At the heart of the ambulance problem is patient handover time

When an ambulance is delayed at an emergency department (ED) not only is the patients enduring additional distress, but the ambulance is denied to someone in the community who may desperately need it.

The HSE knows this. Its National Ambulance Service (NAS) has come in for severe criticism in recent months after a series of deaths involving people who, despite having been triaged by dispatchers as needing an emergency response within 20 minutes, were left waiting for up to 45 minutes for the ambulance to arrive.

At the end of last year, in its National Performance Assurance Report, the HSE identified ambulance delays at emergency departments as a key obstacle to tackling the unacceptable situation where ambulances were repeatedly failing to meet the HSE's target response times.

Hospital turnaround times would “be an area of particular focus by the NAS in 2014”, said the HSE.

Ambulances delays at EDs are not of the NAS’s making. Paramedics cannot hand over a patient to an ED that is full to bursting point.

Emergency consultants across the State have spoken to The Irish Times of the unbearable pressure they are working under.

Just last week the Health Information and Quality Authority described the biggest ED in the mid-west, at Limerick Regional Hospital, as being so overcrowded as to be "unfit for purpose".

Four hours

To take this ED, figures released to Independent TD Denis Naughten last week on ambulance turnaround times show that the 1,128 ambulances that pulled up at Limerick Regional Hospital in April spent an average of 35 minutes waiting to hand over patients. Some 123 of them, or 11 per cent, waited over an hour – including six that waited three to four hours.

The figures obtained by Mr Naughten show that in April 6,206 ambulances, out of a total of 16,333 ambulance attendances at EDs in the month, were delayed for over 30 minutes outside EDs across the State.

Some 1,407 ambulance were delayed for over an hour, of which 1,225 were delayed for between one and two hours. Some 139 were waiting two to three hours; 35 for three to four hours; six for four to five hours; one waited between five and six hours outside Cork University Hospital, while one was left waiting between seven and 14 hours outside the ED at Crumlin Children's Hospital in Dublin.

In total emergency ambulances spent a staggering 8,153 hours and 52 minutes parked outside EDs waiting with their patients. Not only is this frustrating and distressing for the paramedics and patients but it is also dangerous. While ill and distressed patients are in ambulances or on ambulance trolleys they are not in an ED cubicle being cared for.

‘Particularly bad’

Dr Fergal Hickey

, spokesman for the Irish Association of Emergency Medicine, says overcrowded EDs and delayed ambulances are dangerous problems all over the country, but are “particularly bad” in Cork.

At Cork University Hospital ambulances waited on average 47 minutes in April, and 23 per cent of ambulances (213 in all) were waiting over an hour, including 30 that waited up to three hours and another four that waited between four and six hours.

In Dublin, Beaumont Hospital had the longest delays among adult hospitals. The average wait was 34 minutes, with 67 per cent (671 ambulances) waiting over 20 minutes and 11 per cent (124) waiting over an hour.

However the longest and most shameful delays in the capital were at the children’s hospitals.

At Crumlin Children’s Hospital – which receives ambulances from across the State – the average wait was 37 minutes, with 55 per cent (43 ambulances) waiting over 20 minutes and 12 per cent (10) waiting over an hour.

The average delay at Temple Street was 34 minutes, with 42 per cent (22 ambulances) waiting over the target 20 minutes, 9 per cent (6) waiting over an hour.

The NAS has in recent months drawn up, but not yet published, a strategy document which is to be a key component in its efforts to tackle this crisis.

Approved by the director of the National Ambulance Service , Martin Dunne, the Ambulance Turnaround Framework says: "The time taken to transfer responsibility for a patient's care from ambulance professionals to the acute hospital [emergency department] should not exceed....20 minutes."

The 13-page document says once the 20 minute barrier has been breached a complex “escalation process” will be triggered.

The process involves management in the hospital where ambulances are backed up telling the NAS “to allow the NAS to escalate early and provide assistance where possible to the effective streaming of inbound activity” – ie possibly divert ambulances to other hospitals.

If delays go beyond 30 minutes an NAS manager may be deployed to the hospital “to liaise onsite and secure immediate release of delayed resources”; or if delays are going beyond 40 minutes a senior NAS manager must contact the hospital general manager “to escalate delays and impact on the ability of NAS to respond safely – and agree actions and timeframe for resolution”.

If this does not bring delays back below 30 minutes, says the document, the area operations manager is “to escalate to NAS national director” – ie Mr Dunne – “for escalation to HSE national director for acute hospitals”.

Ambulance delays

If this “escalation process” was in place in April Mr Dunne would have likely been summoned to sort out ambulance delays on a daily basis and at every one of the State’s 33 EDs.

The great unmentioned in the NAS’s plan to address delays is resources.

It calls for neither more hospital beds to enable ED staff to move their patients out quicker and enable them to take in new arrivals faster, nor more ambulances/paramedics to ease the intense pressure on those that are struggling to keep up with the demands being made of them.