Holding the Wall

If you have ever worked on an ambulance in the State of California, then you probably already know what this article is about. “Holding the wall” is a term frequently used by EMS providers to describe the act of waiting for a bed assignment in the ED. If you haven’t experienced this, you’re probably reading this with a touch of confusion.

Allow me to explain.

Ambulance crews in most areas of California share the frustration of waiting for bed assignments. When the emergency department becomes over-filled with patients, the ambulance crews are typically instructed to sit with the patient – usually up against a wall, in a hallway – until a bed becomes available. It is not uncommon for crews to experience wait times of 2-3 hours. My personal record is 11.5 hours. During this time, the crew is not available to respond to emergency calls or perform any duties other than monitoring the patient. This creates a major problem for EMS systems as it decreases the amount of available ambulances in any given response area.

The Fresno Bee recently ran an article bringing attention to the problem: http://http://www.fresnobee.com/2014/02/15/3773014/emergency-services-nearly-paralyzed.html

This isn’t a new problem. Ambulance crews have been plagued with long wait times for over a decade. The California Nurses Association (CNA) fought for over 13 years and sponsored legislation to implement mandatory staffing ratios[ref]http://www.nationalnursesunited.org/issues/entry/ratios[/ref]. With the passage of AB 394 in 1999, the Department of Public Health was tasked with creating what they deemed to be fair and safe nurse-to-patient ratios[ref]http://www.leginfo.ca.gov/pub/99-00/bill/asm/ab_0351-0400/ab_394_bill_19991010_chaptered.html[/ref]. These ratios went into effect Jan 1, 2004 and remain in place today. While many argue that AB 394 improved patient safety and created a better working environment for nurses, it didn’t come without it’s share of problems. One of the unintended consequences of these policies is extended waiting times for ambulance crews.

The long waiting periods aren’t as much a product of limited bed availability as it is nurse availability. Emergency departments can throw extra beds in hallways, rooms, lounges, etc. What they usually can’t do is provide enough staff to manage those beds. So what does this mean for the ambulance crews? It means we either get to place our patient in the waiting room, or sit with them until a bed comes available. Obviously, the severity of the patient’s condition dictates which route we go.

“Holding the wall” can be a very frustrating task, especially if you don’t understand the staffing laws. I have seen many crews accuse the staff of being “lazy”, or even intentionally delaying the ambulance crews in an effort to divert other crews to other hospitals. This usually isn’t the case. It’s a system problem, not a nurse problem. Do some hospitals see this happening more often than others? Sure, but this is either due to different patient loads or different ways the hospitals have chosen to deal with the problem.

To compound the problem, more hospitals are shifting their attention to patient-flow in an effort to stay competitive. Many hospitals have implemented policies that direct the nursing staff to fill up all the ED beds regardless of the patient’s acuity, rather than dedicate a fixed number of beds to address the non-urgent patients. This practice often leaves no room for patients that actually have emergent conditions, hence the constant delay of ambulance crews.

What frustrates me about this situation is that the hospitals have effectively taken this from a hospital problem and turned it into an EMS problem. Most of them have flat out refused to address this issue. What’s even worse is how the EMS systems in California have essentially rolled over and allowed it to happen. Bottom line is, this is a problem that the CNA and Department of Public Health have created, and they need to fix it.

As far as the EMS systems are concerned, we have pretty much accepted it and tried to do what we can on our part to lesson the blow to our staffing needs. I have seen management go as far as to send a supervisor with several extra gurneys so that one ambulance crew can monitor all the patients waiting for beds while the others place the spare gurneys in their ambulances and clear the hospital. What I haven’t seen, is an EMS service force the hospitals to address the issue by refusing to wait and placing the patients in a bed or a chair.

I’m not advocating that we put our patients at risk, but we do need to shift this problem back to the people that created it. When the hospitals are forced to deal with a number of patients that exceeds their required staffing ratio, maybe they will go back to the Department of Public Health and demand that something be done to fix the problem. The DPH isn’t going to listen to us. In order for them to take action on complaints from EMS services, they would have to do something that rarely happens in government: Admit that they might have been wrong.

Now don’t get me wrong, I’m not bashing staffing ratios. I’m not a nurse and I don’t have enough experience or knowledge in the hospital environment to form an opinion on the matter. However, I will say that the issue of ambulance wait times wasn’t thought out when the bill was written, and it certainly isn’t being addressed now.

As it currently stands, the staffing ratio for non-critical ED patients is 4-1. Hospital administrators love to throw this in our faces and claim that they must follow the law. What’s ironic, that is that same law also states that there must be a nurse dedicated and available to answer EMS radio calls and that nurse can’t be included in the staffing ratio[ref]http://www.cdph.ca.gov/services/DPOPP/regs/Documents/R-37-01_Regulation_Text.pdf[/ref]. Correct me if I’m wrong, but with a few exceptions, that isn’t happening. I guess following the law is only important when they decide it’s important.

Back in 2011, I left California and moved to North Texas. During that time, I have transported patients to hospitals in areas ranging from Oklahoma to Houston. I have yet to wait on a bed assignment for more than 5 minutes. Actually, 5 minutes is considered a long wait to most of my peers. Is our system here perfect? No. Many would argue that the nurses here are over worked. Having said that, the patients are getting taken care of and the hospital staffing issues aren’t being pushed onto the ambulance crews.

Most of the hospitals in this area have addressed the increased workload by employing support staff in their emergency departments, such as paramedics. Obviously, a paramedic’s function in the ED is limited and they can’t replace the need for nurses. What they can do is perform tasks to help decrease the workload of the nurses. I’m not claiming that employment of paramedics in the ED is the answer. I’m simply pointing out that when a hospital is forced to deal with a problem like ED saturation, they come up with solutions.

The issue with EMS wait times isn’t going to go away until we get serious about addressing the problem. Filing “complaints” or “reports” with the same agency that wrote the law isn’t going to get us anywhere. As long as we continue to allow ourselves to take on the burden of the hospital’s staffing issues, they will never take any real action to address it.



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