Offloads In Ed's

[Niftymedi911]

I like the idea of putting patient's in traige....... but for us it's not just an idea, we are expected to triage accordingly and notifty the recieving hospital on telemetry, that the patient is canidate for triage. Most of the time they just annouce, transport to triage, but every once and while the charge will come, meet us at the door and ask what we got. If its something that cannot go out to the waiting room, we wait..... and wait...... and wait...... and wait..... It's gotten so bad I've even put in a request in to the hospital to install a 12" plasma TV with cable, some chairs and a radio in the EMS hallway at one said hospital bc almost every time I transport, it's a gaurrenteed 1 hr or more wait. The only response I got back was a very rude letter??? I don't know I was just thinking..... maybe a bit too much???? I kid you not I've waited for a bed in the hall 13 min with a STEMI alert......

Anyone got any ideas?? The triage one is an easy answer and like I said we're already doing it as much as we can.

[crotchitymedic1986]

I would actually invite you to convene a "summit" with a representative of each ems agency and each hospital, to see what could be done. Come to the meeting armed with stats and facts, as to how this is affecting your response to 911 calls. There are a multitude of strategies that could be employed, and you may find that the ER staff is on your side, as most of the time the load is pushed down on them with no help from above.

My policy was always, "I will give you 20 minutes", and then I am calling the House Supervisor. If they fail to respond to your request for a summit, or the summit fails, contact JCAHO. Again be ready with facts, not just opinions.

[KAThomas]

Let me tell you, the best ...

Coming into a medical facility (in lieu of the term Hospital, right.) at.... shift change.

Unless your patient is bleeding from the 3rd eyeball in their scalp... you are insignificant for the 27 minutes it takes folks to tell their counterparts what happened, is pending and to have a good shift. Completely ignored.

Now, I understand that there are a wide range of things happening at that time, having worked in an ER myself... but every single person is not supposed to be so engaged that you are on the periphery... until they can get themselves in order. Wow!

As you roll up to the bay and do a quick look at the watch for a "Destination" time for your paperwork, since that info is sometimes erroneous coming from dispatch, and you see you are close to the Witching Hour (yes, that'd be shift change not midnight)... you become completely awash with additional stress that is not needed based on the knowledge you just tacked on extra wait time.

How much time does it add to the "wall" holding event? Enough to be significant.

Makes me wonder how many folks from the Fire Authority and COBRA and Joint Comission and DHS and... actually make it out to see what's going on out there to the people they are suposed to be advocates for.

[FLMedic18]

Nifty, what happened to putting them on a stretcher and tot charge nurse? they were talking about that a while ago. while I was there, we hit 90 minutes at the farthest south in the county.

[JPINFV]

Everyone across the country should come to Los Angeles for a few ride-outs with any Private Ambo Service that provides trans for the 911 contracts and be sent BLS a few times. It'd make your hair fall out. The length of "wall time" varies tremendously. My personal longest was 6 hours. Yeah, it's a violation of the EMTLA policy but even when you complain who actually follows up and what is done about it?

I've never hit 6 hours, but I've come close to it at PIH. On the other hand, there are a few hospitals in So Cal (Hoag Hospital in Newport Beach) where the longest I've waited was 5 minutes, regardless of how busy they were.

[spenac]

Again start denying transport to those that don't need it, start talking to your medical director to get it implemented. Second hospital needs a triage nurse meet you and if patient does not need a bed move them to waiting room.

[Just Plain Ruff]

start charging an hourly waiting fee and billing it to the patient or better yet to the hospital. That will get the hospital powers that be to re-think that policy of letting the patient sit on the ems cots.

The first time a patient comes to the EMS service complaining about the wait time and billed wait time, you can tell them that it's because the hospital made us wait for 2 hours for a bed. They can then go to the hospital administration and complain.

If you start to bill the hospital for waiting the hospital will see the light. Then again, maybe not.

There is no easy answer to this.

[JPINFV]

Again start denying transport to those that don't need it, start talking to your medical director to get it implemented. Second hospital needs a triage nurse meet you and if patient does not need a bed move them to waiting room.

That's only part of the problem. The other problem is the SNFs and assisted living facility that sends anyone and everyone to the hospital. These are patients that can't or shouldn't be placed in the waiting room based solely off of past medical history. Shape up the nursing homes (maybe a bigger challenge than fixing EMS) and you'll fix a fair amount of ER problems on the sole fact that you're removing some of the patients that are least flexible with placement.

[tskstorm]

We all know NYC is a completely separate animal however, If a crew is at a hospital past 40 minutes and a Lt. is available, they will send the Lt. to come figure out whats wrong, if upon arrival we are getting unsatisfactory treatment from the Triage staff, we will call for a Lt. to come and deal with it.

In the event the hospital is just busy and neither the hospital nor the crew are being jerks, and there are 3 ambulances or more, in triage, for 30 or more minutes, the hospital will go on redirection. Redirection is almost like a miniature Diversion, Redirection acts like diversion where no new ambulances can go to that hospital however, the largest difference are 1 Diversion is a courtesy OLMC can still give us permission to transport to that hospital, Redirection you will get redirected to the next most appropriate hospital even with OLMC 2, Redirection is implemented by EMS not by the Hospital, its a management tool of our system, its also a punishment to the hospitals, in an age where hospitals are always looking for more money this is a way of keeping it from them. A lot of Triage nurses will take a 1 minute report find you a bed and sign and time an unfinished PCR and say give it to me when you're done just to keep the patient flow steady. A lot of times when multiple ambulances are in the Triage area waiting someone will remind the staff that the hospital will have to go on redirection if they don't get a move on, and when they hear those words they do move. I'm sure I'm missing some differences and I'm sure some other NYC personnel can add to this.

I don't know if the explanation of how things here work will help you any, my initial thoughts would be anytime you are waiting over 30 minutes notify your supervisor and have them notify appropriate hospital personnel.

[crotchitymedic1986]

following up on tskstorms thoughts. I knew of a trauma center that had its own hospital based ems service. they ran into the same problem of crews "waiting on the wall" for a bed or room. What they did, was to put extra ambulance stretchers in the area, and when a "second" truck from their organization got stuck on the wall, the second ambulance crew would take responsibility for the first crew's patient and their patient, then the first ambulance would go in service with one of the spare stretchers. If no other ambulance came in, a supervisor would wait with the patient to get signatures. Before anyone blows a gasket, the patients waiting on the wall were low-acuity (not active MIs or major traumas).