August 13, 1998

To:Emergency and Protective Services Committee

From:Acting General manager, Toronto Ambulance

Subject:Role of Base Hospitals

Purpose:

To provide Toronto Council with an overview and understanding of the role that Base Hospitals play in the medical oversight of ambulance service delivery in municipalities.

Funding Sources, Financial Implications and Impact Statement:

There are no financial implications arising out of this report.

Recommendations:

It is recommended that this report be received for information.

Council Reference/Background/History:

None.

Comments and/or Discussion and/or Justification:

Toronto Ambulance provides, first and foremost, a medical service to the citizens of the City of Toronto. It is seen as a natural extension of the health care system in that, in most cases, it delivers the same level of acute primary care that would be received in the emergency department of a hospital. Instead of being in a hospital, however, that level of care is delivered to a patient's residence, or to a street, or to a place of work or recreation.

The paramedics who operate from Toronto's ambulances are all highly medically trained and certified. They provide varying sets of critical and complex life saving skills, and perform a number of medically controlled acts. The authority to perform these acts comes directly from hospital emergency department physicians. In effect, the paramedics are most often regarded as the eyes, ears and noses of the physicians.

In recognition of the need to maintain strong medical control over the many paramedical acts which are conducted in the out-of-hospital environment, the Ministry of Health has legislated through the Ambulance Act of Ontario that specific hospitals will be designated as 'base hospitals', and that they will be responsible for the medical oversight of the ambulance services which operate in the regions they serve.

The Base Hospital for Toronto Ambulance is Sunnybrook Health Science Centre. All of Toronto's paramedics operate under the licence of the Medical Director for Sunnybrook. As such, the Base Hospital plays a significant role in decisions affecting the medical components of the delivery of ambulance service in Toronto. However, because the Base Hospital is not a direct employ of either Toronto Ambulance or the City, its role is sometimes seen with confusion.

Attached is a briefing paper that was prepared by the Chair of the Provincial Base Hospital Advisory Group, and the Sunnybrook Health Sciences Centre Base Hospital Program Medical Director in his capacity as a member of the Provincial Medical Advisory Committee. The paper was submitted to the Land Ambulance Transition Taskforce, a group of stakeholders who are making recommendations to the Ministry of Health regarding the downloading of ambulance services from the province to municipalities, and specifically about the proposed changes to the present Ambulance Act and its Regulations.

The paper describes in greater detail the role that Base Hospitals play in the medical integrity of the delivery of ambulance services in Ontario.

Conclusions:

The relationship between Toronto Ambulance and its Base Hospital, Sunnybrook Health Science Centre, is extremely professional and strongly medically integrated. The attached paper is intended to provide Councillors with a better understanding of the Base Hospital function, and how it applies to ambulance service in the City.

Contact Name:

Ron Kelusky Phone: 397-9241 Fax: 392-2115

Ron KeluskyBarry Gutteridge

Acting General ManagerCommissioner

Toronto AmbulanceWorks and Emergency Service

ROLE OF THE BASE HOSPITAL

Preamble

Ambulance service in Ontario has evolved over the last 25 years from a transport service to an integral part of each community's health care system. The citizens we serve are cared for by paramedics who function under the license of a medical practitioner. This physician has the responsibility to ensure that paramedics provide care to all patients at an appropriate standard. In simple terms, Ontario's Base Hospitals are where ambulance vehicles interface with health care; where hospitals open their doors and extend emergency care to the roadside or home.

In Ontario, Medical direction has been provided through a Provincial Base Hospital network. Funded by the Province, through designated hospitals, it provides the hospital-based framework and resources needed to ensure that all components of medical oversight are in place and function appropriately. These components include medical direction, both on-line and off-line medical control, delegation of controlled medical acts, continuing medical education and continuous quality improvement/quality assurance. These key components are essential to a high performance Emergency Medical System. The 21 Base Hospitals are medical authorities that provide leadership and direction and all the key components to multiple Emergency Medical System agencies, both on a system level and at the level of the individual provider.

This, in our view, is appropriate because the jurisdiction of health care is provincial, and ambulance service is an integral part of our health care delivery. The international medical community views the Province of Ontario Base Hospital system as a model of medical direction that combines strong central standards with responsiveness to local issues.

Base Hospitals are the source of medical expertise for out of hospital care, ensuring citizens in Ontario receive the best patient care possible by adhering to province wide standards. Base Hospitals provide four key functions:

1.Medical Direction

The provision of overall guidance and leadership by a medical authority to ensure that the necessary paramedic skill-set is available to the public. Base Hospitals represent a non-biased party that can provide continuous oversight for our Emergency Medical System.

2.Medical Control

The Controlled Acts model as designated by the College of Physicians and Surgeons of Ontario requires a physician who delegates controlled acts to paramedics or other unregulated persons to ensure that a program is in place to train and continually educate and evaluate those persons to whom they delegate. Medical control is necessary to provide paramedic care at any level to the public. "Physicians are responsible for ensuring that the accepted standard of care is maintained in all aspects of their practice, including those entrusted to their staff."¹ In the case of a Base Hospital physician, staff refers to the paramedic.

¹The College of Physicians and Surgeons of Ontario 1998. Controlled Acts 2700.2

3.Continuing Medical Education

Continuing Medical Education is part of the certification process required for medical control. Continuing education ensures that the controlled acts, delegated by the physician to the paramedic, can be carried out in a safe and specific manner. Continuing medical education allows the delegating physician to review the hands-on ability of a paramedic to perform the procedure to standard, as well as continuously updating the paramedic on new and improved ways to render care. Continuing medical education is essential to a paramedic's maintenance of certification.

4.Continuous Quality Improvement and Quality Assurance

Base Hospitals believe that every citizen is entitled to quality out of hospital patient care, that is consistent, appropriate and reliable. To ensure this happens Base Hospitals provide on-going quality assurance and quality improvement initiatives that build consistency, validity and reliability into emergency medical services. This program includes a multitude of activities from chart reviews to patient outcome studies and ride-a-longs to one on one education.

Fundamental Principles for Land Ambulance within a comprehensive Emergency Health Services System

The Five Fundamental Principles for Land Ambulance within a comprehensive Emergency Health Services System outline the foundation of a high quality Emergency Medical System. An independent provincially funded Base Hospital Program is the most effective model that decidedly supports these principles:

1.Seamless

All residents of the Province shall have access to a seamless ambulance service regardless of socio-economic or demographic status and founded on the following principles.

The Provincial Base Hospital Advisory Group (PBHAG) and its Medical Advisory Committee (MAC) coordinate medical direction. The ability to create seamless patient care started with these committees which have representatives from each region in the province. Provincial patient care guidelines and standards, policies and procedures and medical protocols, were developed collaboratively, ensuring standardized advanced life support care in the province of Ontario. The PBHAG is not alone in the quest for standardization. Our model is being used in pursuit of national standardization for pre-hospital care by the Canadian Association of Emergency Physicians (CAEP) and internationally, by the International Federation of Emergency Medicine (IFEM).

Standardization is more than just a matter of the same care in any center in the province. Standardization is cost effective and addresses many risk management issues. The Symptom Relief Program in Ontario is a very cost-effective program, which continues to have a dramatic impact on pre-hospital health care. Provincial program development yielded standardized standing orders, protocols, training programs, certification processes, and evaluation. If left to each municipality to develop their own program, the costs for the same implementation province wide would be extreme.

From a risk management perspective, each municipality will be held in court to the highest provincial standard for any given scenario. With provincially implemented programs, potential risks are greatly reduced.

2. Accessible

Municipalities have a responsibility to ensure reasonable access to ambulance services. Municipalities have an obligation to ensure that ambulance services respond regardless of the location of the request.

Base Hospitals that are funded independently from municipalities and service providers are in the best position to ensure accessibility of citizens to ambulance services that cross municipal boundaries. This includes both land and air ambulance service, as well as inter-facility transport. With hospital restructuring and rationalization of health care, accessible, seamless transport by a qualified health care provider is more important than ever. Base Hospitals' neutral position provides the necessary objectivity to advocate for patients in an unbiased and independent manner separate from local funding agencies.

3.Integrated

Municipalities have a responsibility to ensure that land ambulance service be an integral part of the health care system of the province.

Base Hospitals provide the link between ambulance services and the greater health care community. Our existence cuts across municipal boundaries and provides regional and provincial health integration. Hospitals are designated by the Province based on their ability to support Base Hospital functions. Resources required for Base Hospital to provide medical direction and leadership include: qualified physicians and other professional health care staff, access to community health services, training facilities and equipment, plus other hospital based services including, pharmacy, biomedical engineering, access to clinical areas and staff for consultation and training. The entire infrastructure of the hospital is utilized to provide appropriate Base Hospital services to the ambulance service(s) and the community.

The integration facilitated by Base Hospitals is not limited to general health care. It assists the integration between air and land ambulance for patient care issues. Continuity and quality of care are significant issues in pre-hospital care and inter-facility care. Base Hospital quality assurance reviews this care seamlessly when patient transport by multiple providers is necessary. Ambulance crews using different modes of transportation need to be integrated with regards to patient care standards to allow a smooth transfer without margin for error.

4.Accountable

Municipalities have an obligation to ensure that ambulance services be provided according to the legislation and regulations. The level and quality of care that is provided to patients by municipalities will be monitored by appropriate hospital based medical staff.

Base Hospitals ensure that accountability is maintained on a continuous basis to the standard generated by the medical community itself. This has positive implications regarding liability for the medical directors, ambulance service operators and providers and the funding agency for both Base Hospitals and ambulance services.

The current Base Hospital network throughout the province provides existing ambulance services with quality improvement and quality assurance data relating directly to the quality of patient care provided. Base Hospitals believe that quality patient care depends on our ability to continually improve the quality, efficiency and timeliness of patient care, Base Hospitals are themselves medically accountable to not only their local Medical Advisory Committees, but provincially to the Base Hospital Medical Advisory Committee.

5.Responsive

Municipalities will be responsive to the fluctuating health care, demographic socio-economic and medical demands of the constantly changing environment.

While standards need to be centrally coordinated, their generation will come from local medical directors in consultation with local and regional health care workers and agencies. Provincial standards will support each municipality from a risk management position, while Base Hospitals will ensure that local and regional needs are incorporated within the standards addressing fluctuating health care needs and medical demands.

In Conclusion

Ontario Base Hospitals believe that to achieve the five fundamental principles for land ambulance within a comprehensive emergency health services system, Base Hospitals must remain provincially administered as well as locally responsive. We believe that the public deserves an unbiased agency that is responsible for ensuring citizens receive an appropriate level and quality of care throughout Ontario.