There’s a new cause for Boston’s ambulance delays: Hospital overcrowding

The reasons for the delays aren’t just high call volumes, which have plagued Boston EMS in the past, or acute workforce shortages, which have wreaked havoc with virtually every area of health care and the broader economy. This time, another major cause is hospital overcrowding, triggered by hospitals’ inability to quickly discharge patients to understaffed nursing homes and rehabilitation centers. The hospital capacity crisis is slowing ambulance response times across Greater Boston by forcing EMS workers to stand in line, sometimes for hours, inside busy ERs until overwhelmed hospital teams can take over their patients’ care.

“The sheer number of calls, the emergency room delays, everything is impacting everyone else,” said James Hooley, chief of the city’s EMS department. The mental health crisis, he said, is also a major contributor, as patients call ambulances when they can’t find other means of support.

As a result, callers to 911 are waiting ever longer for help to arrive.

The problem is not isolated to Boston. Across Massachusetts, since early 2019, ambulance responses for all 911 calls held steady at seven minutes but started climbing to eight minutes in January and February 2022 during the initial Omicron surge, state records show. Response times returned to seven minutes after that, but shot back up to eight minutes in December.

“Even two minutes is a really long time if you are with someone suffering cardiac arrest, so any delay is going to be associated with worse outcomes,” said Dr. Frank Friedman, director of geriatric emergency services in the emergency department at Tufts Medical Center.

“The brain can last four minutes without oxygen in normal temperatures and a normal situation, but it’s really hard to expect a meaningful neurological recovery if they’ve been without oxygen for more than four minutes,” Friedman said.

The lengthened response time for ambulances doesn’t mean the patient, in many cases, didn’t receive more immediate care. When someone calls 911 in Boston for a medical emergency, the city typically dispatches a police or fire response team as well, so the first unit on the scene can initiate basic care, particularly if the ambulance team is stuck at a hospital. The city says Fire Department units include a person trained in CPR, as well as external defibrillators, devices that attempt to shock the heart back to a normal rhythm, and Narcan, treatment for a known or suspected opioid overdose.

Inside many emergency rooms, when call volumes go up, EMS workers line up beside their patients on ambulance gurneys and wait. This is what EMTs call “holding the wall,” — standing inside emergency departments until short-staffed hospital teams can take over.

“Sometimes ambulances are backed up at a hospital 12 deep, waiting for the hospital triage nurse to speak to others ahead of them in line,” said David Franklin, a paramedic with Cataldo Ambulance Service, one of the busiest ambulance companies in Eastern Massachusetts.

Ambulance crews were stuck for up to two hours on some days in December at Massachusetts General Hospital and have faced 40 minute delays in January at hospitals in Cambridge and Melrose, Cataldo reports. These dreaded wall times are increasingly popping up, EMTs and paramedics say.

State data show that the median number of times all ambulance crews cited emergency department overcrowding as a reason for their delayed responses nearly tripled from 2019 through 2022 in the area known as Region 4, which includes Boston, Metro West, and as far south as Cohasset.

At Cataldo Ambulance, which serves a large swath of Eastern Massachusetts from Somerville to Salisbury on the New Hampshire border, it’s taking, on average, 90 minutes now for ambulances to complete each call — responding, treating the patient, transporting, unloading, and restocking their trucks. That’s compared to about 60 minutes before the pandemic. And most of that 30 minute increase is due to hospital wall time, said Kevin Turner, Cataldo’s chief operating officer.

Things have gotten so intense that ambulance crews — they work 24-hour shifts — often don’t have time for a break or even to return to base to restock. So Cataldo in July hired a woman whose sole job is to drive from ambulance to ambulance to bolster spirits and restock trucks.

“She drives around giving snacks, giving water, candy, and asking them, ‘How are you doing?’ ” Turner said. “Do they need things at the base? Do they need some bed linens? Just to make sure the crews have what they need.”

Exacerbating the problem is a national shortage of EMTs and paramedics, which has translated to a 30 percent staffing gap for Cataldo. That has meant 30 percent fewer ambulances on the road for just their company.

In Boston, the EMS department counted 43 EMT vacancies in December out of a budgeted 317.

Also slowing response times is the decision by many ambulance companies to do away with blaring lights and sirens while transporting patients with non-life-threatening injuries to the hospital. Research suggests lights and sirens can do more harm than good, posing a significant risk for crashes and injuries to emergency responders and civilians by disrupting traffic flow, especially on busy roadways, when the time saved for the patient being transported is not of the essence.

But it can come with a domino effect on the next call for an ambulance.

“That will just turn that quick little 10-minute ride, if I use lights and sirens I can make it in 10 minutes, it will turn it now into a 20-minute ride,” said Franklin, the paramedic with Cataldo Ambulance Service.

Another factor in slower response times is the widening behavioral health crisis. People seeking mental health services that are not readily available because mental health providers, too, are swamped, are instead dialing 911, paramedics say.

“They’re looking for a person to talk to,” said Victoria Sacco, a Cataldo paramedic.

“We can bring them to the hospital, and they’re gonna get a human” who will offer them a list of mental health providers and tell them to call someone on the list, she said. “Obviously [that] doesn’t help and just sort of repeats the cycle.”

In 2022, Boston EMS recorded over 10,700 behavioral health calls. In 2019, it was about 10,100 such incidents.

“We are trying to get a clinician to work with us in the field to deescalate calls, and maybe they can provide the service onsite, so we would not have to use an ambulance,” said Hooley, the department’s chief.

Another goal, Hooley said, is opening more ambulance stations this fall in busy areas, including the Seaport and West Roxbury.

But fixing one of the department’s biggest challenges, Hooley acknowledged, will be tougher: luring recruits to the service. Officials at the workers’ union, which has soldiered through an opioid epidemic, a global pandemic, and the behavioral health crisis, say it is facing a crisis of its own with exhausted members hip-deep in mandatory overtime to keep the system afloat.

“Our membership has seen a rise in call volume and longer response times over the last year, which is taxing our 911 system and the physical and emotional health of our providers,” Matthew Anderson, president of the Boston Police Patrolmen’s Association EMS division, said in a statement.

The union is in contract negotiations with the city for, among other considerations, higher pay.

Boston EMS says it recently increased minimum pay for new EMTs and is partnering with the school system to encourage students to consider emergency medical services as a career option.

Across Massachusetts and the country, ambulance services are finding it increasingly challenging to fill overtime shifts, said Philip Petit, national director of the International Association of EMTs and Paramedics

In Worcester, the association last year worked with city leaders to establish a $150 “shift incentive” bonus, in addition to overtime pay for the extra shifts, in an effort to ease mandatory overtime, Petit said.

“There isn’t a system I work with around the country that is fully staffed and not dealing with big holes on their schedule that are forcing mandatory overtime,” he said.

Massachusetts is faring somewhat better than some other states. In California, one of the nation’s largest ambulance companies recently said it would halt nonemergency service in Los Angles County.

“But that is not a high litmus test,” Petit said. Massachusetts is “at a tipping point.”

Sacco, the Cataldo paramedic, puts it this way: “EMS is taken for granted, because people feel that any ambulance will always be there,” she said. “Well, yeah. Maybe.”

Kay Lazar can be reached at kay.lazar@globe.com Follow her @GlobeKayLazar.