title: Offload zones to mitigate emergency medical services (EMS) offload delay in the emergency department: a process map and hazard analysis.
abstract: Introduction Offload delay is a prolonged interval between ambulance arrival in the emergency department (ED) and transfer of patient care, typically occurring when EDs are crowded. The offload zone (OZ), which manages ambulance patients waiting for an ED bed, has been implemented to mitigate the impact of ED crowding on ambulance availability. Little is known about the safety or efficiency. The study objectives were to process map the OZ and conduct a hazard analysis to identify steps that could compromise patient safety or process efficiency.
  
  
  METHODS
  A Health Care Failure Mode and Effect Analysis was conducted. Failure modes (FM) were identified. For each FM, a probability to occur and severity of impact on patient safety and process efficiency was determined, and a hazard score (probability X severity) was calculated. For any hazard score considered high risk, root causes were identified, and mitigations were sought.
  
  
  RESULTS
  The OZ consists of six major processes: 1) patient transported by ambulance, 2) arrival to the ED, 3) transfer of patient care, 4) patient assessment in OZ, 5) patient care in OZ, and 6) patient transfer out of OZ; 78 FM were identified, of which 28 (35.9%) were deemed high risk and classified as impact on patient safety (n=7/28, 25.0%), process efficiency (n=10/28, 35.7%), or both (n=11/28, 39.3%). Seventeen mitigations were suggested.
  
  
  CONCLUSIONS
  This process map and hazard analysis is a first step in understanding the safety and efficiency of the OZ. The results from this study will inform current policy and practice, and future work to reduce offload delay.
authors.affiliation: *Emergency Health Services,Dartmouth,NS.
authors.forename: Alix J E
authors.initials: AJ
authors.lastname: Carter
authors.affiliation: †Department of Emergency Medicine,Dalhousie University,Halifax,NS.
authors.forename: James B
authors.initials: JB
authors.lastname: Gould
authors.affiliation: §Department of Industrial Engineering,Dalhousie University,Halifax,NS.
authors.forename: Peter
authors.initials: P
authors.lastname: Vanberkel
authors.affiliation: *Emergency Health Services,Dartmouth,NS.
authors.forename: Jan L
authors.initials: JL
authors.lastname: Jensen
authors.affiliation: †Department of Emergency Medicine,Dalhousie University,Halifax,NS.
authors.forename: Jolene
authors.initials: J
authors.lastname: Cook
authors.affiliation: ††Emergency Health Services,Halifax,NS.
authors.forename: Steven
authors.initials: S
authors.lastname: Carrigan
authors.affiliation: ††Emergency Health Services,Halifax,NS.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Wheatley
authors.affiliation: *Emergency Health Services,Dartmouth,NS.
authors.forename: Andrew H
authors.initials: AH
authors.lastname: Travers
mesh_terms: D000552:Ambulances; D003441:Crowding; D004632:Emergency Medical Services / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006801:Humans; D020380:Needs Assessment / Q000458:organization & administration*; D062209:Patient Handoff; D013997:Time Factors; D061665:Time-to-Treatment; D014187:Transportation of Patients / Q000379:methods
keywords: emergency medical services; emergency service; hospital crowding; process assessment (health care)