Ambulance or corridor? The association between site-level use of ambulance ‘ramping’ as Emergency Department escalation areas and 28-day mortality in admitted patients: a secondary analysis of the UNCORKED study
Abstract
Background and importance: Emergency Department (ED) crowding is an increasing public health concern, with evidence of harms to patients, the public and healthcare systems. When the number of patients requiring emergency care exceeds the capacity of EDs, operational decisions must be made regarding the best place of care for patients. It is not known if there is an association between place of escalation area care (for example ‘ramping’ in an ambulance, or in an ED corridor) and patient outcomes.
Objective(s): This study aimed to assess the association between the relative proportion of all escalation area care that a site provided in an ambulance (the Ambulance:Escalation Index) and all-cause 28-day mortality.
Design: A secondary analysis of a prospective cohort study. Adult patients ≥16 years attending EDs in England, Wales and Northern Ireland in March 2025.
Intervention or exposure (if any): The Ambulance:Escalation Index, a site-level indicator of the proportion of all time in escalation area care provided in an ambulance.
Outcome measures and analysis: The profile of site-level ambulance use was presented descriptively. Multivariable survival analysis was used to assess the primary outcome, all-cause 28-day mortality.
Main results: Of 131 EDs using escalation area, 82 (62.6%) used ambulances as a place of escalation area care. There was a significant association between a site’s increasing use of ambulances as escalation areas and mortality; for each 5% increase in the…
How strong is the evidence?
Evidence Hub reads this as a secondary / pooled analysis, done in people. Its evidence level is 3 of 5 (Moderate · trial / cohort / secondary analysis). Trials without a large randomized design, cohorts and secondary analyses give moderate evidence.
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