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Offload zones to mitigate emergency medical services (EMS) offload delay in the emergency department: a process map and hazard analysis

  • Alix J.E. Carter (a1) (a2) (a3), James B. Gould (a2), Peter Vanberkel (a4) (a5), Jan L. Jensen (a1) (a3), Jolene Cook (a2), Steven Carrigan (a6), Mark R. Wheatley (a6) and Andrew H. Travers (a1) (a2) (a7)...

Abstract

Introduction

Offload delay is a prolonged interval between ambulance arrival in the emergency department (ED) and transfer of patient care, typically occurring when EDs are crowded. The offload zone (OZ), which manages ambulance patients waiting for an ED bed, has been implemented to mitigate the impact of ED crowding on ambulance availability. Little is known about the safety or efficiency. The study objectives were to process map the OZ and conduct a hazard analysis to identify steps that could compromise patient safety or process efficiency.

Methods

A Health Care Failure Mode and Effect Analysis was conducted. Failure modes (FM) were identified. For each FM, a probability to occur and severity of impact on patient safety and process efficiency was determined, and a hazard score (probability X severity) was calculated. For any hazard score considered high risk, root causes were identified, and mitigations were sought.

Results

The OZ consists of six major processes: 1) patient transported by ambulance, 2) arrival to the ED, 3) transfer of patient care, 4) patient assessment in OZ, 5) patient care in OZ, and 6) patient transfer out of OZ; 78 FM were identified, of which 28 (35.9%) were deemed high risk and classified as impact on patient safety (n=7/28, 25.0%), process efficiency (n=10/28, 35.7%), or both (n=11/28, 39.3%). Seventeen mitigations were suggested.

Conclusion

This process map and hazard analysis is a first step in understanding the safety and efficiency of the OZ. The results from this study will inform current policy and practice, and future work to reduce offload delay.

Introduction

Le retard de déchargement des ambulances se définit comme la prolongation de l’intervalle entre l’arrivée des ambulances au service des urgences (SU) et le transfert de la responsabilité des soins donnés aux patients; le problème se produit généralement en période d’encombrement des SU. Des zones de déchargement (ZD) des ambulances, là où les patients arrivés en ambulance sont traités dans l’attente d’un lit au SU, ont donc été ménagées afin d’atténuer l’effet de l’encombrement des SU sur la disponibilité des ambulances. Toutefois, on connaît peu de choses sur la sécurité ou l’efficacité de ces zones. L’étude visait à schématiser le processus du concept des ZD et à mener une analyse des dangers afin que soient décelés les maillons faibles de la chaîne, susceptibles de diminuer la sécurité des patients ou l’efficacité du processus.

Méthode

Les auteurs ont mené une analyse des modes de défaillance (MD) des soins de santé et de leurs effets. Ont été décelés différents modes de défaillance (MD), et les probabilités qu’ils se produisent ainsi que le degré de gravité de leur incidence sur les patients et sur l’efficacité du processus ont été déterminés pour chacun d’eux, après quoi les auteurs ont calculé une cote de danger (multiplication des probabilités par la gravité). Chaque fois qu’une cote de danger était considérée comme « élevée », il y a eu recherche des causes premières et de moyens d’atténuation.

Résultats

Le concept des ZD se divise en 6 grandes étapes: 1) le transport des patients en ambulance; 2) l’arrivée au SU; 3) le transfert de la responsabilité des soins donnés aux patients; 4) l’évaluation de l’état des patients dans la ZD; 5) la prestation de soins aux patients dans la ZD; 6) la sortie des patients de la ZD. Soixante-dix-huit MD ont été relevés et, sur ce nombre, 28 (35,9 %) ont été jugés « à risque élevé » et classés en fonction de leur incidence sur la sécurité des patients (n=7/28; 25,0 %), sur l’efficacité du processus (n=10/28; 35,7 %) ou sur l’un et l’autre de ces éléments (n=11/28; 39,3 %). Ont été suggérées 17 mesures d’atténuation.

Conclusions

La schématisation du processus et l’analyse des dangers constituent la première étape de la compréhension de la sécurité et de l’efficacité des ZD. Les résultats de l’étude jetteront un éclairage nouveau sur la politique appliquée actuellement et sur la pratique en cours, ainsi que sur les futurs travaux visant à réduire les délais de déchargement.

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Copyright

Corresponding author

Correspondence to: Dr. Alix Carter, Dalhousie University, Department of Emergency Medicine, Division of Emergency Medical Services, Halifax Infirmary, Room 3022, 1796 Summer Street, Halifax, NS B3H 3A7; Email: alix.carter@gov.ns.ca

References

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1. Spaite, DW, Valenzuela, TD, Meislin, HW, et al. Prospective validation of a new model for evaluating emergency medical services systems by in-field observation of specific time intervals in prehospital care. Ann Emerg Med 1993;22(4):638-645.
2. Cone, DC, Davidson, SJ, Nquyen, Q. A time-motion study of the emergency medical services turnaround interval. Ann Emerg Med 1998;31(2):241-246.
3. Cooney, DR, Wojcik, S, Seth, N, et al. Evaluation of ambulance offload delay at a university hospital emergency department. Int J Emerg Med 2013;6(1):15.
4. Olshaker, JS, Rathlev, NK. Emergency department overcrowding and ambulance diversion: the impact and potential solutions of extended boarding of admitted patients in the emergency department. J Emerg Med 2006;30(3):351-356.
5. Schafermeyer, RW, Asplin, BR. Hospital and emergency department crowding in the United States. Emerg Med (Fremantle) 2003;15(1):22-27.
6. Richardson, LD, Asplin, BR, Lowe, RA. Emergency department crowding as a health policy issue: past development, future directions. Ann Emerg Med 2002;40(4):388-393.
7. Derlet, RW, Richards, JR, Kravitz, RL. Frequent overcrowding in U.S. emergency departments. Acad Emerg Med 2001;8(2):151-155.
8. Derlet, RW, Richards, JR. Emergency department overcrowding in Florida, New York, and Texas. South Med J 2002;95(8):846-849.
9. Ackroyd-Stolarz, S, Read Guernsey, J, Mackinnon, NJ, Kovacs, G. The association between a prolonged stay in the emergency department and adverse events in older patients admitted to hospital: a retrospective cohort study. BMJ Qual Saf 2011;20(7):564-569, doi:10.1136/bmjqs.2009.034926.
10. Mullins, PM, Pines, JM. National ED crowding and hospital quality: results from the 2013 Hospital Compare data. Am J Emerg Med 2014;32(6):634-639, doi:10.1016/j.ajem.2014.02.008.
11. Cooney, DR, Millin, MG, Carter, A, et al. Ambulance diversion and emergency department offload delay: resource document for the National Association of EMS Physicians position statement. Prehosp Emerg Care 2011;15(4):555-561.
12. Macrae, A, Wang, D, Blanchard, I, et al. UPSTREAMrelief: benefits on EMS offload delay of a provincial ED overcapacity protocol aimed at reducing ED boarding [Abstract]. CJEM 2012;14(S1):S4.
13. Karim, S, Carter, A, Ferguson, J, et al. The evolution of offload delay over a six year period in a provincial EMS system [Abstract]. Prehosp Emerg Care 2009;13(1):91.
14. Capital District Health Authority. Quarterly performance report emergency departments and system flow. 2011. Available at: http://www.cdha.nshealth.ca/system/files/sites/343/documents/quarterly-performance-emergency-february-2011.pdf (accessed July 2014).
15. Newell, K, Hemlin, A, Furlong, G. Offload delay—returning paramedic unit hours to the street: the Ottawa approach. Can Paramed 2013;36(3):20-22.
16. Hendry, L. The Intellegencer. $$$ for ambulance offloading. 2012. Available at: http://www.intelligencer.ca/2012/08/30/-for-ambulance-offloading (accessed August 2013).
17. DeRosier, J, Stalhandske, E, Bagian, JP, Nudell, T. Using Healthcare Failure Mode and Effect Analysis: The VA National Center for Patient Safety’s Prospective Risk Analysis System. J Qual Improv 2002;27(5):248-267.
18. Blanchard, I, Clayden, D, Vogelaar, G, et al. Adult prehospital rapid sequence intubation process map: a clinical management tool [Abstract]. Prehosp Emerg Care 2009;13(1):126.
19. Jensen, J, Walker, M, Denike, D, et al. Paramedic myocardial infarction care with fibrinolytics: a process map and hazard analysis. Prehosp Emerg Care 2013;17(4):429-434, doi:10.3109/10903127.2013.804136.
20. Bosley, S, Dale, J. Healthcare assistants in general practice: practical and conceptual issues of skill-mix change. Br J Gen Pract 2008;58(547):118-124.
21. Chan, PS, Krumholz, HM, Nichol, G, Nallamothu, BK. American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med 2008;358(1):9-17.

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