POSITION STATEMENT ON AMBULANCE RAMPING

Transcription

1 POSITION STATEMENT Document No: S347 Approved: Nov-13 Version No: 01 POSITION STATEMENT ON AMBULANCE RAMPING (ALSO KNOWN AS OFF-STRETCHER OR AMBULANCE TURNAROUND DELAYS) Contents 1. Purpose Defining Ambulance Ramping Background Scope ACEM Position Key Definitions for Data Collection Data Points Responsibility for Data Capture Recommendations for Key Performance Indicators Time to Transfer of Care Time to Clinical Handover (times (e) (b)) Definitions References Dates and Notes PURPOSE This document provides the Australasian College for Emergency Medicine (ACEM) definitions, potential causes and consequences of ambulance ramping. Other terms relevant to the accurate measurement of ambulance service and Emergency Department (ED) interactions are defined, and recommended Key Performance Indicators (KPIs) suggested for monitoring these interactions. 2. DEFINING AMBULANCE RAMPING ACEM defines Ambulance Ramping* as the situation where ambulance officers and/or paramedics are unable to complete transfer of clinical care of their patient to the hospital ED, within a clinically appropriate timeframe, specifically due to lack of an available appropriate clinical space in the ED. *Across Australasia, ambulance ramping is also known as off-stretcher time delays or ambulance turnaround delays. 1 of 5

2 3. BACKGROUND Demand for emergency department and ambulance services is increasing across Australasia. Ambulance ramping has become increasingly common across Australasian hospitals (less so in New Zealand), with ED overcrowding and persistent severe access block for hospital beds significant contributing factors 1. Serious consequences impacting on the community and patient care due to ambulance ramping include: Delayed access to definitive assessment and care in the acute hospital setting 1, with these delays likely to be associated with the same poor outcomes already known to be associated with delayed emergency department care 2. Effects on the timeliness of ambulance responses, as there are fewer crews available to cover the same geographic areas 1. This is reflected in deteriorating response times for critical and emergent patients. Lost ambulance and personnel time for ambulance services, which either reduces ability and flexibility, or increases ambulance service and community costs due to additional overtime or the need for additional crews and ambulances 1. Potential impacts on funding and resultant financial penalties for ambulances and hospitals, as ramping affects key performance measures for ambulance services and EDs. Prolonged poor publicity for health systems, ambulance services, hospitals and EDs, leading to poor staff morale and poor public perceptions of key areas of the health system and personnel within that system. Increased stress and interpersonal conflict between patients, paramedics and ED staff SCOPE This statement is applicable to Australasian Ambulance Services, Emergency Departments and Acute Care Hospitals in general. 5. ACEM POSITION Ambulance ramping is now the most common reason for delays in patients being moved from an ambulance service to ED care (particularly in the Australian context). When it occurs, particularly on a regular basis, it is symptomatic of the overall health system s failure to deal with demand. Ambulance ramping puts patients and staff at unacceptable risk of poor clinical outcomes, both from unnecessary delays at individual hospitals, as well as reducing the ability to manage medical emergencies in the community in a timely manner. To understand where the delays are occurring, and how these are best resolved, ACEM recommends: a) Accurate national data parameters exist for uniform measurement of ambulance turnaround/off-stretcher times, particularly those times under the hospital s control. b) Accurate measurement of where, how and why these delays are occurring. c) Accurate measurement and reporting of effectiveness of ambulance ramping interventions. d) Vigorous research programs need to be promoted regarding the causes, effects and solutions to ambulance ramping, with a particular focus on whether national targets for access to emergency care are effect the incidence of ramping. 2 of 5

3 6. KEY DEFINITIONS FOR DATA COLLECTION ACEM believes the following definitions and data parameters to be appropriate for the measurement of ambulance turnaround times and transfer of patient care. 6.1 Data Points a) Ambulance arrival at the ED: Ambulance arrival at the ED should be measured according to when the ambulance arrives at the hospital ED designated ambulance entrance (the ramp) and the ambulance crew stops their vehicle. b) ED notification time Time recorded: when a paramedic with or without the patient (depending on whether there is ability to accept more patients into the triage area) comes through the ED entrance to the triage area and notifies the ED that they need to be triaged. This is the start time for the ED off stretcher/ambulance turnaround time. c) Patient triage time: Time recorded: triage assessment has been started, and the patient s details have been entered into the ED department s clinical administration system. d) Patient entry to the ED: Time recorded: when the patient physically enters the ED triage area on the ambulance stretcher*. This may be the same time as (c) Patient triage time (and should be when the triage area is free of delay). * This is not a two-way event, and any removal of patients back into ambulances due to reasons such as excessive crowding in triage area/s, should be reported as a sentinel event, other than to transfer the patient back home or to another institution after initial assessment at triage. e) Transfer of Care: Time recorded: when clinical handover to an appropriate staff member has occurred and the patient: Has been moved physically off the ambulance stretcher to an appropriate physical space in the ED; or Is for immediate discharge from the ED after initial assessment; or Leaves the ED with the ambulance service for a clinically appropriate transfer to another clinical service; or Discharges themselves against medical advice. f) Ambulance crew preparation time: Time recorded: once the ambulance crew notify the ambulance dispatch service they are ready for another job. This is the time following clinical handover of the patient, when ambulance crew activities such as cleaning, restocking and completion of paperwork may lead to further delays. This is not part of ramping delays. g) Ambulance egress time: Time recorded: the time that the crew leaves the hospital ambulance bay area (either for a new job, or to await a job elsewhere). 3 of 5

4 6.2 Responsibility for Data Capture Time recording for (a), (b), (d), (f) and (g) are the responsibility of the ambulance services. Time (c) is the responsibility of the hospital and/or ED. Time (e) and (d) should be recorded by both teams to allow for audit, and to avoid gaming. The time from (b) to (e) is the time that is subject to ED related delays, and should be used in measuring ramping (or off-stretcher delays or ED related ambulance turnaround delays) These time measurements can provide useful performance indicators, provided they are: Reliable and reproducible, and recorded in uniform across all jurisdictions. Auditable. The data must be independently analysed and reported, and available for public scrutiny. Data collection is automated wherever possible (e.g. electronic buttons, electronic tagging or push buttons) to facilitate consistency in recorded data and to reduce the risks of gaming. That both ambulance services and hospitals agree to measure and audit in the same ways within jurisdictions. 7. RECOMMENDATIONS FOR KEY PERFORMANCE INDICATORS ACEM recommends a uniform approach to definitions and data capture of ambulance service and ED activities, as they relate to arrival and clinical handover of patients, with agreed KPIs across Australasia for all patients, ambulance services and acute hospital systems. This will ensure (i) accurate measurement of ambulance service and ED performance and (ii) the efficacy of service improvement initiatives are accurately assessed and comparable, allowing better reproducibility and roll out of important initiatives. 7.1 Time to Transfer of Care In a well-functioning system, with good access to cubicles and beds, the time interval of ambulance arrival to clinical handover should routinely occur within 15 minutes and never more than 30 minutes. 7.2 Time to Clinical Handover (times (e) (b)) Within 15 minutes of arriving at an ED, 85% of patients should have their clinical handover completed. Within 20 minutes of entering an ED, 95% of patients should have their clinical handover completed. Within 30 minutes of entering an ED, 100% of patients should have their handover completed. Routine delays over 30 minutes are symptomatic of significant system failures or severe departmental overload, and if occurring regularly, should trigger a systematic review of the hospital and ED. Any episode over 60 minutes should initiate an incident review, which should be completed by a DEM and/or hospital administrator/s and appropriate ambulance service personnel. 4 of 5

5 8. DEFINITIONS ED overcrowding: Refers to the situation where Emergency Department function is impeded primarily because the number of patients waiting to be seen, undergoing assessment and treatment, or waiting for departure, exceeds either the physical capacity or staffing capacity of the Emergency Department 3. Access block: Refers to patients in the Emergency Department who require inpatient care but are unable to gain access to appropriate hospital beds within a reasonable time frame (of 8 hours) REFERENCES 1. Hammond, E., Shaban R.Z., Holzhauser, K., Crilly, J., Melton, M., Tippet, V., Fitzgerald, G.J., Eeles, D., Collier, J. & Finucane, J. (2012). An exploratory study to examine the phenomenon and practice of ambulance ramping at hospitals within Queensland Health Southern Districts and the Queensland Ambulance Service. Queensland Health & Griffith University: Brisbane 2. Hitchcock, M., Crilly, J., Gillespie, B., Chaboyer, W/, Tippett, V., & Lind J. (2010). The effects of ambulance ramping on Emergency Department length of stay and in-patient mortality. Australasian Emergency Nursing Journal: 13(1); Australasian College for Emergency Medicine (ACEM) (2009). P02 ACEM Policy on Standard Terminology. ACEM: Melbourne, Australia 10. DATES AND NOTES Approved by Council: November 2013 ooo Copyright Australasian College for Emergency Medicine. All rights reserved. 34 Jeffcott Street West Melbourne VIC 3003 Ph: Web: 5 of 5