Grand jury concerned about time for offload of emergency patients at hospitals
When a medical emergency occurs outside a hospital, the time it takes for first responders to transport the individual to a hospital for care is critical. And the care received during this period has been the focus of recent attention.
Both a grand jury and the Riverside County Board of Supervisors are concerned about emergency care in the county. The latest is a Riverside County Civil Grand Jury (GJ) report about the time it takes to transfer a patient from the ambulance to the hospital’s care. Last month, the supervisors expressed their concern with the work of the county’s ambulance contractor, American Medical Response (AMR).
For the first time since 2015, when Riverside County awarded the emergency ambulance service contract to AMR, the bboard has denied AMR’s request to extend the contract’s expiration date.
The GJ has focused on the delay it takes to officially transfer patients to hospital care after the ambulance arrives at the hospital. It is not unusual for this transfer to take more than 30 minutes. It happens enough that the emergency service administrators have officially named it, “Ambulance Patient Offload Delays” (APOD). First responders — ambulance or fire crews — who are responsible for the patient until the hospital takes over, call it “wall time.”
According to the GJ report, “County departments, state government and hospital emergency departments have not improved in any significant way.”
APOD applies to patients with nonthreatening emergencies. Patients with trauma, stroke or heart issues are immediately accepted and transferred to emergency treatment areas.
Other patients may have to wait for available space or staff to help. Until the hospital takes responsibility, the transfer teams, and occasionally this includes a fire paramedic, must stay with the patient. Consequently, the ambulance or its crew cannot respond to any other call while awaiting the patient transfer.
The GJ reported there were more than 38,000 APOD incidents at Riverside County hospitals in 2022. That is nearly a 20% increase in three years.
In a joint letter to the state Health and Human Services Agency and the Emergency Medical Services Administration, the president of the California Professional Firefighters and the California Hospital Association urged the state to find solutions to the problem.
“Efficient and timely transfer of care between EMS providers and hospital emergency departments is imperative. A delay in the transfer of care creates stress on EMS system participants and their response times but most concerningly, delays care for the patient,” wrote the two officials.
The state’s Emergency Medical Services Agency (EMSA) set the standard for a delay at more than 30 minutes. Based on the county’s EMSA reports, there were nearly 800 APOD in the week from Feb. 26 to March 4, this year. That’s about a quarter of all patient transports to local hospitals. And the transport crew is unavailable for other calls until the hospital accepts its patient.
While ambulances are the required vehicle for ground transport to hospitals, sometimes fire crews also are affected. Emergency dispatch (9-1-1) will send both a fire crew, which includes a paramedic, and an ambulance to the site of an emergency. Sometimes the emergency is so critical that the fire team paramedic will travel with the ambulance to the hospital.
Of course, that means this fire vehicle is out of service until its full crew is available. This is the reason APOD is a critical problem. Not only ambulances, but occasionally, fire engines are out of service.
Riverside County has 17 hospitals. The occurrence of an APOD varies among them. During that same week, four local hospitals — Eisenhower, JFK, Palo Verde and Riverside University — had APOD for less than 6% of the transports to that hospital. But noticeably, three hospitals — Hemet, Riverside Community and Temecula — had APOD during more than 50% of the transports to their facilities. This represents almost 400 patients, more than half the APOD during that week.
A variety of reasons can cause a delay. According to the GJ, the California Hospital Association (CHA) explains that the potential for delays can be caused by “limited physical space, limited staffing and other issues in recent years, such as the pandemic, patients with substance abuse, and patients with behavioral health needs using the hospital emergency departments for care or medications. County residents sometimes have no primary care doctor and use the hospital emergency departments for their routine medical needs.”
The CHA in its own report noted, “An increase in staff does not increase space in other care settings where patients who do not need emergency services should be transferred. Many hospitals are already using hallways, waiting rooms, disaster tents, and other areas to increase capacity. In addition, COVID-19 has taken a toll on the health care workforce — not just in California but across the country — and hospitals are facing the worst staffing shortage in recent memory.”
To reduce APOD, the Riverside University Health System (RUHS) has taken several steps, according to the GJ. First, RUHS changed its parking area to better accommodate first responder vehicles.
The emergency department now has a dedicated nurse to triage ambulance arrivals. Some equipment, such as X-rays and labs, are now located in the emergency room to avoid the time to move the patient. Walk-in emergency patients are treated in another area.
To address a period when several ambulances may be out of service, Riverside City and Corona have established additional ambulance staff or squads to be available when other ambulances are unavailable.
In its conclusion, the GJ made three recommendations to the county. The first was for the supervisors to review, approve and support programs, including telehealth and Safety-Net Ambulance Programs. These may reduce ER demand or alleviate the shortages when APOD augment.
The second recommendation encouraged EMS to help other county hospitals to systematically work with the Riverside County EMSA to implement improvements similar to RUHS and other high-performing hospitals using “best practices” to decrease APOD.
Thirdly, as an interim solution, Riverside County Fire Department and AMR use available personnel to relieve delayed fire and/or ambulance teams at the hospital emergency departments.
The board and county agencies have 90 days to respond to the GJ.
The supervisors did take some action to try to identify solutions. In January 2002, they approved a request from Supervisor Kevin Jeffries to extend the responsibility of its Fire Ad Hoc Committee to include “working with EMD and other relevant County Agencies to help resolve APOD/Wall Time problems in Riverside County.”
But extended wall times are not a unique Riverside County problem. In January 2021, the state Assembly Committee on Emergency Management held an oversight hearing on the impact of APOD on emergency responses.
This year, Assemblymember Freddie Rodriguez (D – Pomona) introduced Assembly Bill 40 to address this issue. On April 19, the Health Committee approved the bill 15-0. Last week, the Appropriations Committee also approved it unanimously.
Besides telling local EMSAs, such as Riverside County’s, to set an APOD of 30 minutes, AB 40 requires acute care hospitals with emergency departments to meet that standard 90% of the time. Also, hospitals would be required to develop an APOD reduction protocol by June 1, 2024, file the protocol with EMSA and require EMSA to monitor monthly APOD data to ensure the standard is being met.
After the April action, Rodriguez said in a press release, “Extended wall times impact everyone in our emergency medical system as first responders are unable to respond to their next call, the patient they are currently waiting to offload does not receive timely care, and the next patient calling in a life-threatening situation cannot be picked up and transported expeditiously. Patients deserve better, and concrete policies must be adopted to alleviate this issue and ensure timely care.”
