ER Boarding Problems Get Dumped on EMS

The crisis in America’s emergency rooms—staffing shortages, overcrowding, lack of available hospital beds for offloading— exacerbated by a severe national mental health care shortage¹ and the COVID pandemic ultimately trickled down to EMS. But coverage of this issue has failed to illustrate the EMS experience: ambulance crews held hostage to the ED’s struggles, left waiting with their patients, standing next to “the wall,” unable to go out and pick up the next patient in need because ER staff can’t or won’t accept the last one they brought in. 

Studies have correlated ED overcrowding with patient discomfort, reduced privacy, treatment delays, and higher risk of prolonged disease and death, and for employees, higher rates of turnover and burnout. But ambulance patient offload delays also disrupt EMS coverage, compromise care, cause frustration and burnout for EMS personnel, and force patients to wait. 

Key Underlying Issues  

Last November, the American College of Emergency Physicians delivered a letter to President Biden, asserting that ED boarding has become its own public health emergency for a safety net “on the verge of breaking beyond repair.” ACEP organized a national summit of key stakeholders to discuss immediate and long-term solutions to the boarding crisis on Sept. 27 in Washington, D.C., bringing public and private sector leaders together to identify tangible policy and real-world solutions to the boarding crisis. 

“The ongoing boarding issues in emergency departments are having a significant impact on EMS services across many communities,” Jose Cabanas [José Cabañas], MD, MPH, FAEMS, president of the National Association of EMS Physicians, writes in an email to EMS World. “This problem is multifaceted and is influenced by factors such as staffing, hospital throughput, and bed availability. All of these factors are interconnected and create the situation of no beds available in the ED for incoming EMS units,”

Sudave Mendiratta, MD, chair and chief of emergency medicine at the University of Tennessee College of Medicine and Erlanger Health System in Chattanooga, past president of the Tennessee College of Emergency Physicians, and a working emergency physician and ED director, explains how the COVID-19 pandemic was like a stress test for the American healthcare system, and we watched it crash.

"Ambulance crews are being held in the hallways of emergency departments because hospitals are unable to move patients either out of the hospital or to an appropriate care area, inpatient floor, cath lab, or surgical suite, because of lack of downstream resources,” he says. "[EMS professionals], they’re twiddling their thumbs. They’re stuck. The calls are stacking up. When they do get the next call, they’re having to drive way outside of their district, because the other units are holding in other hospitals. So you have this massive amount of inefficiency."

And because the EMS crews aren’t getting needed downtime for resting and recharging, their personal well-being is sacrificed, as well, he says. “Ultimately, they’re just not able to do the job that they’re passionate about.” 

Legal Backdrop 

Experts have looked at the legal backdrop that could be perpetuating this problem. Attorneys Doug Wolfberg and Steve Wirth of the Mechanicsburg, Penn., EMS law firm Page, Wolfberg and Wirth, in a 2021 article in EMS^1,2 stated that the law is clear: Once the patient reaches hospital property (including the parking lot), the hospital is legally responsible for that patient—regardless of what they might imply or even say to the ambulance crew. Hospitals can ask EMS staff to remain with the patient, but EMS can say no.  

This is clearly spelled out in the Emergency Medical Treatment and Active Labor Act, the federal law regulating all acute hospitals in the United States, they note. It also doesn’t matter whose gurney the patient is lying on. But how is the crew able to act on that information? Are they likely to just drop the patient off and drive away?  

In California, Assembly Bill 40, Emergency Medical Services, introduced December 5, 2022, by Rep. Freddie Rodriguez (D-Pomona), would establish an enforceable statewide standard for ambulance patient offload times—effective Dec. 31, 2024, if the bill passes—and require a specific action plan from hospitals failing to meet the standard. 

ACEP supports U.S. Senate Bill S1346, Improving Mental Health Access from the Emergency Department Act of 2023 (introduced by Sen. Shelley Moore Capito, R-WV), to award grants for innovative approaches to securing prompt access to appropriate follow-on care for individuals experiencing an acute mental health episode and presenting for care in an ED. 

What Can EMS Do?  

In the meantime, what can EMS providers do to try to mitigate the worst effects of wall time waiting? Collaborative problem-solving is needed between the EMS and ED to positively influence the admission process to free up ambulance crews to get on to the next emergency.

Could select mental health patients be diverted to psychiatric urgent care centers, or could community paramedics be dispatched to the scene of ambulance calls to intervene short of ambulance transfer? The EMS leadership team can work with hospital administrators to find solutions that improve patient flow and limit wait times for incoming EMS patients, Dr. Cabanas says. 

“Some communities have taken a more targeted approach based on the needs of the system. For example, some communities have implemented more targeted ‘direct to triage’ programs, to ensure that EMS patients are promptly assessed upon arrival at the ED,” he says. Others have deployed EMS clinicians with additional stretchers at facilities with longer transfer times. 

Charles Hwang, MD, EMT-T, FAEMS, FACEP, an assistant professor of emergency medicine at the University of Florida Health in Gainesville and medical director of Levy County, Fla., Department of Public Safety, tells EMS World that efforts to minimize wall time include open dialogue between the medical directors of EMS and the directors of emergency departments or their charge nurses.  

“Ask: ‘Is there anything we can do to facilitate offload?’ I personally have come into the ED when my captain told me I was needed and I would offload patients onto a hospital gurney to get my crews released,” Dr. Hwang says. “As long as there is a respectful dialogue, you can help them understand the realities you face, and sometimes think outside the box.” 

The Patient Flow Coordinator  

One such approach to mitigating boarding and wall time was tested at the Erlanger Health System in Chattanooga, Tenn.³ After an emergency department Paramedic Patient Flow Coordinator (PPFC) position was implemented in the ED in 2017, ambulance offload times were decreased even while average ED patient volume was going up. 

The PPFC is a full-time staff member whose job is to assist the charge and triage nurses in coordinating patient flow and bed assignment for patients arriving at the ER by various routes. This role recognizes the unique skillset of experienced paramedics, a special set of skills they can use to communicate with hospital staff and help to prioritize what gets offloaded and then, hopefully, get the ambulance crew back out into service, says Dr. Mendiratta, who was a co-author of the Erlanger PPFC study. “In our model, the PPFC was shoulder to shoulder with attending physicians and nursing leadership.” 

Robert “Colt” Patterson was one of the patient flow coordinators when the program was launched in 2017. “I’ve had ambulance experience. I can attest to having to wait three, four, and five hours. There were many nights I spent in the hospital’s hallway,” he reports.  

His PPFC role was largely non-clinical, but through regular radio contact with ambulances, helicopters, nursing homes, and others, he would perform triage. “On our computer screen we could see the entire department, every bed, and immediately start making plans. And we’d have to do it on the run because it was evolving continuously.” 

Patterson was in charge of discharges, so he’d go to see the patients and obtain their medications so they could be discharged as quickly as possible. If the patient had a bed assigned, Patterson would help to facilitate transfer upstairs. “We were constantly making sure there was a bed in a trauma bay always open,” he says. Patterson would also make sure those coming through the lobby did not get neglected and sometimes he’d manage a small clinical caseload of patients parked in the hallway.  

But Patterson no longer fills that role, which is no longer practiced full-time at Erlanger. “A year ago, I got my RN license and now I do charge nurse relief. But I’m still a critical care paramedic and I have maintained that license.” 

The PPFC was an effective strategy based on reducing EMS offload times and allowing ambulance crews to return to service faster, Dr. Mendiratta says. So what happened? “I’ll tell you the story. We still have the patient flow coordinators but we are having a hard time protecting the sovereignty of their positions. The resource environment has gotten so austere that we no longer have a PPFC every day of the week, just because our staffing model doesn’t support that anymore.”  

This was a resource paid for by the hospital that was saving money for someone else, Dr. Mendiratta explains. Without greater systemic integration, the equation doesn’t add up. Now a somewhat similar role is performed by captains and lieutenants from the system’s EMS service, who come as needed to the ED to help their crews get their trucks offloaded. It’s not as efficient, Dr. Mendiratta says. But it’s real-time communication. 

References 

1. Alltucker K. Against the backdrop of a mental health care shortage, ER doctors are overwhelmed. USA Today. June 21, 2023: https://www.usatoday.com/story/news/health/2023/06/21/american-hospital-emergency-room-doctors-issue-warning/70341882007/.  

2. Wolfberg D, Wirth S. Ambulances held hostage: Can the hospital make you stay? EMS1, November 16, 2021: https://www.ems1.com/ambulance/articles/ambulances-held-hostage-can-the-hospital-make-you-stay-jQESFoe1BQTrtUYc/. 

3. Martin RA, Buchheit R, Carman J. A paramedic patient flow coordinator improves ambulance offload times in the emergency department. Journal of Hospital Management and Health Policy. 2020 Sept; Volume 4.