# The Association Between Access Block And Ambulance Ramping, And The Impact of COVID‐19: A Retrospective Observational Cohort Study of 25 Queensland Hospitals

## TL;DR

This study shows that ambulance delays in hospitals increased during and after the pandemic, linked to hospital access block and worsened by limited ward bed availability.

## Contribution

This is the first study to explicitly model the relationship between ambulance ramping and access block across 25 hospitals.

## Key findings

- Ambulance offload delays (POST) worsened during and after the pandemic, with compliance dropping below 90%.
- Access block increased from 10% to 17% during the study period and is strongly associated with ambulance ramping.
- Shorter ED length of stay is linked to reduced ambulance ramping.

## Abstract

To explore the characteristics of ambulance ramping and its association with access block before, during and after the first wave of the coronavirus disease 2019 (COVID‐19) pandemic.

Retrospective observational study.

Exploratory data analysis and statistical modelling covering the ambulance–emergency department (ED) interface of the 25 largest public hospitals in Queensland between 1 January 2018 and 31 December 2022.

Primary outcome: The association between ramping, assessed as the ambulance performance target patient off‐stretcher time (POST) and access block, and how COVID‐19 affected these time‐sensitive processes. Secondary outcomes: The association between POST and ambulance response time and between ramping and ED length of stay.

A significant decline in POST performance was observed across the study period, with the mean difference between pre– and post–COVID‐19 periods being 13.1 min (95% CI, 12.9–13.3 min) and 8.9 min (95% CI, 8.7–9.1 min) for Priority 1 and Priority 2 responses, respectively. POST compliance within 30 min dropped from 74% (718,912) pre–COVID‐19 to 66% (694,633) during the first wave of COVID‐19 and 57% (309,815) post–COVID‐19, all below the 90% target. The proportion of patients experiencing access block increased from 10% (91,168) to 17% (87,757) over this same time period. Regression analyses revealed a positive relationship between POST and access block, response time and POST, and ramping and ED length of stay. Before COVID‐19, no significant relationship existed between POST and access block for triage category 1 patients, but longer POST was linked to a higher likelihood of access block for categories 2–5. This trend increased across all categories during and post–COVID‐19.

Achieving the POST target of transferring 90% of patients within 30 min is becoming more difficult, with performance declining. The strong association of POST with access block suggests that access block is driving ramping increases. To reduce delays, efforts should focus on improving access to ward beds and managing hospital capacity issues.

Delays in offloading ambulance patients into emergency departments (EDs) have increased dramatically in recent years and are frequently politicised.

To our knowledge, this study of the ambulance–ED interface at 25 hospitals is the first to explicitly model the relationship between access block and ambulance performance and reveals a strong association between ramping and access block. Shorter length of stay in the ED is associated with reduced ambulance ramping.

Ambulance ramping (offload delays) indicates access block issues within hospital systems, not delays in ED operations. Addressing ramping requires improving ward bed access and overall hospital capacity.