It's a familiar scene at many emergency departments (EDs): gridlock in the ambulance arrival area, with gurneys lined up and emergency medical services (EMS) crews waiting to offload patients. Such delays put patients at risk, prevent paramedics from responding to other calls, and disrupt patient flow throughout the hospital. In 2006, EMS leaders reported that, over the previous five years, the average wait time for handing off ambulance patients to EDs had doubled: from 20 to more than 45 minutes. In some hospitals, particularly in cities, delays regularly stretch to several hours.
A July 2006 memo
from the Centers for Medicare & Medicaid Services (CMS) shed light on the issue. According to CMS, "parking" patients with EMS staff in attendance is "not a solution" to ED overcrowding. Failure to release ambulances back into the field in a timely manner, CMS warned, "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."
ED overcrowding was a problem in the fast-growing city of Las Vegas, and local EMS crews complained that the long waits at area hospitals were affecting their ability to respond to 911 calls within their mandated time frame. In response, the Nevada State Legislature passed Senate Bill 458 in late spring 2005. The legislation created a new standard: Las Vegas–area hospitals should transfer the care of patients from EMS to hospital staff within 30 minutes of an ambulance's arrival. Hospitals are not penalized for not meeting this standard. Instead, the legislation is intended to track trends, identify problems leading to delays, and promote change by making ambulance wait times at individual hospitals part of the public record.
The legislation gave area hospitals about nine months to develop a plan to meet the March 1, 2006, implementation date.
ED "Pit Crews" at Valley Hospital
Valley Hospital Medical Center is a 404-bed tertiary care hospital located in the heart of Las Vegas. Its 54-bed ED treats a wide range of patients: residents, a fair number of the city's 39 million annual tourists, the mentally ill awaiting a bed at a psychiatric facility, and geriatric patients transferred from area nursing homes.
When Jim Holtz, Director of Emergency Services for Valley Hospital, first heard about the new 30-minute standard for transfer of care, he recalls being "a little concerned." Wait times for EMS crews to offload patients at Valley Hospital ranged from 20 minutes to up to six hours, especially during the winter months. But, having worked as a paramedic, Holtz was also attuned to the perspective of EMS providers. "I knew we needed do a better job of getting them back on the street," he says.
Valley Hospital's emergency team developed "EM Xpress"—based on the "pit crew" model of car racing—to expedite the transfer of care between EMS personnel and the ED staff. The brainchild of Holtz, EM Xpress is based on a simple strategy: offload ambulance patients as quickly and safely as possible, minimizing downtime and getting EMS providers back on the road and able to respond to other cases.
The hospital hired EMTs to work as staff ED technicians. Now, during the busiest shift, there is always one ED tech to assist the ambulance crews in offloading patients. One EMS provider gives a report to the charge nurse while the other works with the ED tech to offload the patient to a bed or gurney. If an ED bed is not immediately available, the ED tech can move patients onto one of five gurneys located directly in front of the nurse's station. Then, based on standing orders from the medical director, ED techs perform initial workups. During quiet times, they can also help nurses with triage and other patient care needs. To expand the pool of ED techs, Holtz hired EMTs who were seeking additional hours and/or an opportunity to transition from the field to a hospital setting.
Faster Offloads, Increased Revenue
This new system has yielded impressive results:
- Between January 1 and September 12, 2007, the average transfer of care from EMT crews to ED staff was just under 10 minutes, down from an average of 19 minutes in calendar year 2006.
- Ambulance traffic increased 10% between March 1, 2006, and August 31, 2007.
- Total ED patient visits increased 10% between March 1, 2006, and August 31, 2007.
- Second-quarter 2007 Gallup patient satisfaction surveys placed Valley Hospital above the 80th percentile in terms of wait times, emergency department efficiency, overall nursing care, and quality of ED physicians.
Overall length of stay still averages four or more hours, but the ED team is working with hospital staff and ED physicians to reduce that figure as well.
Not surprisingly, reducing the offload times has improved the hospital's relationships with the ambulance teams. "We really built a rapport with our EMS providers," says Holtz. "It's a change of philosophy to think of them as partners. When they bring someone in, we think, 'This could be someone I know. We need to be able to respond in a timely manner.'"
"I think this model could work with other hospitals," says Holtz. "We took a creative approach, based on working together and doing the right thing for patients."
James L. Holtz
Director of Emergency Services
Valley Hospital Emergency Critical Care Center
Las Vegas, Nevada