As emergency departments (EDs) have become the focus of bottlenecks in the entire health care system—from insufficient inpatient beds leading to hospital boarding to dwindling access to primary care—a siege atmosphere has developed. Although EDs offer around-the-clock access to highly trained physicians and a full suite of imaging and laboratory services, their very success has led to tremendous overcrowding and enormous strains on staff. The combination of a lack of health care access, an impatience for outpatient workups of nonemergent conditions, and an aging population with a growing complexity of health issues has resulted in packed EDs, prolonged wait times, and overwhelmed ED staff with no relief in sight.

Simultaneously, the EMS system has also experienced a huge increase in call volume, and, because of the COVID-19 pandemic, has now experienced a critical loss of paramedics and EMTs, leaving those who remain to deal with the strain of overwork, stagnant wages, and, in many cases, forced overtime. This leads to a vicious circle of more and more professionals exiting the EMS workforce.

Unfortunately, ED staff are faced with an ever-difficult game of Tetris to shuffle patients through, and this has led to a strategy of holding EMS patients on ambulance stretchers, often for hours at a time, in an effort to relieve some of the strain. The domino effect resulting from holding ambulances is hugely impactful to EMS operations, yet wholly sight unseen to most ED staff. EMS resources, like ED beds, are not limitless, and the resulting reduction in available ambulance response can cost lives. In Los Angeles County, major trauma patients have been held on scene with their call queued because there was no available ambulance to even assign to the call. Critically ill and injured patients have been transported in fire engines when they could not wait for an ambulance response. We have also experienced paramedic crews calling their base hospital for medical control for a deteriorating patient while in the ED of a different hospital. Patients endure long hours on a narrow stretcher with poor access to bathrooms or food, no privacy, and in the care of EMS personnel whose very authority to treat inside a hospital is under question.

Strategies to Reduce Delays

It doesn’t have to be this way. A number of strategies may be employed to significantly reduce or even eliminate delays in the offload of ambulance patients. The majority do not require any additional resources on the part of the ED. Some are so obvious that the fact that they have not been employed already in some hospitals is, frankly, mind boggling. We will outline a few that have long been tested and employed by some EDs already.