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.

• Just because the patient arrives by ambulance does not mean that they require an immediate ED bed. Many such patients can safely be taken to the waiting room and triaged along with the patients who arrive on their own. Mode of arrival is not a triage category.
• Patients awaiting an inpatient bed should be sent to an upstairs hallway as soon as their bed is assigned, and they should not be made to wait in the ED for housekeeping to clean their room. Once the previous patient has been discharged, the unit has capacity for a new patient, whether or not their room is ready for them.
• Assign a physician or advanced practice provider to the waiting room to conduct rapid medical screening exams and to manage the volume of low-acuity patients that can be safely discharged without ever occupying an ED bed. Simple tests such as urinalysis, chest X-ray, or extremity X-rays can be ordered, completed, and interpreted with the disposition made from the waiting room.
• Many ED patients who require a bed for part of their stay do not require a bed for their entire stay. Patients with low-acuity conditions such as abdominal pain or flank pain, for instance, can be examined, have labs drawn, be medicated, and have tests performed. Once they have clinically improved or their evaluation is completed, they can be moved to a discharge lounge or waiting room to await their results, their paperwork, a social work consult, or their ride home without continuously occupying an ED bed.
• Create an ambulance–patient waiting area for those patients who cannot go to the main ED waiting room. Staff it with hospital staff who are, unlike EMS workers, credentialed to observe patients in the hospital, and release the EMS personnel back to the community.
• Lastly, a hospital that is so overwhelmed that it must hold ambulances for hours at a time and has exhausted all other options, should be activating its disaster plan.

Some EMS systems have employed EMTs and paramedics to “mind” EMS patients in the ED. This is a poor solution, costing the EMS system money and personnel better deployed responding to calls. If EMS-employed EMTs can watch a patient, then hospital-employed EMTs (or staff such as certified nursing assistants and licensed vocational nurses, among others) can watch a patient. Techniques like these allow one very busy, high-acuity ED of 65 beds seeing around 100,000 patients per year to never hold ambulances.

Holding ambulances is almost always an unnecessary and dysfunctional response to hospital boarding and ED overcrowding that has tragically become normalized. EMS represents a shared community resource that must remain available and accessible, at all times, to respond to critically ill and injured residents. We cannot allow the dysfunction of hospital boarding to consume the EMS system and flow out into the streets.

Dr. Gautreau is clinical professor of emergency medicine, director of pre-hospital care, director of EMS Fellowship at Stanford University School of Medicine, and medical director at the San Jose Fire Department.

Dr. Kazan is assistant clinical professor of emergency medicine at the David Geffen School of Medicine at UCLA, Charles Drew University, and medical director at the Los Angeles County Fire Department.