot study

Activated charcoal (AC) is most effective when administered soon after the ingestion of certain substances. Delays are recognized to occur at times in the administration of AC after arrival of poisoned patients in the emergency department (ED). In addition, it has been recognized that these delays may be avoided if AC administration is begun in selected patients by paramedics while en route to the ED. We present a pilot study evaluating the administration of AC to poisoned patients in the ambulance prior to arrival in the ED. We performed a retrospective review of Emergency Medical System (EMS) run sheets and ED records of poisoned patients during a 6-month period from two area hospitals. Cases were identified that met criteria for the prehospital administration of AC. Cases were divided into two groups: those who received prehospital AC, and those who did not. Groups were compared for ambulance transport time, time from first paramedic contact to AC administration, and whether AC was tolerated by the patient. A total of 14 patients received prehospital AC (group 1). This group was compared to 22 cases that would have qualified under County protocol to receive prehospital AC, but for whatever reason did not (group 2). Group 2 patients all received AC after arriving in the ED. Average ambulance transport times did not statistically differ among groups. The average time from first encounter with paramedics to administration of AC was 5.0 minutes when AC administration was given in the ambulance as compared to 51.4 minutes when delayed until arrival in the ED. Tolerance was similar among the groups. The time to initiate AC administration may be significantly shortened when begun by prehospital personnel. All EMS should consider including AC in protocols addressing the prehospital management of certain poisoned patients.     

Quality of the handover of patient care: a comparison of pre-Hospital and Emergency Department notes

AimThe aim of this audit was to evaluate the accuracy of patient information transfer from pre-hospital reports to Emergency Department (ED) documentation.MethodsThe records of 100 patients seen in the ED resuscitation room of a UK hospital were compared using a pro-forma designed by the research team. Sections of the ambulance service patient report form and the ED documentation were compared for differences. The history of the event leading to the 999 call, the patient’s previous medical history, prescribed medications, allergies and any treatment carried out by the ambulance crew were analysed.ResultsOf the 100 records, 26 had at least one instance where information recorded by the ambulance crew was either omitted or altered during transfer. These fell into various categories including the previous medical history of the patient, the timings of the event bringing them to hospital, frequency of the event occurring, allergies and medications.ConclusionThis audit quantifies the number of patient encounters where written information changes or is lost when care is passed from pre-hospital to hospital staff in the resuscitation room. We have not investigated other parts of the ED or the verbal transfer of information. Further work investigating the causes of these changes in information, any impact on patient care and whether this occurs in other parts of an ED is suggested.     

Testing emergency medical personnel response to patients with suspected infectious disease

OBJECTIVES: In the United States (US), hospitals are required to have disaster plans and stage drills to test these plans in order to satisfy the Joint Accreditation Commission of Healthcare Organizations. The focus of this drill was to test if emergency response personnel, both prehospital and hospital, would identify a patient with a potentially communicable infectious disease, and activate their respective disaster plan. METHODS: Twelve urban/suburban emergency departments (ED) received patients via car and ambulance. Patients were moulaged to imitate a smallpox infection. Observers with checklists recorded what happened. The drill's endpoints were: (1) predetermined end time; (2) identification of the patient and hospital "lock-down"; and (3) breach of drill protocol. RESULTS: None of the ambulance personnel correctly identified their patients. Of the total 13 mock patients assessed in the ED, seven (54%) were identified by the ED staff as possibly being infected with a highly contagious agent and, in turn, the hospital's biological agent protocol was initiated. Of the correctly identified patients, five (71%) were placed in isolation, and the remaining two (29%), although not isolated, were identified prior to their ED discharge and the appropriate protocol was activated. The six remaining mock patients (46%) were incorrectly diagnosed and discharged. Of the hospitals that had correctly identified their "infected" patients, only two (29%) followed their notification protocol and contacted the local health department. CONCLUSION: This drill was successful in identifying this area's shortcomings, highlighted positive reactions, and raised some interesting questions about the ability to detect a patient with a possibly highly contagious disease.     

Patient trust and patient safety for low-priority patients: A randomized controlled trial pilot study in the prehospital chain of care

BackgroundPatients who call for an ambulance but only have primary care needs do not always get appropriate care. The starting point in this study is that such patients should be assigned to as basic of care as possible, while maintaining high levels of patient trust and patient safety.AimTo evaluate patient trust and patient safety among low-priority ambulance patients referred to care at either the Community Health Centre (CHC) or the Emergency Department (ED).MethodsThis randomized controlled trial pilot study compared the level of patient trust and patient safety among low-priority ambulance patients who were randomized into two groups: CHC (n = 105) or ED (n = 83).ResultsThere was a high level of trust in the care received, regardless of whether the patient received care at CHC or ED. Overall 31% fulfilled one or more of the given criteria for potentially jeopardizing patient safety.ConclusionPatient selection for the trial indicated a potential limit in patient safety. There was a high level of trust in the care received regardless of whether the patient received care. The accuracy of patient selection for the new care model needs to be further improved with the intention to enhance patient safety even further.     

Outcomes for Patients Who Contact the Emergency Ambulance Service and Are Not Transported to the Emergency Department: A Data Linkage Study

Objectives: Emergency ambulance services do not transport all patients to hospital. International literature reports non-transport rates ranging from 3.7–93.7%. In 2017, 38% of the 11 million calls received by ambulance services in England were attended by ambulance but not transported to an Emergency Department (ED). A further 10% received clinical advice over the telephone. Little is known about what happens to patients following a non-transport decision. We aimed to investigate what happens to patients following an emergency ambulance telephone call that resulted in a non-transport decision, using a linked routine data-set. Methods: Six-months individual patient level data from one ambulance service in England, linked with Hospital Episode Statistics and national mortality data, were used to identify subsequent health events (ambulance re-contact, ED attendance, hospital admission, death) within 3 days (primary analysis) and 7 days (secondary analysis) of an ambulance call ending in non-transport to hospital. Non-clinical staff used a priority dispatch system e.g. Medical Priority Dispatch System to prioritize calls for ambulance dispatch. Non-transport to ED was determined by ambulance crew members at scene or clinicians at the emergency operating center when an ambulance was not dispatched (telephone advice). Results: The data linkage rate was 85% for patients who were discharged at scene (43,108/50,894). After removal of deaths associated with end of life care (N?=?312), 9% (3,861/42,796) re-contacted the ambulance service, 12.6% (5,412/42,796) attended ED, 6.3% (2,694/42,796) were admitted to hospital, and 0.3% (129/42,796) died within 3 days of the call. Rates were higher for events occurring within 7 days. For example, 12% re-contacted the ambulance service, 16.1% attended ED, 9.3% were admitted to hospital, and 0.5% died. The linkage rate for telephone advice calls was low because ambulance services record less information about these patients (24% 2,514/10,634). A sensitivity analysis identified a range of subsequent event rates: 2.5–10.5% of patients were admitted to hospital and 0.06–0.24% of patient died within 3 days of the call. Conclusions: Most non-transported patients did not have subsequent health events. Deaths after non-transport are an infrequent event that could be selected for more detailed review of individual cases, to facilitate learning and improvement.     

Can paramedics safely decide which patients do not need ambulance transport or emergency department care?

Objectives. To determine whether paramedics can safely decide which patients do not require ambulance transport or emergency department (ED) care. Methods. This was a prospective survey and linked medical record review. Paramedics completed a brief questionnaire for each patient they transported to a university hospital ED during a one-month period. A faculty emergency physician masked to the survey results reviewed hospital records. Ambulance transport was defined as “needed” if the charted differential diagnosis included diagnoses that could necessitate treatment in an ambulance. ED care was defined as “needed” if treatment of these diagnoses would necessitate resources not available in local urgent care centers (UCCs). Results. Two hundred thirty-six patients were transported; 183 corresponding ED charts were found. Agreement between paramedics and need determined by ED chart review was low for both transport method [kappa (κ) = 0.47, 95% confidence interval (95% CI) = 0.34-0.60] and ED care (κ = 0.32, 95% CI = 0.17-0.46). Paramedics recommended alternative transport for 97 patients, 23 of whom needed ambulance transport. Paramedics recommended non-ED care for 71 patients, 32 of whom needed ED care. Conclusion. Paramedics cannot safely determine which patients do not need ambulance transport or ED care. PREHOSPITAL EMERGENCY CARE 2002;6:383-386     

The Effect of Emergency Department Expansion on Emergency Department Overcrowding

Objectives: To examine the effects of emergency department (ED) expansion on ambulance diversion at an urban, academic Level 1 trauma center. Methods: This was a pre‐post study performed using administrative data from the ED and hospital electronic information systems. On April 19, 2005, the adult ED expanded from 28 to 53 licensed beds. Data from a five‐month pre‐expansion period (November 1, 2004, to March 1, 2005) and a five‐month postexpansion period (June 1, 2005, to October 31, 2005) were included for this analysis. ED and waiting room statistics as well as diversion status were obtained. Total ED length of stay (LOS) was defined as the time from patient registration to the time leaving the ED. Admission hold LOS was defined as the time from the inpatient bed request to the time leaving the ED for admitted patients. Mean differences (95% confidence interval [CI]) in total time spent on ambulance diversion per month, diversion episodes per month, and duration per diversion episode were calculated. An accelerated failure time model was performed to test if ED expansion was associated with a reduction in ambulance diversion while adjusting for potential confounders. Results: From pre‐expansion to postexpansion, daily patient volume increased but ED occupancy decreased. There was no significant change in the time spent on ambulance diversion per month (mean difference, 10.9 hours; 95% CI =?74.0 to 95.8), ambulance diversion episodes per month (two episodes per month; 95% CI =?4.2 to 8.2), and duration of ambulance diversion per episode (0.3 hours; 95% CI =?4.0 to 3.5). Mean (±SD) total LOS increased from 4.6 (±1.9) to 5.6 (±2.3) hours, and mean (±SD) admission hold LOS also increased from 3.0 (±0.2) to 4.1 (±0.2) hours. The proportion of patients who left without being seen was 3.5% and 2.7% (p = 0.06) in the pre‐expansion and postexpansion periods, respectively. In the accelerated failure time model, ED expansion did not affect the time to the next ambulance diversion episode. Conclusions: An increase in ED bed capacity did not affect ambulance diversion. Instead, total and admission hold LOS increased. As a result, ED expansion appears to be an insufficient solution to improve diversion without addressing other bottlenecks in the hospital.     

Demand for Emergency Services Trends in New South Wales Years 2010–2014 (DESTINY): Age and Clinical Factors Associated with Ambulance Transportation to Emergency Departments

Objectives: The study aimed to analyze ambulance transportations to Emergency Departments (EDs) in New South Wales (NSW) and to identify temporal changes in demographics, acuity, and clinical diagnoses. Methods: This was a retrospective analysis of a population based registry of ED presentations in New South Wales. The NSW Emergency Department data collection (EDCC) collects patient level data on presentations to designated EDs across NSW. Patients that presented to EDs by ambulance between January 2010 and December 2014 were included. Patients dead on arrival, transferred from another hospital, or planned ED presentations were excluded. Results: A total of 10.8 million ED attendances were identified of which 2.6 million (23%) were transported to ED by ambulance. The crude rate of ambulance transportations to EDs across all ages increased by 3.0% per annum over the five years with the highest rate observed in those 85 years and over (620.5 presentations per 1,000 population). There was an increase in the proportion of category 1 and 2 (life-threatening or potentially life-threatening) cases from 18.1% to 24.0%. Conclusion: Demand for ambulance services appears to be driven by older patients presenting with higher acuity problems. Alternative models of acute care for elderly patients need to be planned and implemented to address these changes.     

Access block causes emergency department overcrowding and ambulance diversion in Perth, Western Australia

Objective: Access block refers to the situation where patients in the emergency department (ED) requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame. We systematically evaluated the relationship between access block, ED overcrowding, ambulance diversion, and ED activity.

Methods: This was a retrospective analysis of data from the Emergency Department Information System for the three major central metropolitan EDs in Perth, Western Australia, for the calendar years 2001–2. Bivariate analyses were performed in order to study the relationship between a range of emergency department workload variables, including access block (>8 hour total ED stay for admitted patients), ambulance diversion, ED overcrowding, and ED waiting times.

Results: We studied 259 580 ED attendances. Total diversion hours increased 74% from 3.39 hours/day in 2001 to 5.90 hours/day in 2002. ED overcrowding (r = 0.96; 95% confidence interval (CI) 0.91 to 0.98), ambulance diversion (r = 0.75; 95% CI 0.49 to 0.88), and ED waiting times for care (r = 0.83; 95% CI 0.65 to 0.93) were strongly correlated with high levels of ED occupancy by access blocked patients. Total attendances, admissions, discharges, and low acuity patient attendances were not associated with ambulance diversion.

Conclusion: Reducing access block should be the highest priority in allocating resources to reduce ED overcrowding. This would result in reduced overcrowding, reduced ambulance diversion, and improved ED waiting times. Improving hospital inpatient flow, which would directly reduce access block, is most likely to achieve this.

     

Thrombolysis Candidates for the Treatment of Stroke at an Emergency Department in Japan

OBJECTIVES: To study the proportion and characteristics of potential candidates for the intravenous administration of tissue plasminogen activator (IV-tPA) among patients with cerebral infarction in a Japanese emergency department (ED). METHODS: A retrospective observational study was performed using patients who had been transported by ambulance between August 1988 and April 2000 to an urban ED of a university hospital located in the Tokyo metropolitan area. Potential candidates for IV-tPA were identified using the criteria of the National Institute of Neurological Disorders and Stroke (NINDS) study. RESULTS: Of all 30,064 patients transported by ambulance, 526 were diagnosed as having cerebral infarction. Among them, 190 patients arrived at the ED within two hours of symptom onset (early ED arrivers). In comparison of their demographics with late ED arrivers (n = 319), atrial fibrillation, male gender, and consciousness disturbance were related with early ED arrivers, while aging and diabetes were related with late ED arrivers. As to the stroke subtype, patients with an embolic infarction accounted for 76.8% among early ED arrivers. Application of exclusion criteria identified 114 patients, who were suitable for the thrombolysis treatment, indicating that the proportion of potential IV-tPA candidates was 21.7% among all cerebral infarction patients and 0.38% among all ED patients. CONCLUSIONS: The number of potential IV-tPA candidates among patients transported to the ED by ambulance in Japan was substantial, where the proportion of embolic infarction cases was extremely high.     

Reasons Why Patients Choose an Ambulance and Willingness to Consider Alternatives

Objectives: To test a hypothesis that patients would accept alternatives to transport to an emergency department (ED) by ambulance and to evaluate factors related to patient willingness to consider alternatives. Concerns about resource utilization have prompted emergency medical services (EMS) systems to explore alternatives to ambulance transport to an ED, but studies have evaluated the safety of alternatives, not patient preferences.
Methods: Trained research assistants surveyed patients transported by ambulance to a university ED. Interfacility transfers, trauma patients, and critically ill patients were excluded. The primary outcome was willingness to accept one of several presented alternatives to ambulance transport to the ED for that visit. Demographic and clinical factors were evaluated for association with willingness to consider alternatives. Relative risks (RR) and 95% confidence intervals (95% CI) were determined by using Mantel-Haenszel stratified methods.
Results: Three hundred fifteen subjects completed the survey. Two hundred forty-seven (78.4%) were willing to consider at least one alternative. One hundred ninety-four (61.6%) were willing to consider transportation by car, and 177 (56.2%) were willing to consider transportation by taxi. Factors associated with willingness to consider alternatives included the following: age 18–65 years (RR, 1.25; 95% CI = 1.03 to 1.49), being unemployed (RR, 1.08; 95% CI = 1.08 to 1.33), use of the ED for routine care (RR, 1.25; 95% CI = 1.17 to 1.35), and not being admitted to the hospital (RR, 1.19; 95% CI = 1.04 to 1.40). Race, gender, health insurance status, and EMS interventions en route were not associated with willingness to consider transportation alternatives.
Conclusions: Many patients transported by ambulance to an ED would have considered an alternative, if one were offered.     

The Effect of Physician Triage on Emergency Department Length of Stay

Background: Emergency Department (ED) overcrowding is a serious public health issue, but few solutions exist. Objectives: We sought to determine the impact of physician triage on ED length of stay for discharged and admitted patients, left-without-being-seen (LWBS) rates, and ambulance diversion. Methods: This was a pre-post study performed using retrospective data at an urban, academic tertiary care, Level I trauma center. On July 11, 2005, physician triage was initiated from 1:00 p.m. to 9:00 p.m., 7 days a week. An additional physician was placed in triage so that the ED diagnostic evaluation and treatment could be started in waiting room patients. Using the hospital information system, we obtained individual patient data, ED and waiting room statistics, and diversion status data from a 9-week pre-physician triage (May 11, 2005 to July 10, 2005) and a 9-week physician triage (July 11, 2005 to September 9, 2005) period. Results: We observed that overall ED length of stay decreased by 11 min, but this decrease was entirely attributed to non-admitted patients. No difference in ED length of stay was observed in admitted patients. LWBS rates decreased from 4.5% to 2.5%. Total time spent on ambulance diversion decreased from 5.6 days per month to 3.2 days per month. Conclusion: Physician triage was associated with a decrease in LWBS rates, and time spent on ambulance diversion. However, its effect on ED LOS was modest in non-admitted ED patients and negligible in admitted patients.     

The pattern of ambulance arrivals in the emergency department of an acute care hospital in Singapore

Methods—All (13 697) ambulance arrivals in 1996 to the ED of Tan Tock Seng Hospital were studied and where relevant compared with the walk in and total arrivals of the same year. The following data were obtained from computer records: (a) patients'' demographic data; (b) number of ambulance arrivals by hour; (c) the classification of the ambulance arrivals by emergency or non-emergency, trauma or non-trauma; (d) cause of injury for trauma cases; (e) discharge status. Results—The ambulance arrivals in 1996 constituted 12.4% of the patient load for this department. There was no difference in modes of patient arrival to the ED by sex and ethnic group. However, there was significant evidence to show that more patients age > 60 came by ambulance than those age < 12 (p << 0.01). Some 98.5% of the ambulance arrivals were emergencies; 40.7% of the ambulance arrivals were attributable to trauma versus 27.3% of the walk in arrivals. The majority of the trauma cases brought in by ambulance were because of road traffic accidents (15.3%) or home accidents (7.4%). The peak in ambulance arrivals was between 2100–2300 hours compared with 1000–1200 for the walk in arrivals. More than half of the ambulance arrivals were admitted. Conclusion—In planning resource allocation and in the development of contingency plans, the resource use of ambulance patients and the pattern of their arrivals should be taken into account.     

Ambulance use by high-acuity patients in a pediatric ED

The objective of this study was to analyze ambulance usage by highest acuity patients as compared with all patients in a suburban pediatric hospital ED. A 1-year retrospective records analysis was conducted of all highest acuity patients (those patients triaged as emergent or critical or admitted to the intensive care unit). A total of 245 patients made 270 high-acuity visits to the ED in 1995. Thirty-one (13%) of the high-acuity patients arrived via ambulance; the rest arrived via private vehicle. The 31 high-acuity patients constituted 8% of the total number of patients arriving by ambulance. There was no significant difference in ambulance usage between insurance groups in the high-acuity patients. Only high-acuity patients with neurologic symptoms (primarily seizures) had a greater relative use of EMS transportation, with 39% of these patients arriving via ambulance (odds ratio 6.6, 95% confidence interval 2.6,16.6). High-acuity patients account for the minority of total ambulance usage in our ED.     

A Prevalence and Management Study of Acute Pain in Children Attending Emergency Departments by Ambulance

Pain is the most common symptom in the emergency setting and remains one of the most challenging problems for emergency care providers, particularly in the pediatric population. The primary objective of this study was to determine the prevalence of acute pain in children attending emergency departments (EDs) in Ireland by ambulance. In addition, this study sought to describe the prehospital and initial ED management of pain in this population, with specific reference to etiology of pain, frequency of pain assessment, pain severity, and pharmacological analgesic interventions. A prospective cross-sectional study was undertaken over a 12-month period of all pediatric patients transported by emergency ambulance to four tertiary referral hospitals in Ireland. All children (<16 years) who had pain as a symptom (regardless of cause) at any stage during the prehospital phase of care were included in this study. Over the study period, 6,371 children attended the four EDs by emergency ambulance, of which 2,635 (41.4%, 95% confidence interval 40.2–42.3%) had pain as a documented symptom on the ambulance patient care report (PCR) form. Overall 32% (n = 856) of children who complained of pain were subject to a formal pain assessment during the prehospital phase of care. Younger age, short transfer time to the ED, and emergency calls between midnight and 6 am were independently associated with decreased likelihood of having a documented assessment of pain intensity during the prehospital phase of care. Of the 2,635 children who had documented pain on the ambulance PCR, 26% (n = 689) received some form of analgesic agent prior to ED arrival. Upon ED arrival 54% (n = 1,422) of children had a documented pain assessment and some form of analgesic agent was administered to 50% (n = 1,324). Approximately 41% of children who attend EDs in Ireland by ambulance have pain documented as their primary symptom. This study suggests that the management of acute pain in children transferred by ambulance to the ED in Ireland is currently poor, with documentary evidence of only 26% receiving prehospital analgesic agents.