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.

"No diversion": a qualitative study of emergency medicine leaders in Boston, MA, and the effects of a statewide diversion ban policy.

STUDY OBJECTIVE: We examine the attitudes of emergency department (ED) key informants about the perceived effects of a statewide ban on ambulance diversion on patients, providers, and working relationships in a large urban emergency medical system. METHODS: We performed a qualitative study to examine the effects of a diversion ban on Boston area hospitals. Key informants at each site completed semistructured interviews that explored relevant domains pre- and postban. Interviews were deidentified, transcribed, coded, and analyzed with grounded theory for emerging themes. We identified important themes focused on patient safety, quality of care, and relationships before and after implementation of the diversion ban. RESULTS: Nine of 9 eligible sites participated. Eighteen interviews were completed: 7 MD ED directors, 2 MD designees, and 9 registered nurse leaders. Although most participants had negative opinions about diversion, some had considered diversion a useful procedure. Key themes associated with diversion were adverse effects on patient care quality, patient satisfaction, and a source of conflict among ED staff and with emergency medical services (EMS). All key informants described some positive effect of the ban, including those who reported that the ban had no direct effect on their individual hospital. Although the period preceding the ban was reported to be a source of apprehension about its effects, most key informants believed the ban had improved quality of care and relationships between hospital staff and EMS. CONCLUSION: Key informants considered the diversion ban to have had a favorable effect on emergency medical care in Boston. These results may inform the discussion in other states considering a diversion ban.