Although ambulance offload delay in Ontario Emergency Departments is a relatively new phenomenon, emergency department (ED) overcrowding has been a provincial and national issue for about 20 years. In February 2005, responding to issues raised by stakeholders such as Emergency Medical Service (EMS) and municipal officials in Ottawa and Toronto, Health Minister George Smitherman established the Hospital Emergency Department and Ambulance Effectiveness (HED&AE) Working Group to advise the Ontario Ministry of Health and Long-Term Care (MOHLTC) on ambulance offload times in EDs.

This report from the Working Group contains recommendations which, if implemented, will allow ambulances to "return to the street" in the short term, and reduce ED pressures in the longer term. In conjunction with other strategic initiatives such as the Wait Time Strategy, Primary Care Reform, and provincial critical care and transport medicine developments, there are opportunities to reduce the number of patients arriving by ambulance to EDs, maximize patient flow-through to provide access to appropriate hospital resources and, most importantly, improve the quality of the patient experience in the ED by providing timely and efficient access to care and services.

In order of priority the Working Group focused the recommendations on:

1. The needs of the patient,
2. Integrating the skills of health care providers effectively, and
3. Effective and efficient utilization of resources.

Also guiding the Working Group were principles related to the need for systemic solutions, for patients to receive optimal care in the right environment, and for patients to receive consistent standards of care and safety across the system.

The principal cause of Ambulance Offload Time (AOT) delay is lack of capacity to treat hospital in-patients, leading to prolonged Emergency Department Length of Stay (ED LOS) and ED overcrowding. Over the years, patients who would have been better cared for in alternate settings remained in acute care beds. As a result of hospital restructuring and financial constraints, acute care beds were reduced without the necessary community supports. This led to the care of in-patients in EDs, followed by ED overcrowding and consequent AOT delays leading to delayed ambulance response to 911 calls in the community.

Best practices are a key part of this report and will enable the appropriate stakeholders to improve practice and achieve benchmarks contained in the recommendations. Among these are:

• Equitable and medically appropriate distribution of those patients requiring ED care
• Timely access to diagnostic imaging, laboratory testing and specialty consultation and disposition
• Timely transfer to an in-patient unit, other facility or home

Both short-term and long-term solutions are required. Over the next few months ambulance offload delays must be significantly reduced as the system is currently approaching a breaking point in some areas of the province. In order to sustain improvement, implementation of the long-term recommendations is critical.

The recommendations are categorized into four groups:

1. Recommendations for the pre-hospital environment (Pre-Emergency Department), largely the responsibility of Emergency Medical Services and Primary Care groups
2. Recommendations for the ED, including standards for patient assessment, diagnostics, consultation and disposition
3. Recommendations to improve patient flow out of the ED to definitive care or follow-up (Post-Emergency Department), including timely transfer to in-patient units and other hospitals when necessary, and access to services that are not acute
4. Oversight and accountability, including key performance indicators, benchmarks and recommendations for stakeholder accountability for achievement of the benchmarks.

The full report may be downloaded from the link below.

REPORT Improving Access to Emergency Services : A System Commitment 43 pages / 459 K / PDF format

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Summer 2005