When is a door not a door? The difference between documented and actual arrival times in the emergency department

A review on ambulance offload delay literature

Ambulance offload delay (AOD) occurs when care of incoming ambulance patients cannot be transferred immediately from paramedics to staff in a hospital emergency department (ED). This is typically due to emergency department congestion. This problem has become a significant concern for many health care providers and has attracted the attention of many researchers and practitioners. This article reviews literature which addresses the ambulance offload delay problem. The review is organized by the following topics: improved understanding and assessment of the problem, analysis of the root causes and impacts of the problem, and development and evaluation of interventions. The review found that many researchers have investigated areas of emergency department crowding and ambulance diversion; however, research focused solely on the ambulance offload delay problem is limited. Of the 137 articles reviewed, 28 articles were identified which studied the causes of ambulance offload delay, 14 articles studied its effects, and 89 articles studied proposed solutions (of which, 58 articles studied ambulance diversion and 31 articles studied other interventions). A common theme found throughout the reviewed articles was that this problem includes clinical, operational, and administrative perspectives, and therefore must be addressed in a system-wide manner to be mitigated. The most common intervention type was ambulance diversion. Yet, it yields controversial results. A number of recommendations are made with respect to future research in this area. These include conducting system-wide mitigation intervention, addressing root causes of ED crowding and access block, and providing more operations research models to evaluate AOD mitigation interventions prior implementations. In addition, measurements of AOD should be improved to assess the size and magnitude of this problem more accurately.

An organized system of emergency care for patients with myocardial infarction: a reality?

An organized system of emergency care is an essential requirement for the modern treatment of ST-elevation acute myocardial infarction. There is a strong need to deliver reperfusion therapy as soon as possible, with primary percutaneous coronary intervention being the preferred option if performed in a timely manner and thrombolytic therapy, particularly in the prehospital setting, being a good alternative if the primary percutaneous coronary intervention-related delay exceeds the equipoise. In this situation, emergency medical services have a primary role in rescuing patients from cardiac arrest, performing prehospital diagnosis, triage and treatment and safely transporting them to the most appropriate cardiological center, including interhospital transfer. A complete reorganization of the healthcare systems in different countries is frequently needed to build an ST-elevation acute myocardial infarction system of care, focusing on fast transport, use of telemedicine and diversion protocols to skip the unsuited centers.

Electrocardiographic recording and timeliness of clinician evaluation in the emergency department in patients presenting with chest pain

Acute chest pain (CP), a leading symptom of persons presenting to emergency departments (EDs), may represent a life-threatening emergency or nonurgent condition requiring routine outpatient follow-up. In either case, rapid provision of an electrocardiogram and clinician evaluation are essential for determining appropriate treatment or discharge from the ED. Data from the National Hospital Ambulatory Medical Care Survey were used to estimate the proportion of hospital ED visits for a chief symptom of CP in adults aged >or=25 years with documentation of both an electrocardiogram and mean and/or median wait time to see a clinician in the ED. In 2004, adults aged >or=25 years made nearly 5.3 million (men 2.5, women 2.8) CP-ED visits. Patients arrived by means of ambulance in only 25% of visits. Overall, a quarter of the patients with CP visits waited <10 minutes to see a physician in 2003 to 2004. Mean wait time was 36 +/- 1.7 (SE) minutes, an increase of 5 minutes from that in 1997 to 1998. In 2003 to 2004, provision of an electrocardiogram was documented for about 80% of all patients with CP-related ED visits and 90% of those with visits for undifferentiated or cardiac CP. The odds of having an electrocardiogram taken in the ED increased (p <or=0.05) for older adults, men, and those triaged as emergency cases (vs unknown or no triage) or who waited <10 minutes to see a physician (vs >or=10-minute wait time). A large proportion of visits were for undifferentiated CP (54%). Cardiac CP accounted for 16% (3% ischemic) and noncardiac CP accounted for 30% of visits. Median wait times for a physician were 12 minutes for those with ischemic CP, 15 minutes for those with other cardiac CP, 18 minutes for those with undifferentiated CP, and 25 minutes for those with noncardiac CP. From 1993 to 2004, ED visits for CP increased for younger (25 to 64 years) adults (1993: 15.6 per 1,000 population, 2.5 million visits vs 2004: 20.9 per 1,000, 4.0 million) and decreased for older adults (>or=65 years) (1993: 9.7 per 1,000; 1.5 million vs 2004: 7.3 per 1,000; 1.3 million). In conclusion, most ED patient visits for undifferentiated and cardiac CP included an electrocardiogram and timely clinician evaluation.