Throughout my career as a field medic, I've spent countless hours in Emergency Departments (EDs), but I've always tried to avoid being a patient myself. However, last year, while vacationing, I found myself in an unexpected situation. During our morning run, my wife, as usual, sped ahead, leaving me to my own pace. With nearly 19,500 miles logged over the past three decades, I was confident in my stride. But that confidence took a hit when I missed a manhole cover and fell hard onto the concrete, landing on my left arm, ribs, and shoulder. Dazed and slightly embarrassed, I initially declined help from a concerned motorist. However, after my wife returned and saw my condition, she insisted we visit the local ED, just three miles away, to get an X-ray. 

Upon arrival at the ED, we quickly went through an insurance check and waited about 30 minutes before a triage nurse took my vital signs. Although she was pleasant, I was surprised she didn't check my breath sounds. She ordered X-rays for my shoulder but not for my ribs, which I later found out were broken. The X-rays confirmed a humerus fracture extending into the humeral head. The doctor provided a sling and a prescription for painkillers, advising me to follow up with an orthopedic specialist. Reflecting on my ED visit, I found the staff to be professional and kind, and I was grateful it wasn't a busy day, even though the 3.5-hour wait felt much longer. 

Frustrating Busy EDs 

Ironically, one of the biggest frustrations for EMTs and medics working in urban areas isn't navigating traffic congestion—it's the congestion they face once they arrive at the Emergency Department (ED). 

Textbooks describe a smooth process: you arrive at the ED, report to the triage area with the patient on your stretcher, get a room assignment, and provide a detailed report to the nurse or team who will take over care. This report expands on any radio communication and includes details on how the patient responded to interventions. After transferring the patient, you wash your hands, complete the patient care report (PCR) while your partner disinfects and prepares the ambulance and stretcher. You might pick up any needed exchange items, take a quick bathroom break, and then head back to your district for another call. Ideally, this takes about 10 minutes, assuming you gathered most of the PCR information en route. If the patient was critical and required extensive care during transport, it might take a bit longer to clean up and gather information at the hospital. Some services expedite this process with an abbreviated "turnover report," providing the electronic PCR later in the shift. It sounds seamless, like something you'd see on TV. 

However, the reality today—and for the past 10 to 15 years in some areas—is that this process often stalls at the "report to triage area and get a room assignment" stage. In a very busy ED, this can take well over an hour, disrupting the entire flow and adding to the frustration of ambulance crews. 

Wonder What the Customers Expect? 

If you live in an area with multiple ERs and urgent care centers, you can check a website for average wait times. However, if you need an ambulance, the destination is often determined by protocols based on your condition, such as major trauma or cardiac issues. The "wait time" can be misleading, as it depends on the severity of your condition, ED staffing, and bed availability both in the ED and the hospital. 

Patients who walk in or arrive by taxi usually wait in the ER until they check in and see a triage nurse. For those arriving by ambulance, there's an additional wait known as "wall time," which is the period before the ambulance crew can hand off the patient to a triage nurse and secure a room or hallway stretcher. In some urban areas, this wall time can exceed an hour, during which the ambulance remains unavailable for other calls.  

I did a quick survey of the ten largest cities, by population, dropped in the downtown zip code and found the average wait time for most ERs on a typical Friday afternoon.  

I did find it interesting that the busiest ED in the Capital District of Albany, NY (where I previous worked and transported to many times) was 6 hours and 8 minutes. Clearly this is not just an urban issue. What’s missing in the chart above is the APOT for patients arriving by ambulance. 

What is the Emergency Medical Treatment and Labor Act (EMTALA)? 

The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law enacted as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (42 U.S.C. §1395dd). It provides that when an individual comes to an ED, they must be stabilized and treated, regardless of their insurance status or ability to pay. EMTALA is often referred to as the “anti-dumping” law and was designed to prevent hospitals from transferring uninsured or Medicaid patients to another hospital without, at a minimum, providing a medical screening exam to ensure they were stable for transfer. 

The law requires the hospital to provide a screening exam to determine if an emergency medical condition exists and, if so, provide stabilizing treatment to resolve the patient’s emergency medical condition. EMTALA also requires Medicare-participating hospitals with EDs to screen and treat the emergency medical conditions of patients in a non-discriminatory manner to anyone, regardless of their ability to pay, insurance status, national origin, race, creed, or color. 

How Does EMTALA Relate to Wall Time and the Ambulance Personnel? 

In July of 2006, the Centers for Medicare & Medicaid Services (CMS) issued an opinion addressing extended ambulance patient offload times and EMTALA:  

• ”This practice may result in a violation of EMTALA and raises serious concerns for patient care and the provision of emergency services in a community. Additionally, this practice may also result in a violation of 42 CFR 482.55, the Conditions of Participation for Hospitals for Emergency Services, which requires that a hospital meet the emergency needs of patients in accordance with acceptable standards of practice.” 

• “A hospital has a EMTALA obligation as soon as a patient presents at a hospital’s dedicated ED or on hospital property (as defined at 42 CFR 489.24(b) other than the dedicated ED, and a request is made on the individual’s behalf for examination or treatment of an emergency medical condition. A patient who arrives via EMS meets this requirement when EMS personnel request treatment from hospital staff.”

Studying the APOT Problem 

A study was conducted to begin to address APOT by defining and collecting California (CA) state-wide data in 2017. First an Ambulance Offload Delay Task Force developed a set of standard definitions and methodology to measure APOT for transported 9-1-1 patients. APOT is defined as the time "interval between the arrival of an ambulance at an ED and the time that the patient is transferred to an ED gurney, bed, chair or other acceptable location and the ED assumes responsibility for care of the patient." Local EMS agencies voluntarily reported data according to the standard methodology to the CA EMS Authority.  

Data were reported for 9-1-1 transports during 2017, from 9 of 33 local EMS Agencies, comprising 37 percent of CA’s population. These represent 830,637 ambulance transports to 126 hospitals. APOT showed significant variation by EMS agencies with half of the them demonstrating significant delays. Offload times vary markedly by hospital and by region. Three-fourths of hospitals detained EMS crews more than 1 hour, 40% more than 2 hours, and one-third delayed EMS by more than 3 hours.  

The authors concluded that, “This first step to address offload delays in CA consists of standardized definitions for data collection to address the significant variability inherent in obtaining data from 33 local agencies, hundreds of EMS provider agencies, and 320 acute care hospital EDs that receive 9-1-1 ambulance transports. The first year of standardized data collection of ambulance patient offload times revealed significant ambulance patient offload time delays that are not distributed uniformly, resulting in a substantial financial burden for some EMS providers in CA.”  (Statewide Method of Measuring Ambulance Patient Offload Times, Backer, H., D’Arcy, T., et al., Prehospital Emergency Care, 2019 May-Jun;23(3):319-326. doi: 10.1080/10903127.2018.1525456. Epub 2018 Oct 25.)  

Moving Forward with Legislation 

This has been a problem for the last two decades in California, and a lot of work has gone into trying to identify the issues and develop tools to document the extent of the problem, as well as strategies to help produce measurable reduction the wall-time. Collecting the appropriate reliable data is clearly a good starting point and then closely monitoring that data on a regular basis to see if interventions are effective. You can’t fix what you don’t measure! Rather than creating another reporting burden, the ePCR system (NEMSIS) was updated to incorporate a signature with a time for when the patient is actually transferred to the hospital’s representative (ie: RN, NP, PA, MD). In this way the data system can produce reports on the percentage of times APOT is within or exceeds the established standard (i.e., 30 minutes). For QA, specific calls that were outliers can be reviewed to try to determine the circumstances at that specific time and ED. Who gets a report on cases that exceed the APOT standards is also specified in the regulations.

The State of California Assembly developed AB-40, which expanded the Health and Safety Code to include section 1797.120.5 (c) which requires the development and implementation of an audit tool to improve the data accuracy of transfer of care with validation from hospitals and local EMS agencies. (regulations to implement AB 40 took effect on June 23, 2025.)

Specifically, AB 40 applies to all general acute care hospitals with emergency departments that receive ambulance-transported patients, as well as local EMS agencies and EMS transport provider agencies subject to ambulance patient offload time monitoring and reporting.

The purpose is to establish statewide standards, protocols, and tools designed to improve the accuracy, efficiency, and timeliness of APOT within California’s EMS system.

The Emergency Responder’s Role 

Understand the issue, and work with the system to implement solutions. Getting angry helps no one and simply tears down years of relationship building! Consider that solutions may involve data collection and measurements but the solutions are really about the improving care for the next patients using the system.

Clarify the myths and misinformation with facts and data. Over the years confusion has occurred since many EMTs were told if they left a patient on a stretcher in the ED hallway without “giving a report to a nurse” that could be considered a form of “abandonment.” In addition, many hospital staff believe that unless the hospital “takes responsibility” for the patient, the hospital is not obligated to provide care or accommodate the patient.

During the pandemic, the APOT problem intensified significantly with reports of EMS crews being held in EDs for over eighteen hours. There are multiple factors contributing to the problem such as: staffing issues (both EMS and ED), millions of new Medicaid patients seeking care in the EDs, high patient volumes, ED overcrowding, hospital through-put challenges. Bottom line here is that APOT is an issue affecting patient care and customer satisfaction which needs to be dealt with by both the hospital staff and the EMS providers.

Working in collaboration with the hospital staff and administration, we should start documenting the frequency and duration of wall-time in our local EMS system. If we do not, like other problems that have occurred in the past, the incidence and duration will rise to an unacceptable level in our community and ultimately someone will say “there needs to be a law with enforcement,” like what has occurred in California.

Best Practices: Sacramento County, California 

A recent article by Rob Lawrence from EMS1 tells the story how Sacramento County improved from the bottom of their state’s APOT performance rankings. The changes didn’t require a state mandate, expensive tech or finger-pointing. This transformation required leaders willing to show up, collaborate and hand over the mic to the people doing the work. 

While the collaborative work was being done, Sacramento’s 911 fire agencies also stepped up and implemented operational changes such as: 

• Dispatch drawdowns to avoid tying up resources on low-acuity calls 

• 50/50 protocols giving paramedics decision-making power to move stable patients directly to waiting rooms — without waiting for nurse permission 

• Surge plans activating private partners to cover when EMS system capacity dropped 

• BLS units and telehealth pilots to absorb and redirect volume appropriately 

The Sacramento County experience is a blueprint others can follow, and it starts with a room full of people, rather than a computer dashboard.  

In Summary 

A couple of comments for your consideration:  

• Don’t leave your station without plenty of supplies in case you do not make it back to the station for the rest of the shift. 

• Know what your Medical Director’s policy is on providing care for your patient while waiting on the wall in the ED. 

• Consider some of the useful resources (see below), existing policies, and best practices that have been developed in other areas. 

• We are all in this APOT “boat” so let’s all work together on solutions rather than complaining and finger pointing. 

• As always, be careful out there!

Some Useful Resources:  

• American Ambulance Association Wall time Tool kit – https://ambulance.org/2022/01/28/wall-times-toolkit/ 

• NAEMT wall time tool kit - https://www.naemt.org/WhatsNewALLNEWS/2022/01/28/wall-time-toolkit 

• https://emsa.ca.gov/wp-content/uploads/sites/71/2025/06/AB-40-APOT-Regulations-Reg-Text-_-FINAL.pdf 

• https://emsa.ca.gov/wp-content/uploads/sites/71/2017/07/Toolkit-Reduce-Amb-Patient.pdf

References 

• https://ambulance.org/2022/01/28/wall-times-toolkit/ 

• https://pubmed.ncbi.nlm.nih.gov/30257596/ 

• https://hospitalstats.org/ER-Wait-Time/ 

• https://emsa.ca.gov/wp-content/uploads/sites/71/2017/07/Toolkit-Reduce-Amb-Patient.pdf 

• https://www.tandfonline.com/doi/full/10.1080/10903127.2018.1525456 

• Statewide Method of Measuring Ambulance Patient Offload Times, Backer, H., D’Arcy, et al., Prehosp Emerg Care, 2019 May-Jun;23(3):319-326. doi: 10.1080/10903127.2018.1525456. Epub 2018 Oct 25.  

• https://www.ems1.com/ambulances-held-hostage/from-73-to-33-minutes-how-sacramento-reinvented-patient-offload-times

About the author: 

Bob Elling, MPA, Paramedic (retired) – has been a career paramedic, educator, author, and EMS advocate for 5 decades. He was a paramedic with the Town of Colonie EMS Department, Albany Times Union Center, and Whiteface Mountain Medical Services. He was also an Albany Medical Center Clinical Instructor at the HVCC Paramedic Program. Bob served as AHA National/Regional Faculty and participated in many successful life-saving legislative campaigns with the You’re the Cure Network. Bob served as paramedic and lieutenant for New York City EMS, a paramedic program director, and associate director of New York State EMS Bureau. He has authored hundreds of articles, videos, Blogs, and textbooks to prepare EMS providers for their career. Bob is the ECSI Medical Editor for the CPR and First Aid Series, Co-Author of EVOS-2, and Co-Lead Editor of Nancy Caroline’s Emergency Care in the Streets.