A symptom of overcrowded emergency departments is the increasing amount of time ambulances are out-of-service because paramedics are delayed at hospitals waiting to transfer patients from their care to empty emergency department gurneys, according to a study to be published in the January 2004 Annals of Emergency Medicine.
"This wait can be for several minutes to several hours, which means the ambulance is out of service for just as long," said Marc Eckstein, MD, lead author of the study and an emergency physician with the Keck School of Medicine of the University of Southern California in Los Angeles, and medical director of the Los Angeles Fire Department.
In one year (April 2001 through March 2002), researchers found a total of 21,240 incidences in which Los Angeles Fire Department ambulances were out of service while paramedics waited to transfer patients to open emergency department gurneys. This means 1 in every 8 ambulance transports involved a delay. Of these, 8.4 percent experienced delays in excess of 1 hour; the median delay was 27 minutes. Researchers also found the highest number of out-of-service incidents occurred during the winter from January through March.
According to the study's authors, the problems of emergency department overcrowding and ambulance diversion result from a myriad of causes. The authors indicate the lack of inpatient beds, particularly monitored and intensive care unit (ICU) beds, is one of the largest contributing factors to overcrowded emergency departments.
"The lack of inpatient beds has caused gridlock in emergency departments across the country," said Dr. Eckstein. "Emergency patients who need to be hospitalized are boarded in emergency departments until inpatient beds become available. This causes the whole system to back up and reduces the ability of emergency medical staff to care for more patients coming by ambulance."
The study's authors point out that critical visits per emergency department in California increased by 59 percent during the past decade, whereas the number of staffed critical care beds decreased by 4 percent. During this same time, the number of emergency departments in the state decreased by 12 percent, resulting in a 27 percent increase in total number of visits per emergency department. In Los Angeles County, there has been a 21-percent decrease in the number of emergency departments in the past decade.
"A recent study of California emergency departments found that patients waited an average of almost one hour to see a physician; now our data show similar delays also exist for patients coming by ambulance just to be transferred from the care of a paramedic to an emergency department gurney," said Dr. Eckstein. "While our study looked only at this problem in Los Angeles, anecdotally we know this is happening in many communities across the country and not just urban areas, but also in suburban and rural hospitals, which often don't have the option to go on diversion."
When emergency departments are overcrowded, some divert ambulances to other hospitals because they cannot safely accept one more acutely ill or injured patient. The study's authors ranked Los Angeles hospitals by the amount of time they were on diversion, and the top 20 were found to be on diversion from one-third to more than two-thirds of the time during the 12-month study period.
More information can be found on the American College of Emergency Physicians website http://www.ACEP.org