Ambulances held hostage

DrParasite

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Read the entire article here

some highlights:
Ambulances in virtually every part of the United States are experiencing significant delays while offloading patients in hospital emergency departments. While ED offload delays have long been a fact of EMS life in larger cities, the crisis has now infiltrated suburban and even rural areas of the country.

The origins of the current crisis are multifaceted. High ED demand (much of it for non-emergency conditions), inadequate hospital staffing, poor hospital throughput and other root causes have all conspired to cause extended wait times as ambulance crews attempt to transfer their incoming patients to hospital beds. For this reason, while the crisis is known by many different names, the most appropriate descriptor is “hospital bed delays.”
A common thread of this crisis is that EMS personnel and ambulance vehicles are being involuntarily held at hospital EDs – or hospital parking lots – until the hospital staff indicate that they are ready to “accept” the patient handoff. In most cases, hospital staff imply – or even directly state – that the EMS personnel are legally responsible for patient care until transfer is accepted by hospital staff. Ambulances and their crews are therefore held hostage, sometimes for hours on end, by hospitals who compel EMS personnel to remain with the patient until such time as the hospital indicates its willingness to accept responsibility for care.
But one thing has become crystal clear: these discussions and this collaboration needs to happen on a level playing field, and the field is currently not level. That playing field can be leveled, and productive discussions can be held and solutions found, if all the parties accept the following fact under federal law:

Hospitals can ask EMS personnel to remain with a patient in the ED, but once a patient has come to the hospital’s property, the hospital bears the legal responsibility for the patient, and EMS personnel remaining with the patient is purely voluntary under the law.
 

EpiEMS

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Thanks for sharing this!

This was the highlight for me:

Hospitals that deliberately delay moving an individual from an EMS stretcher to an emergency department bed do not thereby delay the point in time at which their EMTALA obligation begins. Furthermore, such a practice of “parking” patients arriving via EMS, refusing to release EMS equipment or personnel, jeopardizes patient health and adversely impacts the ability of the EMS personnel to provide emergency response services to the rest of the community. Hospitals that “park” patients [with EMS] may also find themselves in violation of 42 CFR 482.55, the Hospital Condition of Participation for Emergency Services.
From CMS, no less!

It would be interesting to see if EMS handover to a hospital that then delays care has been litigated.
 

Tigger

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It’s intriguing that this is also such a regional problem. There are some areas of this country where holding the wall is commonplace and others where it never happens. What gives?

I’m very appreciative to work in a place where I’ve truly never waited with a patient longer than the time it takes to clean a room. When the hospitals are packed and the patient does not need timely care, we put them in the waiting room (with transfer of care to the triage or charge nurse), and then off we go.
 

BobBarker

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We do IFT and Kaiser's are famous for accepting patients from other hospitals and having no beds available. It's not hard, if you don't have a bed available either don't accept the patient until you do or find another Kaiser that has space available. An ambulance shouldn't have to wait 9hrs with a patient that they accepted and pre-registered.
 

CbrMonster

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It’s intriguing that this is also such a regional problem. There are some areas of this country where holding the wall is commonplace and others where it never happens. What gives?

I’m very appreciative to work in a place where I’ve truly never waited with a patient longer than the time it takes to clean a room. When the hospitals are packed and the patient does not need timely care, we put them in the waiting room (with transfer of care to the triage or charge nurse), and then off we go.
i was flabbergasted when i did a short stint in santa barbara county and never once did i hold a wall, having come from working a over a decade in la and orange county. ive spent a literal entire 12.5hr shift holding the wall with a patient in la county at good ol st francis

Read the entire article here


some highlights:

The whole its only voluntary to stand with the patient at the "wall", yes, but then when is the transfer of care legally being done? because if a nurse doesn't take handoff then transfer of care isnt made and i was lead to believe that is patient abandonment. this raises a lot of questions and red flags in my mind.

after reading further into the article specifically obligations of hospitals and hospital property... am i the only one thats ran calls at hospital parking lots where the hospital staff did nothing and stood by because it wasn't there patient cause it was the parking lot and physically inside the hospital?
 
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CCCSD

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It’s intriguing that this is also such a regional problem. There are some areas of this country where holding the wall is commonplace and others where it never happens. What gives?

I’m very appreciative to work in a place where I’ve truly never waited with a patient longer than the time it takes to clean a room. When the hospitals are packed and the patient does not need timely care, we put them in the waiting room (with transfer of care to the triage or charge nurse), and then off we go.
I had to suggest that to my preceptor during a recert. Light bulb moment for him. I couldnt understand why they didn’t think of it before.
 

FiremanMike

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I had to suggest that to my preceptor during a recert. Light bulb moment for him. I couldnt understand why they didn’t think of it before.
Is it really that uncommon? We’ve been doing it here longer than I’ve been on the job (22 years)..
 
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DrParasite

DrParasite

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after reading further into the article specifically obligations of hospitals and hospital property... am i the only one thats ran calls at hospital parking lots where the hospital staff did nothing and stood by because it wasn't there patient cause it was the parking lot and physically inside the hospital?
Nope, I've done that too... I've also ran calls IN the hospital.

In most of those cases, EMS is used more as a transportation vehicle than a clinical provider, because most ER staff are not willing or able to leave the ER itself. Even if a visitor fell in a medsurg floor, EMS would be called to transport them down to the ER for eval, as the doctors and nurses couldn't/wouldn't treat them. in the parking lot, 9 times out of 10, hospital security would beat us to the parking lot and just walk the person to the ER.
 

Carlos Danger

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am i the only one thats ran calls at hospital parking lots where the hospital staff did nothing and stood by because it wasn't there patient cause it was the parking lot and physically inside the hospital?
This is actually very common. When I was new in EMS I worked inner city and there were two large hospitals in my zone whose parking lots we were regularly dispatched to for various reasons.
 

FiremanMike

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This is actually very common. When I was new in EMS I worked inner city and there were two large hospitals in my zone whose parking lots we were regularly dispatched to for various reasons.
The best is when people call 911 from triage for transport to a different hospital because the wait is too long…
 

OG EMT

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California has Nurse to patient ratios that are imbedded in law. 1 Nurse to 4 patients for the ED. So even if there are unoccupied beds in the ED, if they have maxed out the ratio you have to wait.
 
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DrParasite

DrParasite

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California has Nurse to patient ratios that are imbedded in law. 1 Nurse to 4 patients for the ED. So even if there are unoccupied beds in the ED, if they have maxed out the ratio you have to wait.
you really need to read the article; and if you think you know the laws better than two lawyers, I encourage you to leave that comment on the site, or direct your questions to the authors
 

EpiEMS

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California has Nurse to patient ratios that are imbedded in law. 1 Nurse to 4 patients for the ED. So even if there are unoccupied beds in the ED, if they have maxed out the ratio you have to wait.

Why does that become an EMS problem? PWW make it quite clear that a patient’s percent at the hospital means the hospital has an obligation to follow their EMTALA requirements and cannot use EMS as a crutch.

And that epitomizes everything wrong with California, the only state that has such a law specific to hospital departments.
 

Carlos Danger

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Why does that become an EMS problem? PWW make it quite clear that a patient’s percent at the hospital means the hospital has an obligation to follow their EMTALA requirements and cannot use EMS as a crutch.

And that epitomizes everything wrong with California, the only state that has such a law specific to hospital departments.
That law is a nursing union thing that of course purports to be about patient safety but really is about nothing more than creating more jobs for RNs.
 

Carlos Danger

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Some of the claims made in this article seem dubious. For instance, if it were true that it is a violation of federal law for EMS providers to remain with the patient while waiting for handoff and that it is likely also a Stark law violation (eye roll - is EVERYTHING we don't like a Stark law violation? For some folks the Stark law is like the grand theory that justifies every position they have on every healthcare related issue, no matter how far removed he issue is from physician self referral), then how do hospitals get away with the fact that it has been happening countless times a day all over the country for many years? Has it simply never occurred to any agency to use this legality to their advantage?

I'm no attorney though, so that's all beside my point, which is that the overall tone of the article - that these situations are solely the fault of the hospitals and thus solely the responsibility of the hospitals to fix seems a bit tribal to me, and definitely not written in a way that offers any suggestions on how to deal with the problem. It ignores the reality that these delays happen for multiple complex reasons that are healthcare-system wide issues, not usually just because the ED staff likes to take advantage of or somehow profit off of the EMS providers (as this article suggests), and not usually just because the hospitals are too greedy and cheap to pay enough to attract RNs, as the unions (who have had a hand in directly contributing to this problem) would have you believe.

The reality is that hospitals and ED's get ridiculously busy and backed up for a myriad of reasons and sometimes just don't have room or staff to accept patients. It's really that simple. Complaining about the ED not being able to take a patient right away because they are already well over 100% capacity is not at all unlike complaining that an EMS agency couldn't respond to a 911 call immediately because every one of their units were already on runs. I mean, it sucks and we all love to cast blame and look for simple solutions to complex problems (Why doesn't the EMS agency just hire more paramedics and buy more ambulances!?!? How freakin' complicated is that?!?), but sometimes it just is what it is and there are no easy fixes and it doesn't mean anyone is really doing anything wrong.

I'm not making excuses for hospitals that are chronically understaffed or mismanaged, I'm saying that hospitals don't like the situation either - I can assure you - and would have fixed the problem a long time ago if it were in their practical ability to do so.
 
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DrParasite

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How do hospitals get away with the fact that it has been happening countless times a day all over the country for many years? Has it simply never occurred to any agency to use this legality to their advantage?
in all likelyhood, yes; no one has ever pushed the issue, nor was anyone educated on the law, and how to apply it to their advantage
I'm no attorney though, so that's all beside my point, which is that the overall tone of the article - that these situations are solely the fault of the hospitals and thus solely the responsibility of the hospitals to fix seems a bit tribal to me, and definitely not written in a way that offers any suggestions on how to deal with the problem. It ignores the reality that these delays happen for multiple complex reasons that are healthcare-system wide issues, not usually just because the ED staff likes to take advantage of or somehow profit off of the EMS providers (as this article suggests), and not usually just because the hospitals are too greedy and cheap to pay enough to attract RNs, as the unions (who have had a hand in directly contributing to this problem) would have you believe.
I think you are misinterpreting the tone, and ignoring the facts that this is a hospital problem, not an EMS problem, and EMS should not be forced to provide free labor to the hospital, which is how many hospitals see them.
The reality is that hospitals and ED's get ridiculously busy and backed up for a myriad of reasons and sometimes just don't have room or staff to accept patients. It's really that simple.
No one said otherwise, but you aren't seeing the forest for the trees. Anyone who has transported to a busy ER knows that there are times knows that it gets busy, and nurses are running from patient to patient, and the waiting room is full. However, that is a hospital issue to resolve, not EMS
Complaining about the ED not being able to take a patient right away because they are already well over 100% capacity is not at all unlike complaining that an EMS agency couldn't respond to a 911 call immediately because every one of their units were already on runs. I mean, it sucks and we all love to cast blame and look for simple solutions to complex problems (Why doesn't the EMS agency just hire more paramedics and buy more ambulances!?!? How freakin' complicated is that?!?), but sometimes it just is what it is and there are no easy fixes and it doesn't mean anyone is really doing anything wrong.
Your EMS example is a great one, as that's the legit issue. Why should be the first responder agency need to staff extra units to babysit until an ambulance arrives? If EMS is routinely short on units, that's a systemic issue, and the EMS agency (or the AHJ) is responsible for solving an issue. Why is the FD staffing extra units, or spending hours tied up waiting for EMS to arrive, especially when there are fires with people trapped that they are unable to respond to because they are waiting for an ambulance?

Most ERs don't have the ability to handle an MCI with their current staffing levels (nor do most EMS agencies), so it's unreasonable for them to have enough staff to handle all of the patients when a school bus crashes into a daycare: the flip side is, that's not a routine day, and but if the ER doesn't have the staffing to handle the "routine" call volumes, that's an issue that the hospital management should be addressing
I'm not making excuses for hospitals that are chronically understaffed or mismanaged, I'm saying that hospitals don't like the situation either - I can assure you - and would have fixed the problem a long time ago if it were in their practical ability to do so.
We will have to agree to disagree on this one.

In many hospital systems (esp in Cali), hospitals have been using EMS staff as free labor. Why? idk, but likely because it's cheaper than having to budget for and staff for more nurses.

BTW, this isn't a dig at any of the staff who are actually working in the ER, who are often over worked and are not trying to be mean, but doing what they are told. Most of the staff are just trying to deal with a tough situation. But as I have said on these boards, it shouldn't be EMS's responsibility to provide free labor to the hospital, especially when doing so prevents us from doing our jobs which involve answering 911 calls in our home disticts.
 

Carlos Danger

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in all likelyhood, yes; no one has ever pushed the issue, nor was anyone educated on the law, and how to apply it to their advantage
It seems unlikely to me that the attorneys who wrote this article are the only ones in the country who are familiar with EMTALA. Or that ANY of the other lawyers who contract with EMS agencies or staff attorneys for health systems have ever considered this. JUST these guys, huh? Decades after EMTALA was implemented, they are the ONLY ONES who've thought of this being an issue?

In many hospital systems (esp in Cali), hospitals have been using EMS staff as free labor. Why? idk, but likely because it's cheaper than having to budget for and staff for more nurses.
That may be true in CA, but it actually doesn't make any sense elsewhere because in most places there are no rules on patient ratios in the ED. Also, wait times are known to be a big factor in patient satisfaction, so if all a hospital had to do to improve their throughout and efficiency (and thereby earn better Press-Ganey scores and potentially even decrease the likelihood of lawsuits) was hire some more RNs, why wouldn't they? What an RN earns is a drop in the bucket in the big scheme.

It takes a lot more than nurses to run an ED and get patients assessed, managed, and dispo'd. What about MD's? What about lab and radiology and all the other important ancillary services? When ED's are REALLY backed up, the lack of nursing staff isn't usually more than a contributing factor. It's normally a lack of inpatient beds, which can't be conjured from thin air or hired on in a hurry.
 

johnrsemt

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When I worked in Indianapolis we never had wait times like that: the longest we waited was for beds to be cleaned and made, and we would do that for the nurses.
 
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DrParasite

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Back when I was in NJ, including working on busy cities and transporting to rural hospitals, the longest I ever waited was 20 min; very rarely would we be stuck in the ER longer than 30 minutes... Most ALS patients had a bed within 10 minutes. I would wager that we had a bed once we spoke to registration and chatted with the charge nurse. ALS patients would usually have a bed assigned within 5 minutes of arriving (circling the drain patients had a bed once they walked in the door).

Where I am in NC, the EMS agencies tend not to spend more than 30 in the ER, unless it's a train wreck, and then it's not holding a wall, it's transfer, clean up, paperwork, etc.

I know people who work in NYC, and have never heard of crews spending the majority of their shift in an ER waiting for a bed. Stuck in traffic, sure, but not holding a wall (and I can attest that they do pack them in like sardines in some of the hospitals).

the first time I heard of crews holding a wall for hours was actually on this forum, so it is a concept that I haven't experienced first hand, but appears to be more common out west.
 

NomadicMedic

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Very common here in PA. There are several hospitals that have a standard three hour wait time for EMS crews.
 

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