Time.  It’s a commodity that EMS provider’s (and our patients) live or die by.  Many things impact precious time, but recently the issue of lengthening delays at hospital emergency departments coupled with prolific hospital diversions have grabbed local and national attention.  News headlines on http://www.emsnetwork.org/ abound with tragic stories of hospitals and EMS systems struggling with this national crisis.

EMS leaders across the country report that the average wait time for handing off ambulance patients to an E/D has more than doubled in the past 5 years from 20 minutes to over 45 minutes.  In some large urban areas, E/D delays of 2 – 4 hours are not uncommon. 

In the January 2006 JEMS 200 City Survey, Fitch and Associates calculate the “average” city’s EMS transport volume at 32,616.[1] If the average ambulance wait time in the E/D is 45 minutes, this means that for just the 200 largest cities surveyed, we ‘lose’ 4,892,400 hours a year of EMS system productivity (32,616 x 45 minutes x 200 cities).  A recent analysis of ambulance costs in an urban Florida county revealed a unit hour cost of $114.62.  Using simple mathematics, this equates to $560,766,888 per year in lost productivity costs to the EMS system in JUST those cities surveyed.  Of course, it’s impossible to calculate the human loss due to extended EMS response times while EMS units are idling at E/Ds.

Finding effective methods for dealing with E/D delays and diversions was on the minds of more than 60 EMS leaders when they met for the 1^st time in July 2005 as part of the Access to Care Task Force created by the Florida EMS Advisory Council.  The Task Force had very diverse representation from many EMS agencies and other stakeholders including emergency nurses, private ambulance operators, county and city government, the Florida EMS Bureau, several hospitals and trauma centers, and emergency physicians.

Despite very diverse views on the numerous causes of the crisis, these committed professionals began the daunting task of creating “Best Practices” for minimizing E/D delays and hospital diversions. 

Working proactively through ‘white-board’ sessions and facilitated e-mail discussions, the Task Force developed a white paper identifying several trends that are contributing to the lengthening E/D delay and hospital diversion crisis.

o        Unrealistic Patient Expectations

o        Overuse of the E/D by Private Practice Physicians

o        Hospital Throughput

o        EMS System Design

o        Reimbursement Challenges

o        Government and Regulatory Issues

Once these trends were identified, the Task Force developed statements for each area regarding the “Current State” and “Desired State” for each trend and made recommendations regarding the most appropriate agency or constituency group to be the agent for changing from the current to desired states. 

Throughout the development of the white paper, a number of Task Force members described actions and programs developed in local areas to successfully alleviate the access to care crisis. 

The Task Force members knew that E/D delays and hospital diversions are currently a state and national crisis, but strongly believe that solutions are best determined on a local basis, at least at this point.  To assist with the development of local solutions, the Task Force published a list of the identified actual “Best Practices” that have been successfully implemented to alleviate some of the delays and diversions. 

Some of the recommendations include:

o        EMS providers should communicate with each other on issues common to each other, regardless of competitive service delivery.

o        EMS providers should meet with and discuss issues with E/D managers as well as senior hospital administration (CEO level).

o        Hospitals should implement mechanisms to notify EMS regarding bed availability and patient load status to determine where patients should be directed.

o        EMS Protocols should be adopted that authorize only EMS System Medical Directors to put hospitals on diversion status.

o        EMS Medical Directors should only place hospitals on diversion due to critical infrastructure failures (Unavailability of C.T., cardiac monitor, etc.).

o        EMS Medical Directors should be authorized to place hospitals on diversion if they exceed a reasonable threshold of ambulance wait time and the minimum diversion should be four to twelve hours.

o        Placement of temporary beds in the E/D for use by EMS personnel to place patients when no E/D beds are open and use of an "EMS Action Team” to relieve ambulances at a hospital awaiting beds.

The Florida EMS Advisory Council adopted the white paper and it’s recommendations on December 7, 2005 and will now be moving to assist EMS providers tackle these issues in their local communities, as well as work on the larger project of moving from the ‘current state’ to the ‘desired state’ by engaging the numerous stakeholder groups.

After the development of the recommendations, the Atlanta Regional Office for the Centers for Medicare and Medicaid Services (CMS) issued a memo to all participating hospitals addressing the delay of accepting ambulance of patients once on hospital property.  In the memo, CMS states:

“This practice [delaying ambulance E/D offload] may result in a violation of the Emergency Medical Treatment and Labor Act (EMTALA) and raises serious concerns for patient care and the provision of emergency services in a community.  Additionally, this practice may also result in violation of the Conditions of Participation for Hospitals.”  The memo goes on to state, “A hospital that delays the screening examination or stabilizing treatment of a patient who arrives via transfer from another facility by not allowing EMS to leave the patient could also be in violation of EMTALA.”

The Access To Care Task Force White Paper, as well as the CMS Memo can be viewed and downloaded through the Emergency Medicine Learning and Research Center’s new EMS Clearinghouse at http://www.emlrc.org/clearinghouse/.

Additionally, the Florida Hospital Association recently published its Access to Care report and that report can be viewed and downloaded by visiting the FHA’s website at http://www.fha.org/edreportfront.html

The Baby Boom generation is changing history as it moves through it’s life span.  Many refer to this phenomenon as the “pig through the python.”  The problem of more patients than the healthcare system can handle will get much worse before it gets better. 

Forward thinking healthcare leaders need to act now in order avoid the nasty prospect of being on the wrong end of the python as the pig passes…