The influence of ambulance offload time on 30‐day risks of death and re‐presentation for patients with chest pain

Abstract

mbulance offload times are an increasing problem in Australian health care. Overcrowding in emergency departments (EDs) is causing more frequent and longer delays of ambulance-to-ED transfers. [1][2][3] The adverse effects of offload delays at the system level include associations with poorer ambulance response times, greater access block, longer ED and admission times, and cancellations of elective admissions and procedures. 2,3 The impact of offload delays at the patient level is less clear. Several studies have found delays to assessment and treatment, 4,5 but implications for clinical endpoints such as mortality and re-admission have not been examined in detail.Nearly one in ten calls for ambulance transport in Australia are for people with chest pain, who subsequently receive diagnoses ranging from the benign to the urgent, such as acute coronary syndrome and acute aortic pathology. 6 As timely care is associated with better outcomes for people with a variety of conditions that cause chest pain, 7-9 they are an ideal group in which to examine the influence of ambulance offload time on clinical outcomes.In a large population-based study of ED presentations by people with non-traumatic chest pain, we assessed whether ambulance offload time influenced the risks of death or ambulance reattendance with chest pain within 30 days of the initial ED presentation. MethodsWe undertook a population-based observational cohort study of consecutive presentations by adults with non-traumatic chest pain transported by ambulance to Victorian EDs during 1 January 2015 -30 June 2019. To follow the complete patient journey, pre-hospital data entered by paramedics into Victorian Ambulance Clinical Information System (VACIS) electronic patient care records were linked to the Victorian Emergency Minimum Dataset (VEMD), the Victorian Admitted Episodes Dataset (VAED), and the Victorian Death Index (VDI) (Supporting Information, table 1). Full details regarding the study population and linkage processes have been published, 10 and are also summarised in the Supporting Information (supplementary methods). Study populationConsecutive patients aged 18 years or more were included in our analysis if their VACIS records included pain in the chest, or they received a final or secondary ambulance diagnosis of ischaemic chest pain, acute coronary syndrome, acute myocardial infarction, pleuritic pain, or angina. We excluded patients with traumatic chest pain or ST elevation myocardial infarction (pre-hospital electrocardiography), and those who

Chest Pain Management Using Prehospital Point-of-Care Troponin and Paramedic Risk Assessment

“…Ambulance attendance data between January 1, 2015, and June 30, 2019, for consecutive adult patients with acute, nontraumatic chest pain without ST-segment elevation were linked to the Victorian Emergency Minimum Dataset and the Victorian Admitted Episodes Dataset to determine diagnoses and costs per episode of care. Full details regarding the cohort characteristics (sex, age, socioeconomic status, comorbidities, event location, and diagnoses) and linkage processes have been published previously and are included in the eMethods in Supplement 1. Indigenous Australian race was recorded in emergency or hospital data sets according to self-report, with this being a mandatory question for health services at time of patient admission.…”

Hospital congestion: a market solution to address delayed transfers of care from hospital beds

“…The need for this approach is highlighted by current hospital “ramping” pressures in Australia, which is related to DTOCs and contributes to increased mortality risk 25 …”

Modelling the Application of Telemedicine in Emergency Care

“…According to the triage procedure, the hospital staff has very little knowledge of the actual status of the patients waiting in the ambulances (see Figure 1). However, offloading them more quickly into the emergency departments does not fix the problem about additional risks to patient health [15]. Due to the overload, patients may end up waiting a long time before they are attended to by emergency department staff [16], and paramedics may need to step in and provide services prior to the emergency department to alleviate the pressure [17], or an improvement of the workflow is needed to increase efficiency by building on existing resources [16].…”