Offloads In Ed's

[Niftymedi911]

This season (snowbirds) in our county we have seen an extreme jump in call volume and the number of sick patients. Most of the time we would expect it due to season but this year as by far been the worst in the past 5 yrs. We've done in excess of over 11,000 EMS calls this past month. Now, the biggest problem we keep running into which I know everyone has experienced a time or two was the long offload (wait) time in the ED. I'm interested to see or find out if anyone has been part of a CQI or a committe of some sort to better the situation for EMS personel at the ED's with offload times. Our agency has done some ( as in calling into a transportation officer before transport to request a specific hospital, and based on offload times and the like are directed to that facility or must go to another destination. The ED's also update their status to better inform us on a computer program so we can see the offload issues. But in a day where close to 350-400 9-1-1 calls for help come in and maybe a total of 100 ED beds county/system wide, its kinda hard to balance things.

Just wondering if anyone has advice or a situation where a study was done to help things along. FYI my average offload time this past week was 1 hr 9 mins. We're at times getting close to running out of units (status Red) bc of the ED crowding of EMS units. And we have 37 trucks.

Better Info to help understand:

5 County Hospitals (All owned by health system) / 1 120 bed Private hospital owned by HMA

Biggest ER is 25 beds, smallest ER is 10 beds

Approx 2000 beds total county wide

Out of season population: 550k-600k

In Season: Approx 1-3 million

Offload time is defined as time of arrival @ ED to RN taking report

Offload is defined as being assigned a bed, moving the patient to the bed, RN walk in, give verbal written report to RN, Rn takes over pt care

Any and all information is helpful and apprieciated!

[Arizonaffcep]

We had a similar issue here in Tucson, however the average wait times are no where near over an hour. We tried everything...from different divert polices, rotations, etc. Now what we use is a "no divert policy." What that means is, hospitals are NOT allowed to go "on divert" unless it's an extreem measure (ie internal disaster such as flooding, bomb scare, etc.). That's it. No if's and's or but's! Funny thing is, it seems to work! The hospitals have really responded to the back up by upping their "flow-through" rates. Now, the average wait time is around 15-20 min, IF there is a wait. Most hospitals around here try to keep several (1-3) beds open for the random train-wreck from triage or EMS-whichever fills them first.

[Niftymedi911]

That's the thing the hospitals here are also not allowed to divert. The only that stops us from going to said place is an internal disatser. We still have an issue. My record this year (09) is 2 hrs 48 minutes and that was last week.

[Arizonaffcep]

Found this...thought it might apply...

Maxine_5.bmp

[Niftymedi911]

No lie that's sitting on the wall of my station......

[CBEMT]

Unfortunately, as busy as our hospitals are this is pretty much an alien concept. Even when our trauma center ER has no beds available, there are still hospital stretchers to put them on, and they can stack then 10 deep in Ambulance Triage if necessary. These would be patients not considered critical or even urgent, though sometimes even an "urgent 2" will have to sit there for awhile. (It does get aggravating when some loudmouth drunk ends up next to grandma from the nursing home.)

Longest offload time I can remember is 20 minutes waiting for a bariatric bed to be brought up from storage.

[spenac]

Triage nurse needs to triage non emergent patients to the waiting room. EMS needs to triage patients and say no when they are non emergent.

[EMS49393]

We can't say no to any patient that wants transport. We can call them a candidate for triage and that will sit their non-urgent butt in the waiting room. We have a problem with over-crowding in our ER's and went to a no diversion policy last March. Hospitals are allowed to divert services in a "temp" fashion. The hospital I work for has neuro capability, but rarely has neuro services. They can go on neuro-temp diversion on days they have no neuro docs. Our off-loading times have diminished since the policy was put into to place.

The real change in off-loading times is really due to being able to put patients in the waiting room. That's a relatively new concept here, and most citizens still think an ambulance is a guaranteed bed in back. There are probably a dozen of us that are comfortable enough to suggest a patient is a candidate for triage. Putting stable patients with toe and butt complaints in the waiting room frees up beds for patients that are deemed urgent, emergent, or critical. There are also half a dozen or so of us that will not transport a code that we've worked on scene for a period of time with no result. We have the option to terminate in the field with consult, and I utilize it. That saves countless hours of a bed being tied up while waiting on transport to the morgue, clean-up, decon, etc.

We don't actually have a committee on hospital turn times, but you gave me one hell of an idea to present to my supervisors, both in the hospital, and in my EMS job.

[KAThomas]

Everyone across the country should come to Los Angeles for a few ride-outs with any Private Ambo Service that provides trans for the 911 contracts and be sent BLS a few times. It'd make your hair fall out. The length of "wall time" varies tremendously. My personal longest was 6 hours. Yeah, it's a violation of the EMTLA policy but even when you complain who actually follows up and what is done about it?

Even with that as a known fact, LA EMS is a Fire Department based system and as long as our Fire Department isn't transporting, most don't see a need to field triage appropriately.

You call 911 and you've been tossing your lunch, or so you say, for a few hours... you're given the option to go in the Ambulance that's right here... you walk into the ER and they have a considerable amount of folks who have worse conditions and then you wait.... and more often than not you get triaged relatively quickly and then you wait... and wait... and wait and... you get the idea.

A good charge nurse puts folks in the waiting room based on complaint and a quick assessment but that in itself is a roll of the dice.

It makes most folks leave this field for anything else where they don't feel like their time is not worth much.

The horror story I have is about transporting a "regular" and waiting 4 and 1/2 hours to be relieved by another crew who continued to hold the wall with him another 4 hours.

Whoa!

[CBEMT]

8 hour shift, one or two patients.... no wonder the pay sucks.