STALLED: What works to improve SafeTy, pAtient experience, outcomes and costs reLated to deLayed ambulance handovers at Emergency Departments? A whole system approach

Principal / Lead investigator
Co-investigators / research team
  • Dr Adam Lloyd, Scottish Ambulance Service
  • Mrs Adele Battaglia, PPI Representative based in England
  • Professor Alan Watkins, Swansea University
  • Mr Andrew Rosser, West Midlands Ambulance Service NHS Foundation Trust
  • Dr Ashrafunnesa Khanom, Swansea University
  • Professor Deborah Fitzsimmons, Swansea University
  • Ms Hilary Pillin, The Association of Ambulance Chief Executives
  • Dr Jenna Jones, Swansea University
  • Mrs Lynne Wright, PPI Representative based in England
  • Dr Mari Jones, Swansea University
  • Mrs Martina Brown, South Central Ambulance Service
  • Dr Natalie Joseph-Williams, Cardiff University
  • Mr Steve Belt, North West Ambulance Service NHS Trust
  • Professor Steve Goodacre, The University of Sheffield
  • Dr Timothy Driscoll, Swansea University
Type of study

Mixed-methods research


There has been a problem in the UK and other countries for many years, that at busy times Emergency Departments (ED) become unable to manage the flow of patients. Patients remain in the ambulance, sometimes for several hours. In some areas this practice is rare, in others it is common. When ambulances are queuing, patients are not receiving full ED care and ambulances are unavailable, so there are ‘knock-on’ effects on patients and staff throughout the urgent and emergency care system.

We aim to provide evidence about what works to reduce harms related to ambulance queuing.

Our objectives are to:

  1. Describe what has been published about what works to reduce ambulance queuing and related harms
  2. Identify initiatives in use across the UK to reduce queuing
  3. Identify EDs where ambulance queuing is rare and understand what policies and practices are being used in those hospitals to reduce delays in patient handover
  4. Assess impact of successful queue management on patient flows, safety, experience, health and costs
  5. Predict wider impacts of initiatives on patient flow through emergency care
  6. Produce guidance about what works to reduce delayed handovers

We will use a mix of methods to answer our questions. We will look for existing evidence about initiatives to reduce delayed handovers at ED and survey ambulance services (with follow up at EDs) about what initiatives exist within their areas. We will group initiatives into categories of similar types e.g. ED doctors working in delayed ambulances; paramedics working in ED; or use of additional space. We will analyse existing data to identify sites where ambulance queues are rare and sites where queues are more common. We will present findings at a stakeholder event to help us to select four sites where ambulance queues are rare (Group 1) and four sites where queues are more frequently seen (Group 2).

We will carry out work at these sites to understand what makes a difference to their performance. We will compare important patient outcomes between groups, including death rate; proportion of patients sent a 999 ambulance, taken to ED, admitted to hospital and waiting times. We will send questionnaires to a sample of patients in each group to compare their experiences, quality of life, use of non-NHS services and safety concerns. We will review case notes to compare safety issues between groups. We will use patient flow data to determine initiatives that may be most beneficial to the NHS. We will interview patients to find out more about their experiences. We will interview stakeholders from across the emergency care system, including ED and hospital staff, ambulance clinicians and call takers, healthcare managers and commissioners about their experiences and views. Finally, we will hold stakeholder workshops towards the end of the study to help us interpret findings and make recommendations about how to reduce harms to patients associated with delays in patient care when ambulances are queuing.How could this research potentially benefit patients?

Public / patient involvement

We have included public and patients views throughout the process of developing and preparing this study application, respecting them as equal members of the research team throughout. Public and Patients Involvement and Engagement (PPIE) representative co-applicants - Adele Battaglia and Lynne Wright - have been Research Development Group members from the outset and part of all discussions about the scope and detail of this study proposal. They have drawn on their personal experience of emergency and unscheduled healthcare, one as a patient and the other a carer. They confirm the importance and urgency of research into improving ambulance handovers at EDs and have supported the inclusion of objectives to explore effects on patients and family/carers. They reminded us to consider the effects on staff of delays in the system who can find it difficult to remain efficient and compassionate and how this contributes to patient distress. They had concerns regarding the stress that is caused to vulnerable groups such as frail elderly people, particularly those with dementia.

We will establish a Public Advisory Panel of 12 public contributors from areas where handover delays are low (n=6) and areas where handover delays are higher (n=6). The Panels will have the opportunity to meet face to face at the beginning and end of the study, as well as hybrid meetings at least bi-annually. We will ensure our research is inclusive and that we have a wide representation of lived experience in using emergency ambulance services and ED or supporting family members within this Panel. Panel members will be recruited from diverse backgrounds and experiences, with support of 3rd Sector Organisations and clinicians. Both Panels will be supported to meet at key stages of the study to provide in-depth input to study design, interpretation and dissemination. Study PPIE and Panel members will be invited to attend stakeholder workshops and final data synthesis meeting. In addition, we will recruit two public contributors to the independent Study Steering Group to provide independent oversight.

How could this research potentially benefit patients?

The potential impact of the research is to reduce queueing in ambulances outside EDs and therefore improve patient and staff experience and outcomes.



Total grant value

£ 1,504,067

Start date

March 2024

End date

March 2026

Outputs generated (Reports / Publications / Impact) 

To follow


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Further information 

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