听is a professor in the Department of Industrial Engineering at听.
A hospital鈥檚 emergency department (ED) has long been considered the canary in the coal mine for the health-care system: when it鈥檚 congested, the whole hospital is congested.
Routine and prolonged ED congestion has since led to declarations that patients waiting in an ambulance outside the ED are the new .
But when ambulances waiting outside the ED become routine and prolonged, another new canary appears: patients at home waiting for an ambulance. They may represent the truest analogy for the canary in the coal mine because they are and are a clear indicator that the health-care system is congested at a dangerous level.
Pinch points
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Delayed handovers of patients arriving by ambulance is a challenging health-care systems around the world. In the United Kingdom, the National Health Service has made eliminating handover delays one of its three priorty reforms for pre-hospital urgent care in its 10-year .
In , where health care is provided by provinces, have all experienced challenges handing over patients in a timely manner.
Australia has seen long lineups of ambulances queueing at hospitals, and has committed to hiring thousands of paramedics in an effort to combat in patient handover times.
Beyond ambulance handovers, delays and congestion also occur at other areas: the ED, wards and long-term care are some of the pinch points common in health-care systems around the world.
As an industrial engineer researching and working in health-care patient flow, this raises the question: where鈥檚 the next pinch point?
Code zero
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We know hospital congestion is routinely caused by , which occurs when patients are blocked from flowing through the system by a lack of downstream capacity. This is often rooted in an inability to discharge patients from the hospital, which is often due to lack of space in long-term care.
Naturally, this stalls the flow of patients, causing them to wait in ward beds to be discharged from the hospital, in ED hallways waiting for ward beds, in ambulances waiting for ED beds, and eventually at home waiting for an ambulance.
This last group represents a new pinch point. Although ambulances not meeting targeted response times is not new, it is a relatively new phenomenon that there are no ambulances available to respond to calls in a timely manner 鈥� a situation known as 鈥渃ode zero.鈥�
This new pinch point however, is substantially different from the others. The patients affected have not yet been seen by health-care providers, are not within meters of health-care services, and their urgencies are not known. These patients are at home, in unknown duress, waiting.
Patients waiting with an ambulance on the 鈥渞amp鈥� (known as 鈥渞amping鈥�) or in a hallway between the ED and the ward are known to be at for adverse outcomes. Patients with hospital stays prolonged by delay are likewise at for hospital-borne infections and adverse outcomes.
Less is known about patients waiting at home for an ambulance, but given their precarious circumstance, it is logical to assume they are also at high risk.
Patients at risk
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Many emergency services system evaluations in , and the have reported waiting times longer than performance targets. But the extent to which they are waiting is new.
It has become all too common to read about code zero situations, in which there are no ambulances available. Again there are reports from , the and . People are dying while waiting.
In Australia, ambulance ramping and call delays were recently linked to .
In three examples from the U.K., a woman , a man to take him to the hospital, and an 87-year-old for an ambulance and then 13 hours in the ambulance at the hospital.
In all three U.K. cases, long handover delays and ambulance ramping were identified as the cause of ambulance unavailability.
System failures spilling over
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In Canada, the frequency of zero ambulances available , with offload delays identified as the number one cause. Code zeros are reported to be daily occurrences, with prolonged frequencies and durations . A woman in died after waiting seven hours for an ambulance.
A 鈥渃anary in the coal mine鈥� is an early indicator of potential danger or failure. The response was insufficient when the ED鈥檚 canary died, and the failure spilled over to the ambulance service. Now, with prolonged offload delays routinely causing zero ambulances to be available, the ambulance ramping canary isn鈥檛 long for this world either.
This time when the failure spills over, the 鈥渃anary鈥� at risk is not a metaphorical bird, but is instead a patient waiting at home for an ambulance.
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