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Australasian Emergency Nursing Journal xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Australasian Emergency Nursing Journal

journal homepage: www.elsevier.com/locate/aenj

Case study

Concepts, antecedents and consequences of ambulance ramping in

the emergency department: A scoping review
Chris Kingswell a , Ramon Z. Shaban b,d,f,∗ , Julia Crilly c,d,e
a
School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Fraser Coast Campus, 161 Old Maryborough Road, Hervey Bay, Qld,
4655, Australia
b
School of Nursing and Midwifery, Griffith University, Health Sciences Building (N48), 170 Kessels Road, Nathan, Qld, 4111, Australia
c
School of Nursing and Midwifery, Griffith University, Clinical Sciences 2 Building (G16), Parklands Drive, Southport, Qld, 4215, Australia
d
Menzies Health Institute Queensland, Griffith University, Health Sciences Building (N48), 170 Kessels Road, Nathan, Qld, 4111, Australia
e
Department of Emergency Medicine, Gold Coast Health, 1 Hospital Boulevard, Southport, Qld, 4215, Australia
f
Department of Infection Control, Division of Infectious Diseases and Immunology, Gold Coast Hospital and Health Service, 1 Hospital Boulevard, Southport,
Qld, 4215, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Patients arriving at the Emergency Department (ED) via ambulance can experience a delay
Received 9 March 2017 in receiving definitive care. In Australia, this phenomenon is referred to as ‘Ambulance Ramping’, ‘Patient
Received in revised form 17 July 2017 Off Stretcher Time Delay’ or ‘Offload Delay’. As a direct consequence of crowding, and in the context of a
Accepted 30 July 2017
worldwide increase in ED and ambulance usage, hospital and ambulance service function is hampered.
Available online xxx
The aim of this review was to synthesize the literature with respect to the conceptualisation, meaning,
antecedents and consequences of Ambulance Ramping.
Keywords:
Methods: This was a scoping review and synthesis of the literature. Six search terms were employed: emer-
Ambulance ramping
Delay
gency medical technician; paramedic; ambulance; hospital emergency services; delay; and ambulance
Emergency nursing ramping. Journal articles that discussed Ambulance Ramping (or similar terms), and were published in
Paramedic English between 1983 and March 2015 were included. PubMed and CINAHL Plus databases were searched,
with secondary searches of reference lists and grey literature also undertaken.
Results: Thirteen papers were selected and inform this review. Several terms are used internationally to
describe phenomena similar to Ambulance Ramping, where there is a delay in patient handover from
paramedics to ED clinicians. Antecedents of Ambulance Ramping included reduction/limitation of ambu-
lance diversion, patient acuity, the time of day, the day of the week, insufficient ED staff, insufficient ED
beds, and high ED workload. Consequences of Ambulance Ramping include: further delays in patients’
ability to receive definitive care and workforce stressors such as missed meal breaks, sick leave and staff
attrition.
Conclusion: While the existing research literature indicates that Ambulance Ramping is problematic, little
is known about the patient’s experience of Ambulance Ramping; this is required so that an enhanced
understanding of its implications, including those for emergency nurses, can be identified.
© 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

Introduction co-morbidities [6]; poor accessibility of primary care providers,

The number of patients presenting to emergency departments
(ED) is increasing in Australia [1] and worldwide [2,3]. The
increased demand for ED services globally has been attributed
to a number of factors such as the growing elderly population
with disproportionate ED attendance [4,5]; increasing population
∗ Corresponding author at: Department of Infection Control, Gold Coast University
Hospital, 1 Hospital Boulevard, Southport, Qld, 4215, Australia.
E-mail address: r.shaban@griffith.edu.au (R.Z. Shaban).
particularly after hours [7]; changing health-seeking behaviours
[8]; and improved access to healthcare for socially disadvantaged
people [3,9]. Such factors have led to ED and hospital crowding,
and poor patient outcomes [10–13]. The challenge for the emer-
gency healthcare system is to deliver safe and effective health care
to an increasing number of patients in a timely, cost efficient man-
ner. Ambulance Ramping is a consequence of overcrowding and
involves a delay to definitive emergency care for patients arriving
to the ED by ambulance [14]. Ambulance Ramping may be unsafe

http://dx.doi.org/10.1016/j.aenj.2017.07.002
1574-6267/© 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Kingswell C, et al. Concepts, antecedents and consequences of ambulance ramping in the emergency
department: A scoping review. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.07.002
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Fig. 1. Measures of Ambulance Patient Delays in Triage and Handover in the ED. QH = Queensland Health; ED = Emergency Department.

for patients in the ED, and for patients in the community waiting
for an ambulance.
Inefficiencies at the ambulance–ED interface is an international
concern with reports arising within the US [15–18], Australia
[19–21], Canada [22] and the UK [23]. Delaying ambulances at
the ED creates resource inefficiencies and can impact on ambu-
lance response time and community safety. Understanding the
causes and consequences of Ambulance Ramping will better inform
research into the patient’s experience of the emergency health-
care system, which is necessary to inform the quality and safety of
this system [24]. This paper presents a synthesis of the literature
with respect to the conceptualisation, meaning, antecedents and
consequences of Ambulance Ramping.
Methods
This scoping review of the literature was designed to provide
an overview of a particular topic [25] − Ambulance Ramping.
Searches of databases PubMed and CINAHL Plus with Full Text
through EBSCO Host, was conducted to identify academic literature
on ambulances waiting in the ED. Six search terms present in article
titles were used: emergency medical technician; paramedic; ambu-
lance; hospital emergency services; delay; or ambulance ramping.
Only full-text academic articles published in English between 1983
and 2015 were included. Reference lists, related citations, emer-
gency healthcare journals, and grey literature searches were also
conducted using web-based search engines Google and Google
Scholar. The titles and keywords were screened for relevance (by
CK), with on-topic titles retrieved in full text, and related topics
retrieved in abstract version. Related papers reporting Ambulance
Ramping (or similar) were included. Papers were excluded if they
did not: document a delay in ambulance patient handover to ED
staff; detail any antecedents or consequences of delay in ambulance
patient handover to ED staff; or document delays of ambulance
crews within the ED. Data extracted (by CK) from included articles
were: author, year and country of study, study aim, definition of
ambulance ramping (or similar term), sample/population, and main
results/findings. Tables were used as structures to display and inte-
grate research findings. This was supplemented with an assessment
of level of evidence of the selected articles according to recom-
mendations of the National Health and Medical Research Council
(NHMRC) [26]. All articles included in this review were assessed
for their level of evidence and included regardless of their level of
evidence to provide a description of the current research in this
area. Regular meetings were held between the authors to discuss
the findings and reach consensus.
Results
The search yielded 761 potential papers. Thirteen articles met
our criteria for inclusion for review (see Table 1), with most being
multi-site studies from developed countries, and involving a geo-
graphical area serviced by a network of hospitals, with at least one
trauma center or tertiary hospital. Five single site studies were con-
ducted in Canada, the United States, and Australia. Assessing these
articles using NHMRC guidelines [26] revealed no level I (system-
atic reviews of randomised controlled trials (RCTs)), II (RCTs), or
III-1 studies (pseudo-RCTs). However, there were two level III-2
comparative case controlled studies; both had Ambulance Ramp-
ing as an outcome, and identified risk factors for the experience.
There were three level III-3 studies (interrupted time series stud-
ies without control group), and eight level IV studies − seven of
these were traditional observational studies (direct observation or
utilising ambulance service and hospital data), and one involved a
computer simulation.
Conceptualising ambulance ramping
Ambulance Ramping is a term mostly used in Australian studies
to describe a set of practices within the emergency healthcare
system, at the interface between ambulance services and EDs [21].
Ambulance Ramping was recently defined as “the situation where
patients transported to an ED by ambulance experience delays (of
more than 30 min) in offload from the ambulance trolley to an ED

Please cite this article in press as: Kingswell C, et al. Concepts, antecedents and consequences of ambulance ramping in the emergency
department: A scoping review. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.07.002

department: A scoping review. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.07.002
Please cite this article in press as: Kingswell C, et al. Concepts, antecedents and consequences of ambulance ramping in the emergency
Table 1
Studies exploring Ambulance Ramping.
Study
AMBULANCE TEMPORAL DEFINITIONS
Spaite, et al. [27] (USA)
Cone, et al. [28] (USA)
OBSERVATIONAL STUDIES OF AMBULANCES IN ED
Eckstein and Chan [17] (USA)
Segal, et al. [22] (Canada)
Cooney, et al. [16] (USA)
Clarey, et al. [29] (UK)
Design (level of evidence)*
Observational study (IV)
Observational study (IV)
Observational study (IV)
Observational study (IV)
Observational study (IV)
Observational study (IV)
Aim
To develop a time interval model
for evaluating EMS systems.
To examine the delivery interval of No definition.
EMS crews.
Evaluate the effect of ED crowding
on ambulance availability.
To quantify the time periods of
EMTs in a single ED.
Determine the median AOD.
Determine if AOD was associated
with ratings of ED crowding.
Evaluate the effectiveness of a
dedicated handover nurse to
reduce the time from arrival to
handover.
Definition of Ambulance Ramping
No definition.
Ambulances were “out of service”
15 min after arrival at ED.
No definition.
AOD = Ambulance Ramping
15 min to complete ambulance
handover
Sample/Population
300 patient care transfers (no
dates)
122 patient care transfers in a
University Hospital ED,
Philadelphia (no dates)
172,981 ambulance transports to
59 EDs in Los Angeles, from April
2001 to March 2002.
152 ambulance transports by
EMTs, in Montreal, Canada,
June–August 2003.
483 ambulance patients
transported to a Level 1 academic
trauma center over from March
2010 to March 2011.
Simulated ambulance patient
handovers, variable presentation
times, several models of ED
Handover Nurse rosters (models
varied by the number and shift
times of nurses).
AENJ-386; No. of Pages 8
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Results/Findings
Hospital interval of an EMS crew
delivery of a patient can be divided
into two distinct phases: a delivery
interval, and a recovery interval.
Delays in patient care transfer
C. Kingswell et al. / Australasian Emergency Nursing Journal xxx (2017) xxx–xxx
were “rare”; the average delivery
interval took less than 4 min.
ARTICLE IN PRESS
12.5% of all ambulances were
ramped. The average delay in
transfer was 27 min (IQR =
20–40 min).
Seasonal variability: AR (October) =
9.7%, AR (February) = 17.6%
Longest duration of AR = 405 min
Mean pre-triage interval = 8.79 min
(95% CI: 7.55–10.04)
Mean triage interval = 5.14 min
(95% CI: 4.49–5.79)
Mean post-triage interval =
31.33 min (95% CI: 29.08–33.58),
No causes of delay noted.
Mean TAT was significantly greater
(5 min), 07:30–10:00 h
Median AOD = 11 min (IQR: 5–21)
AOD significantly increased with
measures indicating increased ED
crowding, (p < 0.001).
72% of the time the reason for AOD
was ED bed availability.
1 dedicated ED Handover Nurse at
all times, 34% of ambulance
patients wait more than 15 min for
handover, 62% nurse utilisation.
3

Table 1 (Continued)
department: A scoping review. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.07.002
Please cite this article in press as: Kingswell C, et al. Concepts, antecedents and consequences of ambulance ramping in the emergency
Study
ANTECEDENTS OF AR
Sprivulis and Gerrard [30] (Aus)
Asamoah, et al. [31] (USA)
Vandeventer, et al. [32] (USA)
Cone, et al. [33] (Aus)
Burke, et al. [34] (USA)
Design (level of evidence)*
Interrupted time series without
controls (III-3)
Interrupted time series without
controls (III-3)
Observational study (IV)
A retrospective observational
study (IV)
Interrupted time series without
controls (III-3)
Aim
Evaluate pre-emptive ambulance
distribution with real-time,
Internet-accessible ED workload
schematic.
To determine the effect of limiting
ambulance diversion on
ambulance drop-off times.
To determine whether Hospital
TAT was associated with patient
acuity, destination hospital, or
time of day.
To describe the ambulance
turnaround interval.
To describe the ambulance
handover delay.
To identify variables that predict
handover delay.
To determine the effect of a
statewide ban of ambulance
diversion (in Jan 2009).
Massachusetts.
Definition of Ambulance Ramping
“Offload delay” (Ambulance
Ramping) > 20 min.
“Drop-off times” (TAT)
“Addition unit time”
>15 min
TAT
> 30 min considered delayed.
“Ambulance offload delay”
(Ambulance Ramping)
No record of Ambulance Ramping.
Ambulance turnaround time
recorded.
Sample/Population
Pre-trial: July–Sep/2002 (33,352
ambulance patients)
Post-trial: July–Sep/2003 (33,371
ambulance patients), 8 EDs in
Perth, WA.
73,295 ambulance transports to 10 After ambulance diversion was
EDs,
Pre-trial: Sep/2004–Feb/2005,
Post-trial: Sep/2005–Feb/2006
61,094 ambulance patient
transports between July/ 2008 and
June/2009 large, urban EMS
service, 7 EDs in the network
141,381 accurately reported
ambulance transports in NSW
during 4 months of 2009.
9 EDs, 77% of Boston and 100% of
Cambridge ambulance patients
4
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Results/Findings
2 dedicated ED Handover Nurses at
all times, 1% of ambulance patients
wait more than 15 min for
handover, 31% nurse utilisation.
This model does not take into
account the timings of bed
allocations, and ambulance
handover subsequent to this.
The proportion of people subject to
offload delay increased from 0.66%
to 0.67%.
C. Kingswell et al. / Australasian Emergency Nursing Journal xxx (2017) xxx–xxx
The mean patient offload delay
increased significantly by 12 min
(p < 0.001).
ARTICLE IN PRESS
limited, mean drop-off time
increased by 1.66 min (95% CI,
0.33–2.98).
Additional unit time across the
whole ED network increased by
178 h per month (95% CI 74–283)
(32%).
Significant association between
TAT and patient acuity; increased
acuity = increased TAT.
Significant association between
TAT and destination hospital;
increased ambulance presentations
= increased TAT.
Significant association of TAT with
time of day; increased TAT
between 0600 h and 1500 h.
The median TAT was 29 min (IQR:
20–42), the longest TAT was 9:51 h.
The median AR was 15 min (IQR:
9–25), the longest AR was 8:43 h.
Significant predictive factors of
handover delay include: aged over
65 years, large hospital size,
metropolitan location, arriving
between midday and 6 PM, and
arriving during Winter. A
significant predictive factor of not
experiencing handover delay is:
being a deteriorating patient.
Median TAT decreased by 2.2 min
(95% CI, −3.3 to −1.2) following
diversion ban.

department: A scoping review. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.07.002
Please cite this article in press as: Kingswell C, et al. Concepts, antecedents and consequences of ambulance ramping in the emergency
Table 1 (Continued)
Study
CONSEQUENCES OF AMBULANCE RAMPING
Hitchcock, et al. [20] (AUS) Case controlled, observational
study (III-2)
Hammond, et al. [21] (AUS)
*
Levels of evidence are determined according to the guidelines published by the National Health and Medical Research Council [25]; EMS = Emergency Medical Service; ED = Emergency Department; IQR = Interquartile
range; AR = Ambulance Ramping; EMT = Emergency Medicine Technician; CI = Confidence Interval; TAT = Turn-around Time; AOD = Ambulance Offload Delay; NSW = New South Wales; LOS = Length of Stay; Qld = Queensland;
ATS = Australasian Triage Scale; SEQ = South East Queensland.
Design (level of evidence)*
Cohort Study (III-2)
Aim
Identify the effect of ambulance
ramping on length of stay in ED,
in-hospital mortality.
To define ambulance ramping in
EDs. To identify antecedents to
ambulance ramping.
Definition of Ambulance Ramping
15 min allocated to complete
patient care transfer, after which
Ambulance Ramping occurs.
15 min allocated to complete
patient care transfer, after which
Ambulance Ramping occurs.
Sample/Population
Pre-trial: Jan to Dec 2008.
Post-trial: Jan to Dec 2009.
619 adult ambulance patients with
an offload time >15 min, 1238
matched patients with an offload
time <15 min. Single ED in
southeast Qld, June to August 2007.
10,043 patient presentations made Patients who experienced
via ambulance to 10 public EDs in Ambulance Ramping had a
Qld during May 2008. 3260
ramped ambulance patients were
compared with 5137 non-ramped
ambulance patients.
Paramedics and ED clinicians were Patients who experienced
interviewed.
AENJ-386; No. of Pages 8
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Results/Findings
Median ED LOS (admitted patients)
decreased by 10.4 min (95% CI,
−19.2 to −1.6) following diversion
ban.
Median patient attendance rates at
EDs increased by 3.6% (95% CI,
0.7–6.6) following diversion ban.
Time to triage was longer for
Ambulance Ramping patients
(10 min, IQR: 5–17) than for
non-ramped patients (4 min, IQR:
C. Kingswell et al. / Australasian Emergency Nursing Journal xxx (2017) xxx–xxx
2–6), significant difference
(p < 0.001).
ED LOS > 8 h, increased frequency
ARTICLE IN PRESS
of Ambulance Ramping patients
(42.8%) than non-ramped patients
(33.9%), statistical difference
(p < 0.001).
No significant difference in
in-hospital mortality was
identified
Ambulance Ramping patients were
significantly more likely to: be ATS
category 3, arrive on Tuesday and
Thursdays, and arrive during
evening shifts (14:30–23:00).
significantly longer ED LOS:
Ambulance Ramping = 330 min
(IQR: 205–540), non-ramped
patients = 277 (IQR: 166–455),
significant difference (p < 0.001).
Ambulance Ramping also
experienced access blocked
significantly more often:
Ambulance Ramping = 47.4%,
non-ramped patients = 39.4%,
significant difference (p < 0.001).
Ambulance Ramping patients were
significantly more likely to: be ATS
category 3, arrive on Tuesday,
Thursdays and Fridays, and arrive
during day and evening shifts
(07:00–23:00).
Ramping is not practiced or
reported on in a consistent manner
across SEQ ED.
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Table 2 The antecedents of ambulance ramping

Time measures of Ambulance Ramping studies* .

Authors Time measures studied The antecedents of Ambulance Ramping and other similar phe-
Spaite et al. [27] (USA) TM2 nomena such as slow turnaround time and drop-off time appear
Cone et al. [28] (USA) TM1, TM2 to be similar globally. The antecedents of Ambulance Ramping that
Eckstein and Chan [17] (USA) TM2 have been documented include: i) limited ability for ambulance
Segal, et al. [22] (Canada) TM3, TM4 diversion [29–31] ii) patient acuity [20,32,33], iii) the time of day
Cooney, et al. [16] (USA) TM2
[20,21,32,33], iv) the day of the week [20,21], v) insufficient ED
Clarey et al. [29] (UK) TM2
Sprivulis and Gerrard [30] (Aus) TM2 staff [15,18,21], vi) insufficient ED beds [18,21], and vii) high ED
Asamoah et al. [31] (USA) TM1 workload [16,32].
Vandeventer et al. [32] (USA) TM1 Regarding the antecedent of ambulance diversion (the prac-
Cone et al. [33] (Aus) TM1, TM2
tice of redirecting ambulances to other EDs during time of ED
Burke et al. [34] (USA) TM1
Hitchcock et al. [20] (Aus) TM3 crowding), an Australian study [30] found this was associated with
Hammond et al. [21] (Aus) TM2 a significant increase in the duration of Ambulance Ramping by
Queensland Health [14] (Aus) TM5 12 min. A similar study conducted in the US [31] found that limiting
*
The time measures are displayed in Fig. 1. (Aus) = Australia; TM = Time measures. ambulance diversion significantly increased the drop-off time, and
significantly increased the ‘additional unit time’ (time ambulances
spent delayed) across the whole ED network. Whilst the results
from these two studies seem contradictory, the underlying driver
treatment area” [14]. Observational studies documenting the time for diverting ambulances is a department that is crowded and in
ambulance crews spend in the ED have been undertaken in the both studies, the practice of ambulance diversion did not impact
USA, Canada, the United Kingdom, and Australia between 1983 positively on Ambulance Ramping time.
and 2015. A wide range of terms similar in meaning to Ambulance Certain times of the day, days of the week, and season are also
Ramping have been used and include: patient handover delay; associated with increased rates of Ambulance Ramping. In Aus-
patient parking, patient off stretcher time and ambulance offload tralian studies, day and evening shifts have been found to be times
delay. Varied temporal measures used to report on ambulance of increased Ambulance Ramping frequency [20,21], and similar
times in the ED were identified in the literature (see Fig. 1 and trends have been reported in the USA [32]. In terms of days of the
Table 2). week, Ambulance Ramping occurs more frequently on Tuesdays,
While five different ambulance-related time measures in the Thursdays [20,21], and Fridays [21]. Further, regarding season, Eck-
ED were identified from the literature, the measure reflecting the stein and Chan [17] found Ambulance Ramping frequencies were
notion of off-load time is time measure 2 (Fig. 1). Offload time lowest in Autumn, and highest in Winter. The study by Cone et al.
begins with arrival at the ED and ends with the transfer of patient [33] where Ambulance Ramping was more frequent during winter
care [27]. Ambulance Ramping occurs when this time is longer (July) compared to other months.
than the acceptable timeframe to achieve patient transfer. Studies Studies of Ambulance Ramping found that moderate acuity
vary in their temporal definition of what constitutes an acceptable patients experience Ambulance Ramping more than high acuity
offload time, beyond which is considered to be a delay in the trans- patients [20,21,33], but this finding is not consistent within the
fer of patient care. Acceptable offload times ranging from 10 min included studies [32]. Moreover, ambulance patients presenting to
[18], and up to 30 min [16,33], have been published (see Table 3). large metropolitan hospitals experience ramping more often, and
Studies regarding Ambulance Ramping (and equivalent terms) have a greater chance of being ramped for more than 60 min [32,33].
have documented frequencies from 0.66% of ambulance patients
[30] to 38.1% [21]. However, these results are not directly compa-
rable, as the acceptable time delays were different (20 and 15 min The consequences of ambulance ramping
respectively). Long delays of over 1 h waiting for clinical handover
have been reported, with two studies finding delays of more than Several studies have explored the consequences of Ambulance
an hour occurred for 4.8% [33] and 8.4% [17] of ambulance arriving Ramping (see Table 1). Recent quantitative research has examined
patients. The longest duration of Ambulance Ramping reported in the effect of Ambulance Ramping on patient and health service out-
these studies was 523 min [33] (see Table 3). comes [20,21], including: longer time to triage [20], longer patient’s

Table 3
Studies on Ambulance Ramping in the Emergency Department: frequencies and durations.

Study Time Measure 2 terms and timeframes Frequency of delay Median duration of Ramping

Eckstein and Chan [17] (USA) >15 min >15 min = 12.5% 27 min (IQR: 20–40)
“EMS out of service” >1 h = 8.4% Longest duration = 405 min.
Sprivulis and Gerrard [30] (Aus) >20 min >20 min Pre-intervention = 38 min. (IQR 18–68)
“Offload delay” Pre-Intervention = 0.66% Post-intervention = 50 min. (IQR 25–108)
Post-Intervention = 0.67%
Hitchcock, et al. [20](Aus) >15 min Not documented 11 min (IQR: 6–21)
“Ambulance Ramping”
Hammond, et al. [21] (Aus) >15 min >15 min = 38.1% 22 min (IQR: 18–33)
“Ambulance Ramping” Longest duration = 215 min.
Cone, et al. [33] (Aus) >30 min >30 min = 17.3% AR = 17 min (IQR: 11–26)
“Handover delay” >1 h = 4.8% Longest duration = 523 min.
Cooney, et al. [16] (USA) >30 min Not documented 11 min (IQR: 5–21)
“Ambulance offload delay” Longest duration of AR = 157 min.
Clarey, et al. [29] (UK) >15 min 1 handover nurse: AR = 34% 1 hand-over nurse = 15 min
“Patient handover delay” 2 handover nurses: AR = 1% 2 hand-over nurses = 1 min
Simulation model data

Aus = Australia; EMS = Emergency Medical Service; AR = Ambulance Ramping; IQR = Interquartile range.

Please cite this article in press as: Kingswell C, et al. Concepts, antecedents and consequences of ambulance ramping in the emergency
department: A scoping review. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.07.002
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C. Kingswell et al. / Australasian Emergency Nursing Journal xxx (2017) xxx–xxx
length of stay [20,21], higher levels of access block (i.e. admitted
patients spending longer than 8 h in the ED because of a lack of
inpatient bed capacity) [20,21], and admission rate [21]. Each of
these outcomes were worse during times of Ambulance Ramping,
or for patients who experienced Ambulance Ramping.
Another consequence is a delay in the ability to triage new
ambulance arriving patients. This delay can be significantly longer
for patients who experience Ambulance Ramping compared to
patients not experiencing Ramping [20,22]. The implication of this
delay to triage was noted in a qualitative study [21] that described
a three-phase triage process: an initial first check of all ambu-
lance patients to identify high acuity patients; a second phase of
formal triage; and a third informal triage of all patients waiting
for a bed when a bed became available to identify the priority
patient [21]. In this report by Hammond et al. [21] ED shift coordi-
nators and triage staff were often affected by Ambulance Ramping,
and reported high levels of stress and trends of work avoidance.
Paramedics also reported increased stress due to missing breaks
and working mandatory overtime, verbal and sometimes physical
abuse, an inability to give their patients the care they require, and
an inability to perform their primary role of responding to medi-
cal emergencies in the community. Resignations were reported by
paramedics due to stress and frustration with Ambulance Ramp-
ing. Paramedics and ED clinicians agreed that patients experiencing
Ambulance Ramping receive care that is ‘suboptimal’ [21]. Notably,
this study reported high levels of ambulance ramping (38%) [21].
Other factors may have impacted on the workforce that contributed
to the negative staff views on issues other than or in addition to
Ambulance Ramping.
Discussion
This scoping review of the literature highlighted several
antecedents and consequences of Ambulance Ramping that have
implications for patient outcomes. Implications for paramedics and
ED nursing and medical staff are less prominent in the literature. A
concerted effort for more consistent use of definitions and outcome
measures used to report on Ambulance Ramping is required. The lit-
erature available on the subject of Ambulance Ramping was mostly
quantitative and observational. The ethical concerns of random
allocation to conditions of delayed treatment prohibit collection
of higher level evidence through an RCT. In the absence of a level II
study, an international multi-site study, employing identical tem-
poral definitions and outcome measures for Ambulance Ramping,
would demonstrate the global nature of this phenomenon. A time-
motion study of EDs in developing countries would also be of value
to determine whether patients arriving by ambulance experience
delays in the transfer of their care to the ED clinicians. In this review,
only a few qualitative studies were identified that focused on the
paramedics and ED clinicians perspective of Ambulance Ramping.
The patient perspective of Ambulance Ramping has not yet, as far
as we are aware, been accounted for, but is certainly warranted so
that ED clinicians (nurses and doctors) can advocate for them effec-
tively. Without this knowledge, ED clinicians must remain sensitive
to the needs of patients who are delayed in the ED and individualise
care to meet their needs.
Whilst the patient perspective of Ambulance Ramping is yet
to emerge from the literature, the patient perspective of a closely
related subject, ED crowding, has been studied and warrant con-
sideration. Patients experiencing crowding in ED reported being
treated without dignity or compassion, a lack of privacy, feelings of
physical insecurity, and a lack of information from staff regarding
their care [34,37]. Despite these experiences, patients were reluc-
tant to complain about the care they received through fear that it
would compromise future care, and that other patients would miss
Please cite this article in press as: Kingswell C, et al. Concepts, antecedents and consequences of ambulance ramping in the emergency
department: A scoping review. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.07.002
7
out if they received better care [34,37]. Patients withheld informa-
tion from clinicians for reasons of compromised privacy and refused
thorough physical examination [35]. Patients also expressed a
reluctance to return to the ED in the future [34,37]. Sun et al. [36]
found that a communication breakdown and unmet expectations
of care were great predictors of future ED usage. These findings may
hold true for patients experiencing Ambulance Ramping, however
further research is warranted.
Limitations
This literature review was limited in certain elements. First, only
English language articles were reviewed and so there may be a
language bias. Second, we only included reports where the term
Ambulance Ramping (or similar) was evident in the title. Thus,
articles may have been missed if the term was mentioned in the
abstract, but not the title. Third, we may have not captured reports
from other countries and health departments that use terms other
than those used in this review to describe Ambulance Ramping.
Fourth, one author undertook identification of studies and thus
there may be a selection bias. Fifth, this was a scoping review of
the literature. Whilst scoping reviews tend to take a ‘less formal’
approach than systematic reviews, this approach fit with the pur-
pose of the review, which was to provide an overview of a particular
topic − Ambulance Ramping.
Conclusion
This scoping review of the literature highlighted several
antecedents and consequences of Ambulance Ramping that have
implications for patient outcomes. Implications for paramedics and
ED nursing and medical staff are less prominent in the literature.
In order to inform practice, further focus on the potentially mod-
ifiable antecedents of Ambulance Ramping is required along with
qualitative research designed to understand the human impact of
Ambulance Ramping. This is necessary to bring some balance to the
knowledge and focus of Ambulance Ramping.
Funding
There was no funding associated with this manuscript
Provenance & conflict of interest
• Author Chris Kingswell has no conflicts of interest to declare.
• Author Professor Ramon Shaban is Editor-in-Chief of the Aus-
tralasian Emergency Nursing Journal but had no role in the peer
review or editorial decision-making of the paper whatsoever, and
was blinded to the submission in the Elsevier Editorial System.
• Author Professor Julia Crilly has no conflicts of interest to declare.
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