Improved outcomes for emergency department patients whose ambulance off-stretcher time is not delayed

Improving urban emergency medical service systems through brownfield transformation in Huangshi, China

A comprehensive emergency medical service (EMS) system significantly enhances a city's capacity to prevent and mitigate disasters. Using Huangshi as a case study, this research evaluated the service radium coverage rate of the current EMS system by examining its transport capacity, population density, and prevalence rate, finding it to be only 61.49% with an inefficient spatial layout. To address this, we proposed transforming urban brownfields into EMS parks. By selecting the most suitable brownfields based on capacity and service radius, we increased the coverage rate to 90.21%. We introduced a new "consultation-referral" model, where existing EMS facilities serve as pre-diagnosis and triage centers, and the urban brownfield EMS parks function as isolation and centralized treatment centers. GIS network analysis confirmed the feasibility, showing all transit times to be under 30 min. The methodology outlined in this study-comprising "demand assessment, supply optimization, and feasibility verification"-not only strengthens the city's EMS system but also facilitates the renewal of urban brownfields. This approach can serve as a valuable reference for enhancing EMS systems in other cities.

Inequities in ambulance allocation associated with transfer delay and mortality in acute coronary syndrome patients: evidence from 89 emergency medical stations in China

BACKGROUND

Allocation of healthcare resources has a great influence on treatment and outcome of patients. This study aimed to access the inequality of ambulance allocation across regions, and estimate the associations between ambulance density and pre-hospital transfer time and mortality of acute coronary syndromes (ACS) patients.

METHODS

This cross-sectional study was based on an integrated database of electronic medical system for 3588 ACS patients from 31 hospitals, ambulance information of 89 emergency medical stations, and public geographical information of 8 districts in Shenzhen, China. The primary outcomes were the associations between ambulance allocation and transfer delay and in-hospital mortality of ACS patients. The Theil index and Gini coefficient were used to assess the fairness and inequality degree of ambulance allocation. Logistic regression was used to model the associations.

RESULTS

There was a significant inequality in ambulance allocation in Shenzhen (Theil index: 0.59), and the inequality of inter-districts (Theil index: 0.38) was greater than that of intra-districts (Theil index: 0.21). The gap degree of transfer delay, ambulance allocation, and mortality across districts resulted in a Gini coefficient of 0.35, 0.53, 0.65, respectively. Ambulance density was negatively associated with pre-hospital transfer time (OR = 0.79, 95%CI: 0.64,0.97, P = 0.026), with in-hospital mortality (OR = 0.31, 95%CI:0.14,0.70, P = 0.005). The ORs of Theil index in transfer time and in-hospital mortality were 1.09 (95%CI:1.01,1.10, P < 0.001) and 1.80 (95%CI:1.15,3.15, P = 0.009), respectively.

CONCLUSIONS

Regional inequities existed in ambulance allocation and has a significant impact on pre-hospital transfer delay and in-hospital mortality of ACS patients. It was suggested to increase the ambulance accessibility and conduct health education for public.

The influence of ambulance offload time on 30-day risks of death and re-presentation for patients with chest pain

OBJECTIVE

To assess whether ambulance offload time influences the risks of death or ambulance re-attendance within 30 days of initial emergency department (ED) presentations by adults with non-traumatic chest pain.

DESIGN, SETTING

Population-based observational cohort study of consecutive presentations by adults with non-traumatic chest pain transported by ambulance to Victorian EDs, 1 January 2015 - 30 June 2019.

PARTICIPANTS

Adults (18 years or older) with non-traumatic chest pain, excluding patients with ST elevation myocardial infarction (pre-hospital electrocardiography) and those who were transferred between hospitals or not transported to hospital (eg, cardiac arrest or death prior to transport).

MAIN OUTCOME MEASURES

Primary outcome: 30-day all-cause mortality (Victorian Death Index data).

SECONDARY OUTCOME

Transport by ambulance with chest pain to ED within 30 days of initial ED presentation.

RESULTS

We included 213 544 people with chest pain transported by ambulance to EDs (mean age, 62 [SD, 18] years; 109 027 women [51%]). The median offload time increased from 21 (IQR, 15-30) minutes in 2015 to 24 (IQR, 17-37) minutes during the first half of 2019. Three offload time tertiles were defined to include approximately equal patient numbers: tertile 1 (0-17 minutes), tertile 2 (18-28 minutes), and tertile 3 (more than 28 minutes). In multivariable models, 30-day risk of death was greater for patients in tertile 3 than those in tertile 1 (adjusted rates, 1.57% v 1.29%; adjusted risk difference, 0.28 [95% CI, 0.16-0.42] percentage points), as was that of a second ambulance attendance with chest pain (adjusted rates, 9.03% v 8.15%; adjusted risk difference, 0.87 [95% CI, 0.57-1.18] percentage points).

CONCLUSIONS

Longer ambulance offload times are associated with greater 30-day risks of death and ambulance re-attendance for people presenting to EDs with chest pain. Improving the speed of ambulance-to-ED transfers is urgently required.

Impacts of an EMS Hospital Liaison Program on Ambulance Offload Times: A Preliminary Analysis

INTRODUCTION

Ambulance patients who are unable to be quickly transferred to an emergency department (ED) bed represent a key contributing factor to ambulance offload delay (AOD). Emergency department crowding and associated AOD are exacerbated by multiple factors, including infectious disease outbreaks such as the coronavirus disease 2019 (COVID-19) pandemic. Initiatives to address AOD present an opportunity to streamline ambulance offload procedures while improving patient outcomes.

STUDY OBJECTIVE

The goal of this study was to evaluate the initial outcomes and impact of a novel Emergency Medical Service (EMS)-based Hospital Liaison Program (HLP) on ambulance offload times (AOTs).

METHODS

Ambulance offload times associated with EMS patients transported to a community hospital six months before and after HLP implementation were retrospectively analyzed using proportional significance tests, t-tests, and multiple regression analysis.

RESULTS

A proportional increase in incidents in the zero to <30 minutes time category after program implementation (+2.96%; P <.01) and a commensurate decrease in the proportion of incidents in the 30 to <60 minutes category (-2.65%; P <.01) were seen. The fully adjusted regression model showed AOT was 16.31% lower (P <.001) after HLP program implementation, holding all other variables constant.

CONCLUSION

The HLP is an innovative initiative that constitutes a novel pathway for EMS and hospital systems to synergistically enhance ambulance offload procedures. The greatest effect was demonstrated in patients exhibiting potentially life-threatening symptoms, with a reduction of approximately three minutes. While small, this outcome was a statistically significant decrease from the pre-intervention period. Ultimately, the HLP represents an additional strategy to complement existing approaches to mitigate AOD.

Predicting Ambulance Patient Wait Times: A Multicenter Derivation and Validation Study

STUDY OBJECTIVE

To derive and internally and externally validate machine-learning models to predict emergency ambulance patient door-to-off-stretcher wait times that are applicable to a wide variety of emergency departments.

METHODS

Nine emergency departments provided 3 years (2017 to 2019) of retrospective administrative data from Australia. Descriptive and exploratory analyses were undertaken on the datasets. Statistical and machine-learning models were developed to predict wait times at each site and were internally and externally validated.

RESULTS

There were 421,894 episodes analyzed, and median site off-load times varied from 13 (interquartile range [IQR], 9 to 20) to 29 (IQR, 16 to 48) minutes. The global site prediction model median absolute errors were 11.7 minutes (95% confidence interval [CI], 11.7 to 11.8) using linear regression and 12.8 minutes (95% CI, 12.7 to 12.9) using elastic net. The individual site model prediction median absolute errors varied from the most accurate at 6.3 minutes (95% CI, 6.2 to 6.4) to the least accurate at 16.1 minutes (95% CI, 15.8 to 16.3). The model technique performance was the same for linear regression, random forests, elastic net, and rolling average. The important variables were the last k-patient average waits, triage category, and patient age. The global model performed at the lower end of the accuracy range compared with models for the individual sites but was within tolerable limits.

CONCLUSION

Electronic emergency demographic and flow information can be used to estimate emergency ambulance patient off-stretcher times. Models can be built with reasonable accuracy for multiple hospitals using a small number of point-of-care variables.

Choice of Transport to Hospital in Nonurban Areas in Life-Threatening Situations: A Qualitative Research

The time it takes to begin treatment in life-threatening situations is critical. Ambulance transport to the hospital in such situations ensures quick and effective treatment but is not always readily available in nonurban areas, or not preferred by the public, for various reasons. The purpose of this qualitative study was to examine the factors that deter or encourage ambulance use in life-threatening situations in the geographic periphery from clients' perspectives. We conducted interviews with 71 patients in 3 medical centers who had arrived by ambulance or by private transport, and with the 3 emergency department directors. The findings revealed that awareness of the clinical situation and health literacy, accessibility of emergency services, geographical conditions, and social and economic factors are central in the decision to utilize this service. We detail research recommendations for strengthening public health literacy and access to services.

Seasonal variations of patients presenting dyspnea to emergency departments in Europe: Results from the EURODEM Study

Background/aim

To describe seasonal variations in epidemiology, management, and short-term outcomes of patients in Europe presenting to an emergency department (ED) with a main complaint of dyspnea.

Materials and methods

An observational prospective cohort study was performed in 66 European EDs which included consecutive patients presenting to EDs with dyspnea as the main complaint during 3 72-h study periods. Data were collected on demographics, comorbidities, chronic treatment, prehospital treatment, mode of arrival of patient to ED, clinical signs at admission, treatment in the ED, ED diagnosis, discharge from ED, and in-hospital outcome.

Results

The study included 2524 patients with a median age of 69 (53–80) years old. Of the patients presented, 991 (39.3%) were in autumn, 849 (33.6%) were in spring, and 48 (27.1%) were in winter. The winter population was significantly older (P < 0.001) and had a lower rate of ambulance arrival to ED (P < 0.001). In the winter period, there was a higher rate for lower respiratory tract infection (35.1%), and patients were more hypertensive, more hypoxic, and more hyper/hypothermic compared to other seasons. The ED mortality was about 1% and, in hospital, mortality for admitted patients was 7.4%.

Conclusion

The analytic method and the outcome of this study may help to guide the allocation of ED resources more efficiently and to recommend seasonal ED management protocols based on the seasonal trend of dyspneic patients.

Length of Stay in the Emergency Department and Its Associated Factors at Jimma Medical Center, Southwest Ethiopia

Background

Prolonged emergency department stays can adversely affect patient outcomes leading to an increased length of hospital admission and higher mortality. Despite this fact, there are few data describing emergency department length of stay and associated factors in Ethiopia.

Objective

To assess length of stay in the emergency department and its associated factors among patients visited adult emergency department of Jimma Medical Center, Jimma town, southwest of Ethiopia.

Methods

Institution-based cross-sectional study was conducted from April 9, 2018 to May 11, 2018. Overall, 422 patients presented during study period were sequentially included in the study. A semi-structured questionnaire was used to collect data through interview, observation and medical record review. The collected data were cleaned, entered to Epi-data 3.1 and exported to SPSS version 21 for binary and multivariable logistic regression analysis. To identify factors associated with outcome variable, candidate variables were fitted to multivariable analysis, and those with P-values <0.05 were considered as significantly associated.

Results

More than one-third, 162 (38.4%), experienced prolonged length of stay in the emergency department. The odds of prolonged stay were higher among rural area residency (AOR, 3.0; CI, 1.279–7.042), evening presentation (AOR, 4.25; CI, 1.742–10.417), and night-time presentation (AOR, 14.93; CI, 4.22–52.63), and having at least one diagnostic investigation (AOR, 4.48; CI, 1.69–11.88). However, participants who did not experience shift changes of nurses during their stay (AOR, 0.003; CI, 0.001–0.010) had a less prolonged stay.

Conclusion

A significant proportion of patients experienced a prolonged stay at the emergency department. Age, rural residency, evening and night-time presentation, shift change and having a diagnostic investigation were predictors of prolonged stay. Thus, establishing time-targeted service for patients can reduce the length of stay.

A data linkage study of suspected seizures in the urgent and emergency care system in the UK

INTRODUCTION

The urgent and emergency care (UEC) system is struggling with increased demand, some of which is clinically unnecessary. Patients suffering suspected seizures commonly present to EDs, but most seizures are self-limiting and have low risk of short-term adverse outcomes. We aimed to investigate the flow of suspected seizure patients through the UEC system using data linkage to facilitate the development of new models of care.

METHODS

We used a two-stage process of deterministic linking to perform a cross-sectional analysis of data from adults in a large region in England (population 5.4 million) during 2014. The core dataset comprised a total of 739 436 ambulance emergency incidents, 1 033 778 ED attendances and 362 358 admissions.

RESULTS

A high proportion of cases were successfully linked (86.9% ED-inpatient, 77.7% ED-ambulance). Suspected seizures represented 2.8% of all ambulance service incidents. 61.7% of these incidents led to dispatch of a rapid-response ambulance (8 min) and 72.1% were conveyed to hospital. 37 patients died before being conveyed to hospital and 24 died in the ED (total 61; 0.3%). The inpatient death rate was 0.4%. Suspected seizures represented 0.71% of ED attendances, 89.8% of these arrived by emergency ambulance, 45.4% were admitted and 44.5% of these admissions lasted under 48 hours.

CONCLUSIONS

This study confirms previously published data from smaller unlinked datasets, validating the linkage method, and provides new data for suspected seizures. There are significant barriers to realising the full potential of data linkage. Collaborative action is needed to create facilitative governance frameworks and improve data quality and analytical capacity.

Impact of the Four-Hour Rule policy on emergency medical services delays in Australian EDs: a longitudinal cohort study

INTRODUCTION

Delayed handover of emergency medical services (EMS) patients to EDs is a major issue with hospital crowding considered a primary cause. We explore the impact of the 4-hour rule (the Policy) in Australia, focusing on ambulance and ED delays.

METHODS

EMS (ambulance), ED and hospital data of adult patients presenting to 14 EDs from 2002 to 2013 in three jurisdictions were linked. Interrupted time series 'Before-and-After' trend analysis was used for assessing the Policy's impact. Random effects meta-regression analysis was examined for associations between ambulance delays and Policy-associated ED intake, throughput and output changes.

RESULTS

Before the Policy, the proportion of ED ambulances delayed increased between 1.1% and 1.7% per quarter across jurisdictions. After Policy introduction, Western Australia's increasing trend continued but Queensland decreased by 5.1% per quarter. In New South Wales, ambulance delay decreased 7.1% in the first quarter after Policy introduction. ED intake (triage delay) improved only in New South Wales and Queensland. Each 1% ambulance delay reduction was significantly associated with a 0.91% reduction in triage delay (p=0.014) but not ED length of stay ≤4 hours (p=0.307) or access-block/boarding (p=0.605) suggesting only partial improvement in ambulance delay overall.

CONCLUSION

The Policy was associated with reduced ambulance delays over time in Queensland and only the immediate period in New South Wales. Associations may be due to local jurisdictional initiatives to improve ambulance performance. Strategies to alleviate ambulance delay may need to focus on the ED intake component. These should be re-examined with longer periods of post-Policy data.

Prehospital Point-Of-Care Lactate Increases the Prognostic Accuracy of National Early Warning Score 2 for Early Risk Stratification of Mortality: Results of a Multicenter, Observational Study

The objective of this study was to assess whether the use of prehospital lactate (pLA) can increase the prognostic accuracy of the National Early Warning Score 2 (NEWS2) to detect the risk of death within 48 h. A prospective, multicenter study in adults treated consecutively by the emergency medical services (EMS) included six advanced life support (ALS) services and five hospitals. Patients were assigned to one of four groups according to their risk of mortality (low, low-medium, medium, and high), as determined by the NEWS2 score. For each group, the validity of pLA in our cohort was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. In this study, 3081 participants with a median age of 69 years (Interquartile range (IQR): 54-81) were included. The two-day mortality was 4.4% (137 cases). The scale derived from the implementation of the pLA improved the capacity of the NEWS2 to discriminate low risk of mortality, with an AUC of 0.910 (95% CI: 0.87-0.94; p < 0.001). The risk stratification provided by the NEWS2 can be improved by incorporating pLA measurement to more accurately predict the risk of mortality in patients with low risk.

Improving emergency department transfer for patients arriving by ambulance: A retrospective observational study

Objective

Extended delays in the transfer of patients from ambulance to ED can compromise patient flow. The present study aimed to describe the relationship between the use of an Emergency Department Ambulance Off‐Load Nurse (EDAOLN) role, ED processes of care and cost effectiveness.

Methods

This was a retrospective observational study over three periods of before (T1), during (T2) and after (T3) the introduction of the EDAOLN role in 2012. Ambulance, ED and cost data were linked and used for analysis. Processes of care measures analysed included: time to be seen by a doctor from ED arrival (primary outcome), ambulance‐ED offload compliance, proportion of patients seen within recommended triage timeframe, ED length of stay (LoS), proportion of patients transferred, admitted or discharged from the ED within 4 h and cost effectiveness.

Results

A total of 6045 people made 7010 presentations to the ED by ambulance over the study period. Several measures improved significantly between T1 and T2 including offload compliance (T1: 58%; T2: 63%), time to be seen (T1: 31 min; T2: 28 min), ED LoS (T1: 335 min; T2: 306 min), ED LoS <4 h (T1: 31%; T2: 33%). Some measures carried over into T3, albeit to a lesser extent. Post‐hoc analyses showed that outcomes improved most for less urgent patients. The annualised net cost of the EDAOLN (if funded from additional resources) of $130 721 could result in an annualised reduction of approximately 3912 h in waiting time to be seen by a doctor.

Conclusion

With the EDAOLN role in place, slight outcome improvements in several key ambulance and ED efficiency criteria were noted. During times of ED crowding, the EDAOLN role may be one cost‐effective strategy to consider.

Trends and barriers of emergency medical service use in Addis Ababa; Ethiopia

BACKGROUND

The increasing burdens of trauma and time sensitive non-communicable disease in Addis Ababa necessitate a robust emergency medical care system. The objectives of this study were to assess the proportion of patients who used emergency medical services (EMS) and to quantitatively and qualitatively assess barriers to EMS utilization in Addis Ababa.

METHODS

A cross-sectional quantitative and qualitative study was conducted on patients who visited five selected public hospitals in Addis Ababa with specific emergency conditions. Data were collected by trained nurses using a standardized questionnaire. Descriptive statistics and logistic regression was done on cleaned and coded quantitative data using SPSS version 20. Thematic analysis was performed on the qualitative data. Ethical approval was obtained prior to the study.

RESULTS

A total of 429 participants completed the survey with a non-response rate of 5.1%. The most common emergency scene was the home (n = 222, 51.8%) followed by road side (n = 159, 37.1%). Only 87(20.3%) patients arrived by ambulance, though a majority (53.4%) of participants recalled at least one access number for an ambulance service and 96.3% stated that ambulances were an important part of the continuum of care for their emergency condition. A higher proportion of participants believed that ambulance transportation is generally safer (n = 341, 78.5%) and faster (n = 298, 69.5%) than emergency transport by taxi or private car. Patients who were non-Amharic speaking had a negative association with arriving by ambulance (P = 0.001, OR 0.47; C.I, 0.31, 0.71). The median acceptable time to get the ambulance (according to respondent's perception) was 16 min but actually perceived ambulance waiting time was 40 min.

CONCLUSION

EMS utilization in Addis Ababa is relatively low and emergency patients are instead being transported by taxi or private car. Perceived longer ambulance waiting time and language barriers may have contributed for low utilization. Findings of this study suggest an action to improve access by improving ambulance availability while simultaneously enhancing the public's knowledge and perception of EMS in Addis Ababa.

Are emergency medical services offload delay patients at increased risk of adverse outcomes?

OBJECTIVE

Emergency department (ED) and hospital overcrowding cause offload delays that remove emergency medical services (EMS) crews from service and compromise care delivery. Prolonged ED boarding and delays to inpatient care are associated with increased hospital length of stay (LOS) and patient mortality, but the effects of EMS offload delays have not been well studied.

METHODS

We used administrative data to study all high-acuity Canadian Triage Acuity Scale 2-3 EMS arrivals to Calgary adult EDs from July 2013 to June 2016. Patients offloaded to a care space within 15 minutes were considered controls, whereas those delayed ≥ 60 minutes were considered "delayed." Propensity matching was used to create comparable control and delayed cohorts. The primary outcome was 7-day mortality. Secondary outcomes included hospital LOS and 30-day mortality.

RESULTS

Of 162,002 high-acuity arrivals, 70,711 had offload delays 60 minutes. Delayed patients were more likely to be female, older, to have lower triage acuity, to live in dependent living situations, and to arrive on weekdays and day or evening hours. Delayed patients less often required admission and, when admitted, were more likely to go to the hospitalist service. Main outcomes were similar for propensity-matched control and delayed cohorts, although delayed patients experienced longer ED LOS and slightly lower 7-day mortality rates.

CONCLUSION

In this setting, high-acuity EMS arrivals exposed to offload delays did not have prolonged hospital LOS or higher mortality than comparable patients who received timely access.

Delays in arrival and treatment in emergency departments: Women, children and non-trauma consultations the most at risk in humanitarian settings

INTRODUCTION

Delays in arrival and treatment at health facilities lead to negative health outcomes. Individual and external factors could be associated with these delays. This study aimed to assess common factors associated with arrival and treatment delays in the emergency departments (ED) of three hospitals in humanitarian settings.

METHODOLOGY

This was a cross-sectional study based on routine data collected from three MSF-supported hospitals in Afghanistan, Haiti and Sierra Leone. We calculated the proportion of consultations with delay in arrival (>24 hours) and in treatment (based on target time according to triage categories). We used a multinomial logistic regression model (MLR) to analyse the association between age, sex, hospital and diagnosis (trauma and non-trauma) with these delays.

RESULTS

We included 95,025 consultations. Males represented 65.2%, Delay in arrival was present in 27.8% of cases and delay in treatment in 27.2%. The MLR showed higher risk of delay in arrival for females (OR 1.2, 95% CI 1.2-1.3), children <5 (OR 1.4, 95% CI 1.4-1.5), patients attending to Gondama (OR 30.0, 95% CI 25.6-35.3) and non-trauma cases (OR 4.7, 95% CI 4.4-4.8). A higher risk of delay in treatment was observed for females (OR 1.1, 95% CI 1.0-1.1), children <5 (OR 2.0, 95% CI 1.9-2.1), patients attending to Martissant (OR 14.6, 95% CI 13.9-15.4) and non-trauma cases (OR 1.6, 95% CI 1.5-1.7).

CONCLUSIONS

Women, children <5 and non-trauma cases suffered most from delays. These delays could relate to educational and cultural barriers, and severity perception of the disease. Treatment delay could be due to insufficient resources with consequent overcrowding, and severity perception from medical staff for non-trauma patients. Extended community outreach, health promotion and support to community health workers could improve emergency care in humanitarian settings.

Emergency department models of care in Queensland: a multisite cross-sectional study

Objective The acuity and number of presentations being made to emergency departments (EDs) is increasing. In an effort to safely and efficiently manage this increase and optimise patient outcomes, innovative models of care (MOC) have been implemented. What is not clear is how these MOC reflect the needs of patients or relate to each other or to ED performance. The aim of this study was to describe ED MOC in Queensland, Australia. Methods Situated within a larger mixed-methods study, the present study was a cross-sectional study. In early 2015, leaders (medical directors and nurse managers) from public hospital EDs in Queensland were invited to complete a survey detailing ED activity, staffing profiles, treatment space, MOC and National Emergency Access Target (NEAT) performance. Routinely collected ED information system data was also used. Results Twenty of the 27 EDs invited participated in the study (response rate 74%). An extensive array of MOC were identified that were categorised into those that facilitate input, throughput and output from the ED. There was no consistent evidence as to the relative effectiveness of these MOC in achieving ED performance benchmarks, such as NEAT performance. Conclusion There is considerable variability in the MOC used throughout EDs in Queensland. A more complete analysis of the relative effectiveness of different MOC either in isolation or as part of a comprehensive approach would help inform more consistent MOC in Queensland EDs. What is known about the topic? MOC in any given ED are implemented in response to factors such as the geographical location of the hospital, hospital-specific characteristics and service profile, staffing profile and patient demographic profile. In the era of time-based targets, they may also serve to address a particular aspect of flow in the face of rising ED demand. Although many of the MOC attempt to deal with flow in a linear fashion, target specific phases of the ED journey or address particular patient cohorts, what is clear is that not all EDs are shaped and formed the same. What does this paper add? The study provides a comprehensive description of the varied models of care operating within Queensland public hospital EDs and how they relate to ED performance. A basic taxonomy of contemporary ED MOC is necessary to allow comparison between departments and inform decisions regarding safety, efficiency and cost-effectiveness. What are the implications to practitioners? A contemporary understanding of the presence and profile of ED MOC that currently exist within a network of hospitals and health services is important for managers, clinicians and patients to inform decision-making regarding the safety, clinical effectiveness and cost-effectiveness of these models. This understanding can also inform where and how further improvements in care delivery can progress.

A review on ambulance offload delay literature

Ambulance offload delay (AOD) occurs when care of incoming ambulance patients cannot be transferred immediately from paramedics to staff in a hospital emergency department (ED). This is typically due to emergency department congestion. This problem has become a significant concern for many health care providers and has attracted the attention of many researchers and practitioners. This article reviews literature which addresses the ambulance offload delay problem. The review is organized by the following topics: improved understanding and assessment of the problem, analysis of the root causes and impacts of the problem, and development and evaluation of interventions. The review found that many researchers have investigated areas of emergency department crowding and ambulance diversion; however, research focused solely on the ambulance offload delay problem is limited. Of the 137 articles reviewed, 28 articles were identified which studied the causes of ambulance offload delay, 14 articles studied its effects, and 89 articles studied proposed solutions (of which, 58 articles studied ambulance diversion and 31 articles studied other interventions). A common theme found throughout the reviewed articles was that this problem includes clinical, operational, and administrative perspectives, and therefore must be addressed in a system-wide manner to be mitigated. The most common intervention type was ambulance diversion. Yet, it yields controversial results. A number of recommendations are made with respect to future research in this area. These include conducting system-wide mitigation intervention, addressing root causes of ED crowding and access block, and providing more operations research models to evaluate AOD mitigation interventions prior implementations. In addition, measurements of AOD should be improved to assess the size and magnitude of this problem more accurately.

The ethics of ambulance ramping

Ramping is the practice of requiring paramedics to continue to care for patients rather than hand over clinical responsibility to the ED. It arose as an alternative to admitting patients to EDs that are deemed to be already operating at or beyond capacity. This paper analyses the ethics of ramping. Ramping has been embraced by some ED practitioners and policymakers as a solution to the problem of ED patients suffering increased risks of harm as a result of waiting times within ED. However, this perspective fails to adequately consider the implications, especially the opportunity cost of requiring paramedics to remain at the hospital rather than make themselves available for other patients. From this perspective, ramping negatively impacts the wider provision of emergency medical services, with potentially serious consequences for people's health. Advocates of ramping must consider people in the community who require a medical emergency response.

Emergency department 'undercrowding' is associated with decreased waiting times

OBJECTIVE

To evaluate the effect of a sudden and sustained decrease in patient presentations on waiting times and other measures of workload and flow following the opening of a large, greenfields ED adjacent to our own.

METHOD

A descriptive study involving all patients presenting to a private urban district hospital ED for two 60 day periods, immediately before and after the opening of the tertiary hospital ED. Changes in median waiting time, case-mix distribution, method of arrival, total admissions and total waiting time were compared pre-opening and post-opening. Non-normally distributed variables were analysed using Mann-Whitney U-tests. Categorical variables were compared using χ(2) analyses.

RESULTS

Patient presentations decreased by 28% with a parallel decline in median waiting time of 15 min (from 26 to 11 min) (P < 0.001). Total waiting time was approximately 29 h less per day in the post-opening period. Patient urgency by triage category did not change significantly (P = 0.316), whereas the proportion of presentations by ambulance decreased 15.9% (P = 0.048) and admission rate increased from 29.1% to 32.6% (P = 0.002).

CONCLUSIONS

Patient presentation numbers are strongly associated with and likely impact on median waiting time. Understanding that controlling demand can lead to significant benefits in patient processing, flow and overall patient perceived level of care and satisfaction is relevant to any discussion on ED overcrowding and the deleterious effects of access block.

Ambulance use in Pakistan: an analysis of surveillance data from emergency departments in Pakistan

Background

The utilization of ambulances in low- and middle-income countries is limited. The aim of this study was to ascertain frequency of ambulance use and characteristics of patients brought into emergency departments (EDs) through ambulance and non-ambulance modes of transportation.

Methods

The Pakistan National Emergency Departments Surveillance (Pak-NEDS) was a pilot active surveillance conducted in seven major tertiary-care EDs in six main cities of Pakistan between November 2010 and March 2011. Univariate and multivariate logistic regression was performed to investigate the factors associated with ambulance use.

Results

Out of 274,436 patients enrolled in Pak-NEDS, the mode of arrival to the ED was documented for 94. 9% (n = 260,378) patients, of which 4.1% (n = 10,546) came to EDs via ambulances. The mean age of patients in the ambulance group was significantly higher compared to the mean age of the non-ambulance group (38 ± 18.4 years versus 32.8 ± 14.9 years, p-value < 0.001). The most common presenting complaint in the ambulance group was head injury (12%) while among non-ambulance users it was fever (12%). Patients of all age groups were less likely to use an ambulance compared to those >45 years of age (p-value < 0.001) adjusted for gender, cities, hospital type, presenting complaint group and disposition. The adjusted odds ratio of utilizing ambulances for those with injuries was 3.5 times higher than those with non-injury complaints (p-value < 0.001). Patients brought to the ED by ambulance were 7.2 times more likely to die in the ED than non-ambulance patients after adjustment for other variables in the model.

Conclusion

Utilization of ambulances is very low in Pakistan. Ambulance use was found to be more among the elderly and those presenting with injuries. Patients presenting via ambulances were more likely to die in the ED.