Emergency departments (EDs) are dynamic and complex practice environments. One aspect of ED care that can present particular ethical and medico-legal challenges is the management of ambulance offload delay.
In this article, ambulance offload delay refers to a situation where a lack of ED beds prevents incoming ambulance patients from being transferred to hospital staff. In this instance, patients remain on ambulance stretchers under the care of Emergency Medical Services (EMS).
Physicians who work in the ED may feel uncertain about their medico-legal liability and their duty to care for patients when ambulance offload delays occur. However, there are strategies members can use to optimize safe medical care and mitigate medico-legal risk when working in this complex environment.
Case scenario: Patient complains of delay in management of active chest pain
Shortly before midnight, a 63-year-old man is brought to the ED by EMS after the sudden onset of retrosternal chest pain. Triage is delayed due to high patient volumes, requiring the paramedics to perform an electrocardiogram (ECG) and administer aspirin in the hallway. The triage nurse shows the ECG to the ED physician, who circles an area of concern and verbally orders morphine and a repeat ECG every 15 minutes. However, the physician is unable to assess the patient himself because he is called away stat to the resuscitation room to assess a critically ill patient.
Over the next three hours, the patient is transferred to an ED bed and remains hemodynamically stable with intermittent chest pain, which is reported to the physician. Four hours after the patient’s arrival in the ED, the physician personally assesses the patient for the first time and determines the patient is having acute ischemic chest pain. Ninety minutes later, a repeat ECG demonstrates ST elevation in inferior leads with an increased repeat troponin at infarction levels. Six hours after the patient’s arrival, the physician prescribes clopidrogel and consults cardiology for a STEMI.
Once recovered from the myocardial infarction, the patient complains to the medical regulatory authority (College) about the lack of urgency on the part of the ED physician in assessing and treating him. The College is critical of the physician for not assessing the patient earlier and in person, particularly after becoming aware of the abnormal ECG. It notes the physician could have seen the patient in the hallway and not waited for the transfer to the ED bed. Alternatively, the College says, the physician should have asked for more detailed updates from the nursing staff.
When is a duty of care established?
A physician’s liability for harm suffered by a patient related to medical care will largely depend on whether the physician is found to have owed a duty of care to the patient. Generally speaking, a duty of care arises once a doctor-patient relationship is established.
When an ED physician performs an initial patient assessment, makes a clinical decision regarding the patient’s acuity, orders tests, or initiates treatment (including those delegated through a standing order or medical directive), the physician will likely be found to have entered into a doctor-patient relationship.
The duty of care can arise even if the physician has not had any personal contact with the patient. It can also arise if the initial assessment occurs in a hallway, an ambulance stretcher, or a temporary holding area. Refusing to see a patient may not mitigate your duty of care if the patient is in need of emergency treatment and you are aware of their condition.
The standard of care and ambulance offload delays
Physicians who owe a duty of care to a patient are expected to provide a specific standard of care. Failing to meet this standard may expose physicians to a regulatory authority (College) complaint or civil legal action.
When determining the relevant standard of care, a College or court will typically evaluate the decisions and actions of the physician in light of the facilities, equipment, and personnel available at the time. At least one court has stated that the standard of care will be influenced by the resources available and that physicians cannot reasonably be expected to provide care that is unavailable or impracticable due to scarce resources.2
When physicians are notified of a patient arriving in the ED but experiencing ambulance offload delay, they will generally be expected to act reasonably and to take the best interests of the patient into account. A College or court will be mindful of the challenging circumstances, but may find it unacceptable for a physician to leave a patient under the care of EMS alone if the physician knows the patient’s condition requires greater clinical involvement. The standard of care will likely be heightened once the patient has been registered and triaged in the ED, even if the patient is in a hallway or temporary holding area. In these circumstances, courts and Colleges will be unlikely to accept that a physician can evade a duty of care by simply declining to see the patient.
Team communication and situational awareness
While effective team communication is always essential in EDs, it becomes even more critical when patients are receiving care from paramedics. Physical distance between physician and patient may make it difficult for a physician to be aware of changes in the patient’s condition and may limit a physician’s situational awareness.
Team members should be encouraged to speak up when the patient’s condition changes or worsens. The team includes the patient and all healthcare workers who have a stake in the patient’s care—including EMS providers caring for patients waiting for an ED bed. Physicians should welcome and encourage input from all team members to maintain situational awareness of the patient’s status and acuity.3
When providing care in any public space, it is important to be alert to the challenges of maintaining patient privacy. This is especially true in crowded places such as hallways or temporary holding areas. Patient privacy can be enhanced by using temporary drapes or adjusting the volume or content of a conversation to better protect the patient’s personal health information.
Developing protocols to promote patient safety
Setting specific protocols for the effective management of patients experiencing ambulance offload delay can promote patient safety and reduce medico-legal risk. Such protocols might address, among other things: clear communication between EMS, the triage team, and the ED physician; the roles and responsibilities of various healthcare professionals when the ED is crowded; standards for record keeping; and ways of optimizing triage.
The bottom line
Emergency departments are under increasing stress due to ED crowding and issues related to access block.4 While physicians may not be able to fix the structural issues that are driving ED crowding, they can contribute to strategies that maximize safe care when ambulance offload delays occur.
- Use reasonable care—i.e. care that would be expected of a similarly qualified physician in a similar situation—when managing patients experiencing ambulance offload delay, even when providing only a rapid initial assessment.
- Recognize that refusing to see a patient who requires urgent care may put you at medico-legal risk. You may owe a duty of care to a patient before having personal contact with them.
- If a patient on an ambulance stretcher, in a hallway, or in a temporary holding area gives you reason for concern, ask team members and the patient to communicate any changes in condition. Work with the care team to ensure that appropriate protocols are in place to monitor and re-assess patients at reasonable intervals.
While based on a real case, some facts in this scenario have been altered to protect patient and physician privacy.
Mathura v Scarborough General Hospital,  OJ No 3960 (SCJ), aff’d 2000 CanLII 16852 (CA)
Canadian Medical Protective Association. CMPA Good Practice Guide: Situational Awareness. CMPA [cited 2020 Feb 25]
Innes, G. “Sorry—we’re full! Access block and accountability failure in the health care system.” CJEM;2015 March [cited 2020 Feb 18];17(2):171-179 DOI:10.2310/8000.2014.141390