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Ambulance ramping is a symptom of a failing healthcare system

Hospital access block and ambulance ramping are terms more commonly seen and heard in the media in recent times, but what do they mean and why are they important?

What do they mean?

Hospital access block refers to the situation where patients in the emergency department requiring admission to wards, are waiting for more than eight hours for transfer.

Ambulance ramping refers to the situation where ambulances are lines up at emergency departments unable to offload patients due to the emergency department having reached patient capacity.  In NSW ambulance ramping is said to occur when patients are left waiting more than 30 minutes in ambulances before being transferred to the emergency department.   The aspirational target in NSW is for 90% of cases to be transferred from an ambulance to the emergency department within 30 minutes[1]. Sadly, every year sees a drop in the percentage meeting the target.

What’s the cause?

It appears to be universally accepted that there is no single cause for ambulance ramping but rather there is a multitude of factors which result in an increase in demand for treatment in emergency departments and a reduced capacity to meet the demand.

Emergency departments appear to be the bottleneck in the system. So why are they so congested?

Although there have been anecdotal indications that lower acuity care patients (who could otherwise be treated by GPs) have been clogging up emergency departments, the data suggests the opposite – that in fact an increase in lower acuity care patients in the emergency departments actually results in less delay for acute patients needing admission to wards and therefore a quicker availability of emergency bed spaces.[2]  Instead, delays and limited access to important services in the community are major factors driving demand for emergency department services. These include aged care services arising as the result of understaffing or lack of access to mental health services for those in need.[3]

The increased demand for emergency healthcare is coupled with a decrease in availability of wider healthcare services within hospitals. Beds in the emergency department cannot be freed up when patients ready for transfer to other wards or external services cannot be admitted as they too are at capacity.  The emergency department is caught in the middle – paralyzed as it were, unable to admit or discharge/transfer patients. It speaks of a healthcare system in crisis.

What is the effect?

During ambulance ramping, paramedics are unable to handover their patient which means they are no longer able to respond to other emergency calls. Instead they must wait with the patient in the ambulance bay or hospital corridor until they are transferred into the care of the emergency department.   This severely impacts response times for ambulance call outs which in turn creates unmanageable demand on call centres and results in callers not being able to get through to triple zero.

Both access block and ambulance ramping result in significantly poorer outcomes for patients whose diagnosis and treatment is delayed often resulting in a longer hospital stay and worse health outcomes.  Access block creates inefficiencies in the system as treating staff are diverted from dealing with acutely sick patients in order to maintain treatment for those waiting to be transferred out of emergency.  Overcrowding and under resourcing is a top workplace stressor for staff causing poor morale and burnout. [4]

How can it be resolved?

A recent article in the Guardian hit the mark when it said:

This is not an ambulance problem. It’s a health service problem and it’s a nationwide one.”[5]

More paramedics and ambulances without wider change is not going to solve the problem.  Creating capacity in the emergency department is key but it is a tough ask.  It requires an overhaul of the whole system beyond just the emergency room and the hospital.

Demand for emergency care out of hours is unable to be met when the progression of patients through the broader healthcare system is largely stalled.  Perhaps we need to rethink the traditional Monday to Friday working hours model which is the norm for most healthcare providers outside of the emergency department setting.  The blockage in the flow of the system reaches critical point relatively quickly when there is a large influx of patients into the emergency department (both by ambulance and independently) and a conversely slow trickle of patients leaving the emergency department.

The pressure builds when patients ready for discharge cannot leave because they are waiting for other services such as aged care, disability, mental health and social services or patient transport to become available.

According to a recent article written by paramedic and actuary Sophie Dyson, “Downstream capacity and patient flow are the system issues here.[6]

On 26 July 2022, the NSW Parliament established an inquiry into the impact of ambulance ramping and access block on the hospital emergency departments.  Submissions are currently open until 11 September 2022 with a hearing scheduled for early October.   The Hon. Greg Donnelly MLC, Chair of the Committee has said:

This inquiry will examine the causes of ambulance ramping, access block and emergency department delays. It will also consider the effects these issues have on patients, paramedics, emergency department and other hospital staff.”[7]

Encouragingly, the inquiry has a mandate to take a wider look at the impact of other variables in the system. The inquiry is not only tasked with evaluating the problems.  importantly, it will also evaluate existing measures put in place by NSW Health as well as explore solutions by reference to strategies used both nationally and overseas to address these issues.  Let’s hope it finds the answers to our broken system.

[1] https://www.ama.com.au/articles/ama-ambulance-ramping-report-card

[2] https://acem.org.au/Content-Sources/Advancing-Emergency-Medicine/Better-Outcomes-for-Patients/Access-Block

[3] https://www.theguardian.com/australia-news/2022/jul/18/paramedics-left-shaking-their-heads-as-ambulance-ramping-debate-misses-the-point

[4] https://acem.org.au/Content-Sources/Advancing-Emergency-Medicine/Sustaining-our-workforce/Workforce-sustainability

[5] https://www.theguardian.com/australia-news/2022/jul/18/paramedics-left-shaking-their-heads-as-ambulance-ramping-debate-misses-the-point

[6] https://taylorfry.com.au/articles/ambulance-delays-why-more-paramedics-is-only-a-short-term-fix/

[7] https://www.parliament.nsw.gov.au/lcdocs/other/17425/Media%20Release%20-%20New%20inquiry%20-%20Impact%20of%20ambulance%20ramping.pdf

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