March 2, 1998
To: Emergency and Protective Services Committee
From: Ron Kelusky
Acting General Manager
Subject: Impact of Hospital Restructuring On Toronto Ambulance
Purpose:
To advise Toronto Council of the current and potential impacts of hospital closures and hospital restructuring on Toronto Ambulance, both in the short and long term.
Funding Sources, Financial Implications and Impact Statements:
There are no immediate financial implications for this issue, however, there may come a point in the future when Council will determine it is in the best interests of the residents of Toronto to approve funding which would allow Toronto Ambulance to hire additional staff. This may be required in order that there are adequate resources to meet the increasing demands of service delivery.
Recommendations:
It is recommended that this report be received for information.
Council Reference/Background/History:
There has been considerable attention in the media as of late with respect to the subject of hospital closures and emergency department unavailability. Concerns have been raised as to whether this is an isolated phenomenon, or whether it is a trend which will only worsen.
Toronto Ambulance has felt the impacts of the hospital closure situation. In response to numerous and varied inquiries, it is providing this report to Council as an information update, and for its consideration in the context of possible future budget deliberations relating to ambulance service resource levels.
Comments and/or Discussion and/or Justification:
On March 13, 1997, the Provincial Health Services Restructuring Commission formally announced its decision regarding the future restructuring of institutional health services within Toronto. The report recommended the future requirements of health services and the realignment/closure of some of the existing medical facilities within the Toronto area. The report contained no specific reference to the effect that these decisions would have on the current and future delivery of Emergency Medical Services (EMS) within the community.
Ambulance Service Interaction With Hospitals:
On an annual basis, Toronto Ambulance transports 120,000 (1997) emergency patients to hospitals. In Toronto. In addition, a further 58,000 patients receive medical transportation to and from institutions and residences on a non-emergency basis.
Approximately 10% to 12% of all patients which are seen in hospital emergency departments are transported there by Toronto Ambulance. These patients are moved from all areas of the city, based on the presenting condition of the patient and under protocols established jointly between Toronto Ambulance and the hospitals providing emergency and specialized services.
The 1997 announcement by the Health Services Restructuring Commission is resulting in the closure of 6 of the 21 acute care facilities in Toronto (Branson, Queensway, Northwestern, St. Joseph
=s, Wellesley and Women=s College). This represents 29% of Toronto=s emergency departments.
Patient Demand Impacts of Health Services Restructuring and Other Factors:
In April, 1997, Toronto Ambulance calculated that the effect of this decision would result in the redistribution of 25,000 emergency patients and 11,000 non-emergency patients. This accounts for 21% of ambulance emergency patient volume, and 19% of the non-emergency patient volume, based on 1997 statistics. These are patients who would normally have been transported to one of the six facilities which are closing, but who will now be diverted to one of the remaining facilities.
It should be noted these figures represent the immediate effects, based on historical information, and do not account for additional volume as a result of an aging population, abnormal demand fluctuations and any other changes in health care policy.
Based on the experiences of other jurisdictions, it is expected there will be a nominal increase in the number of emergency calls in those areas which were previously served by the hospitals which are closing. These reflect the number of area residents who would normally have found their own way to a hospital (e.g. by personal car, or with a relative) but who will now elect to call for an ambulance as a result of longer travel distances or concerns about getting to a hospital on their own. It is estimated that this extra volume will be about 1500 to 5000 patients per year.
Notwithstanding the predicted redistribution and increases in call volumes, it is also expected that there will be a natural increases in the demand for emergency pre-hospital care services by the year 2001 (these increases were cited by the consulting firm of Ernst & Young in their 1996 review of Toronto Ambulance). These are forecast to be in the range of 18,000 call transports, of which 13,000 will be emergency patients.
A summary of the anticipated call volume increases is as follows:
Redistributed emergency patients 25,000
Potentially redistributed transfer patients 11,000
>
New= requests from >closed= hospital areas up to 5,000
Natural demographic increase in demand 18,000
Total: 59,000
Health Services Restructuring - Accuracy of Forecasts:
It must be noted that the forecasts of the impacts of health services restructuring on Toronto Ambulance had, to this point, been based on the best available information. They were subject to some degree of fluctuation, either upward or downward.
Unfortunately, there has been no central data source which can predict with certainty the full effects of the hospital restructuring process. However, in assessing the impacts of health services restructuring, the Department has tended, overall, to use conservative figures. It is more reasonable to anticipate that its forecasts will, over time, be adjusted upwards rather than downwards.
The accuracy of the exact timing of the increases in overall demand depends on:
(a) when exactly hospitals close (some are closing sooner, and some later, than scheduled)
(b) the level of reduced availability (some emergency departments may be open but will have reduced capacity and will not be able to accept regular ambulance flow) (c) the ability of other hospitals to absorb additional patient demand
Current Hospital Environment:
The closure of the six identified hospital emergency departments (as per the Health Services Restructuring Report) was to take place over a twenty month period commencing the end of November, 1997 to the end of June, 1999.
However, this schedule has already been altered. One emergency department (the Northwestern Hospital) was not scheduled to close until June, 1999, but closed in November, 1997. Another (the North York Branson) had the same closing date but has been forced to close its emergency department routinely at night, as of December, 1997. The Doctor
=s Hopsital will be closing its emergency department starting June, 1998, and not December, 1998 as originally planned.
Similarly, two hospitals - the Queensway and Women
=s College - were supposed to close in November, 1997, but remain open today as they explore other consolidation options. And hospitals not targeted in the initial health services restructuring initiatives are now becoming involved in related health services consolidation efforts (similar rationalization of health services in the GTA is seeing discussions about the possible integration of hospital resources between, for example, Etobicoke General and Peel Memorial)
At the same time, changes to the types of services being offered at all hospitals as a result of rationalization and integration are having, and are going to have, further impacts on service
delivery , and on ambulance service directly (for example, an obstetric patient which might normally have been transported to a certain emergency department will now be redirected if the hospital in which the emergency department is located does not offer obstetrical services).
The
>Withering Effect=:
In addition, a variable which was not easily folded in to all demand projections is what is known as the
>withering effect=. This simply means that even hospitals which were not scheduled to close until next year have already begun to experience changes to their emergency department patient flow.
This is occurring in two main ways. First, staff (physicians and nurses) in the affected hospitals who know that their hospital is expected to close are already seeking employment opportunities elsewhere. Some of the hospitals are then having periodic difficulty maintaining sufficient staffing levels, and are unable to handle high patient volumes.
Second, some patients who would normally have attended at the emergency department of one of the identified hospitals are electing instead to bypass those hospitals to seek care at hospitals where they are more assured of being able to access uninterrupted, longer term follow up.
The combination of these
>withering effects= phenomena have accelerated the patient demand impacts of health services restructuring. In turn, Toronto Ambulance has felt the service impacts much sooner than anticipated.
Hospital Responses to Increased Ambulance Volumes:
Hospitals have the ability, through a centralized resource management system, to influence the amount of ambulance traffic that arrives in their emergency departments. The system permits some redistribution, and therefore some equalization, of ambulance patient demand.
When an emergency department
=s staff, bed or equipment resources are becoming overextended, the hospital can declare itself on ReDirect Consideration (RDC) status. This is communicated to Toronto Ambulance, which in turn communicates to ambulance crews that only patients with life-threatening illness or injury should be taken to that particular hospital. In this situation, patients with lesser illness or injury are diverted to hospitals which are capable of handling the patients in a more timely manner.
In extreme situations, an emergency department can declare itself to be on Critical Care Bypass (CCB) status, which means it does not have the ability to adequately handle patients with even
life-threatening conditions. In these cases the hospital is to be avoided altogether by ambulances, which is actually in the best interests of those ambulance patients being transported. Again, these patients are rerouted to hospitals that are further away, but are ultimately tended to faster and more definitively once they arrive.
Through the RDC and CCB system, hospitals can control some of the emergency patient volume which arrives at their doors.
Impacts on Toronto Ambulance:
The combination of the reduction of hospital emergency departments through health services restructuring,
>withering effects= and the current closure of hospitals through the RDC and CCB processes, is impacting on Toronto Ambulance in a number of ways:
(1) Longer call transport times: patients being diverted to hospitals further away has resulted in an increase in the time it takes to transport a patient from where the call originated to the closest available hospital.
(2) Longer
>in-hospital= times: ambulance crews have historically taken between 20 and 25 minutes to >clear= from a hospital once they have delivered a patient. This time is now being prolonged. In recent days, there have been incidents of crews being tied up in emergency departments for over an hour, as a direct result of the unavailability of emergency department beds. Crews have literally been forced to stay with patients who have remained on ambulance stretchers.
(3) Longer call completion times: the average time to complete a call was in 1997 about one hour. With same number of patients being moved to fewer available hospitals, and with hospitals becoming increasingly congested, call completion times have increased. The range of the increase has varied. But overall, completion times are being extended by approaching ten minutes.
(4) Increased frequency of out-of-Toronto transports: multiple closures of Toronto hospitals is, in some circumstances, resulting in Toronto ambulances having to reroute to hospitals outside Toronto. As well, in some cases, the patient populations served by North York Branson and the Queensway are often electing to be transported to York Central and Mississauga (respectively) rather than to adjacent Toronto area hospitals. This is resulting in Toronto ambulances travelling out-of-town more frequently, which is further increasing transport, and therefore, call completion times.
(5) Potential for increased response times for emergency calls: the closure of six emergency departments will create geographic coverage
>holes=. The Toronto Ambulance fleet will have to become increasingly more mobile, or just increased, to compensate.
(6) Reduced system flexibility: Toronto Ambulance has a measure of built in
>surplus capacity= which it uses to service non-emergency calls, to provide >stand-by= coverage, to respond to to profound fluctuations in demand, or to respond to major, unexpected incidents. This flexibility is now being stretched to the limit in just meeting the demand of hospital unavailability. The Department would find itself in a precarious situation should a large-scale disaster or multi-patient situation present itself in the near future, as its resources are already fully committed on a day to day basis.
In addition to the above, the front-line staff of both Toronto Ambulance and hospital emergency departments are facing rising levels of frustration, as the proportion of available medical resources decrease in response to the overwhelming increases in patient demand. Patients and their relatives are understandably frustrated as well, especially when they are diverted away from hospitals they might be geographically close to, or where they have been treated before.
The incidence of hospital unavailability through the RDC and CCB system is reaching extremely difficult proportions. Toronto Ambulance has noticed a steady rise in the
>restricted= or >out-of-service= times of hospitals since August/September 1997. In January, 1998, average hospital unavailability time hit an unprecedented high of 32%. This compares with just 18% at the same time last year.
At the time of this writing, the February, 1998, figures were not available, but it is anticipated that
will reflect the same extraordinary increase in the incidence of hospital unavailability.
Toronto Ambulance Reactions - Short Term:
Representatives of Toronto Ambulance have undertaken the following initiatives to help mitigate the current hospital and patient demand situation. They include:
* presentations to the Ontario Hospital Association Special Committee examining the current hospital situations
* providing the Health Services Restructuring Commission with a copy of our historical database, to assist it in the analyses of patient distribution patterns
* daily contact with the Ministry of Health, Emergency Health Services representative regarding the current status of the hospital situations
* daily contact with Unit Managers and C.E.O.s of affected hospitals as part of our day-to-day management of the situation.
* communications with staff about the pressures being faced
Toronto Ambulance Reactions - Longer Term
The longer term responses to the present hospital situation are financially focussed. They require the hiring of additional staff to keep up with the increases in demand, so that service levels are not compromised.
The Department has estimated, conservatively, that it will need approximately 45 additional staff to meet the increased demands created as a result of both health services restructuring and natural demographic changes, once both are fully realized. It calculated this by taking the increased number of patient transports and factoring in the current and projected increases in call transport and call completion times. This equated to an overall increase in staff productivity hours, which then translated into actual staff numbers. The dollar cost is estimated to be $2.5 million. This is a figure which the Ministry of Health acknowledged as being appropriate and consistent with their own demand forecasts.
In the fall of 1997, the Department included this requested increase in funding as part of its preliminary 1998 operating budget submission. However, after discussions with representatives of the Toronto Transition Team, a decision was made to remove the requested increase. The rationale for the change was that it might be better to wait and see what the actual impacts of health services restructuring would be before any budget commitments were made. The Department
=s only concern in response to this change was that it desired to have sufficient lead time to recruit and prepare new staff (normally about 3 to 4 months), and that it would be in a difficult situation if it had to manage the impacts for this period of time before it could access the new staff.
As an alternative, Toronto Ambulance was advised to explore the possibility that $1.3 million be put into a contingency account so that, if necessary, it could be permitted to hire the equivalent of 23 FTEs in 1998, if service demand warranted. Unfortunately, in the face of the financial pressures standing before all of the City of Toronto (and the pursuit of expenditure reductions), this has not occurred.
Conclusions:
Health services restructuring and the present state of increasing hospital closures is having a measurable impact of the levels of institutionally based medical service in Toronto. These impacts are occurring much sooner than was originally forecast.
Because ambulance services are an extension of the emergency medical system, Toronto Ambulance is also being impacted. It is dealing with increased transport times, increased in-hospital times and overall increased call completion times. As more and more hospitals are unavailable for longer periods of time, there appear to be no immediate mechanisms for relief.
The Department is maintaining service delivery, but has lost all of its system flexibility in doing so, and, should the present trends continue, will require additional staff resources.
The Province
=s health services restructuring initiatives and long term community based care models are supposed to be accompanied by >reinvestment= in the out-of-hospital medical environment. For Toronto Ambulance this has not happened, and it is being caught in the >squeeze= institutional and medical service restructuring.
It may be the City
=s desire to pursue with the Province strategies for ensuring there is tangible support for the financial reinvestment initiatives, and that Toronto is reimbursed accordingly.
Lastly, the front-line paramedics, communications officers and supervisors of Toronto Ambulance are to be commended for their dedication and professionalism in maintaining the highest degrees of emergency medical services during this very difficult period of health care transition.
Contact Name:
Ron Kelusky
Acting General Manager
Phone: 397-9240
Fax: 392-2115
Ron Kelusky Barry Gutteridge
Acting General Manager Commissioner
Toronto Ambulance Works and Protective Services
