Patient dependency: Nursing on the ramp

Wayne Varndell1,2, Elizabeth Ryan,1 Alison Jeffers1 and Nadya Marquez-Hunt1

1 Prince of Wales Hospital Emergency Department, Barker Street, Randwick, NSW, 2031.
2 Faculty of Health, University of Technology, Broadway, Sydney, Australia, NSW, 2007.

Background: Demand for access to emergency care continues to increase despite lack of acute care resources, frequently leading to ramping and delays in patient flow in the emergency department.  The number of patients ramped or occupying the ambulance bay has received increasing attention by the media. The emergency department (ED) is a dynamic environment, in which a high volume of undifferentiated patients with varying levels of urgency, must be assessed and treated in a timely manner, primarily by emergency nurses. However, the impact of ramping and increasing number of patients occupying the ambulance bay on nursing workload is not known.

Aim: To examine the degree of dependency (nursing workload) of patients occupying the ambulance bay using the Jones Dependency Tool (JDT).1

Method: Between September and October 2015, patients occupying the ambulance bay were evaluated using the JDT.  Patient characteristics were retrieved from the electronic patient health care record system.  Total direct nursing care time (TN) was calculated for each JDT level.

Results: A total of 640 patients occupied the ambulance, 205 (32%) were evaluated using the JDT.  On reviewing patient flow data, a mean average of 4 (SD 2, range 0-12) patients occupying the ambulance bay for nearly an hour (mean 0.9h; SD 0.7h; range 0.3h-4.8h).  Ambulance bay occupancy peaked at two distinct times, 13:00hrs and 17:00hrs, with the bulk (n=332; 51.9%) of patients presenting mid to late afternoon.  A total of 150.6 hours of direct nursing care were consumed by patients located in the ambulance bay.  Over the course of the study, there were few instances (n=24; 3.7%) when no patients were being cared for in the ambulance bay.  Patients being cared for in the ambulance bay typically originated from the waiting room (n=107; 52%), were male (n=106; 52%), aged 54 years (SD 22y), with semi-urgent symptoms (ATS 3, n=146; 71%) requiring acute area level care (n=152; 74%) and admission (n=103; 50.2%). Patients were largely (n=134; 65.4%) of moderate dependence, compared to those of total (n=2; 0.9%), high (n=2; 0.9%) or low (n=67; 32.7%) dependence.  Commonly direct nursing care related to reassessment (498 episode, TN=41.5h; 27.6%), pain management (186 episodes, TN=29.6h; 19.7%) and pathology collection (130 episodes, TN=28.2h; 18.7%). Moderately dependent patients waited the longest to exit the ambulance bay (1.1h; SD 0.7h), compared to patients who were of total (0.9h; SD 0.8h), high (0.3h; SD 0.1h) or low (0.5h; SD 0.3h) dependence, and received the most direct nursing care time (TN=104.1h; 69%). No correlation between triage category and JDT level was found (p=0.67).  JDT level significantly correlated to direct nursing time and likelihood of admission (p=<.001).

Conclusions:  Total numbers and triage category may be insufficient to describe the impact on nursing workload from patients occupying the ambulance bay.  The JDT is able to identify patient dependency that may better inform resource allocation.

  1. Varndell, W., Fry, M., Gallagher, R., and MacGregor, C., Measuring patient dependency: performance of the Jones’ Dependency Tool in an Australia adult emergency department. Australasian Emergency Nursing Journal, 2013. 16: p. 64-72


Wayne Varndell is Clinical Nurse Consultant at Prince of Wales Hospital Emergency Department, and NSW Branch President for the College of Emergency Nursing Australasia. Wayne has held various educational and advanced practice roles in emergency nursing, and is an active academic within the field of emergency care. His research interests include quality of care and illness experiences of individuals presenting to ED, extended and advanced nursing practice, and pain and sedation management of critically ill intubated patient in ED. He has received over $950,000 in research and project funding, and in 2014, was awarded Australasian Emergency Nurse of the Year.