December 2, 1998

To:Emergency and Protective Services Committee

From:Commissioner, Works & Emergency Services

Subject:Continuing Evolution of the Ambulance Act of Ontario and Identified Potential Financial Implications

Purpose:

To update the Committee and Council of the status of the Ambulance Act of Ontario and its Regulations and to bring to the Committee's and Council's attention, potential financial implications within the current Act.

Funding Sources, Financial Implications and Impact Statement:

There are no immediate funding considerations associated with this report, however, there are potential financial implications.

Recommendations:

It is recommended that this report be received for information and that appropriate consultation and further assessment be undertaken.

Council Reference/Background/History:

As of January 1, 1998, under the Services Improvement Act (Bill 152), the funding responsibility for land ambulance services in Ontario has been downloaded to the upper tier municipalities.

The management and operation of the ambulance service is governed and regulated by the Ambulance Act of Ontario and its Regulations and was originally brought to the attention of the Emergency and Protection Services Committee in a report dated April 1, 1998.

The Ministry of Health has been working with the Land Ambulance Transition Task Force to review and reform the legislative framework for ambulance service in Ontario. Toronto Ambulance has made presentations to this Task Force and we await the results of their deliberations. The current Ambulance Act has been extended through to March 31, 1999 and as of yet, we do not know what its final form will be.

There are a number of areas in the current Ambulance Act which we feel must be assessed in greater depth as they may result in financial implications not only to the Ambulance Services Division but to other departments within the City of Toronto.

Comments and/or Discussion and/or Justification:

A copy of the general overview of the initial changes to the Ambulance Act and Regulations originally submitted to the Emergency and Protective Services Committee is attached for reference.

The following are the sections of concern:

Part 1 Definitions

The "old" Act defined ambulance as "a conveyance used or intended to be used in an ambulance service for the transportation of persons requiring medical attention or under medical care."

The current definition is, "a conveyance used or intended to be used for the transportation of persons who, (a) have suffered a trauma or an acute onset of illness ... or (b) have been judged by a physician to be in an unstable medical condition and to require, while being transported, the care of a physician, nurse ... and the use of a stretcher".

The section referred to under part (a) refers to emergency calls but our concern is that part (b) may not reference non-emergency calls.

Toronto Ambulance transports approximately 176,000 patients annually of which approximately 40% or 70,000 patients fall into the broad category of non-emergency. These patients are today transported without charge to the patient as per OHIP regulation as the majority of these calls involve a medical institution.

There is in the community a number of patient transportation services which transport non-emergency patients but charge the patient a fee of up to $65.00 per call. This sector of the industry is both unregulated and unlicensed but discussions with Licensing have been undertaken.

Our concern is that should we be excluded from providing service to patients deemed to be in a "stable" medical condition, this group of patients may be charged a fee for service previously non-existent and may be interpreted as a "user fee" by the general public.

Part VI General

The current Ambulance Act provided, "If a person who is transported in an ambulance is receiving general assistance from a municipality under the General Welfare Assistance Act or assistance under the Ontario Works Act 1997 or is a dependent of a person receiving such assistance, the municipality or the delivery agent is also liable for and shall pay the person's share of the ambulance service operator's fee as established under subsection 22 1 (s)."

There is currently a co-payment of $45.00 charged to a patient transported by ambulance by the receiving hospital.

In discussion with Community Services, we have estimated that approximately 81,920 persons receive assistance in a month; from this population we anticipate transporting 6,500 patients of which 4,000 would be emergency calls and subject to the $45.00 co-payment. This could result in a bill to the municipality of about $180,000 per annum, payable to the receiving hospitals; should Toronto Ambulance be excluded from the non-emergency sector, the 2,500 non-emergency patients would cost the municipality $162,500 per annum.

It is interesting to note that of the $45.00 co-payment collected by the receiving hospitals, they are required to submit $15.00 to the provincial government; from the figures we have presented, this would translate into $60,000 per annum.

The figures we have presented, represent City of Toronto residents; it is our understanding that there are approximately 3,900 non-resident persons receiving assistance in a month. This Division could transport 308 in a year of which 184 would be emergencies, costing approximately $8.280.00 to be paid to the receiving hospitals and $8,060.00 for non-emergency calls.

Regulations, Part II, Licences

There is a requirement that the municipality apply for a licence to operate and/or provide ambulance service and there have been discussions concerning a certification process to maintain the credential. The current licensing fee is negligible, however, our research has shown that certification could amount up to $25,000.

Part III Qualifications

There is a new qualification in the Regulation which prohibits any one with six or more demerit points on their driver's licence from being employed as a paramedic.

We are currently determining how many of our staff could be affected by this requirement. Toronto Ambulance may incur employment separation/settlement costs and must incur replacement costs.

There are also Regulations which outline mandatory training requirements for both operations and communications personnel.

Should the Regulations stay as they are, there may be additional costs incurred should this required training exceed that which we currently provide.

Conclusions:

Toronto Ambulance will continue to monitor the evolution of the Ambulance Act and Regulations and will continue to assess the potential impacts and implications and will advise the Emergency and Protective Services Committee and Council of the final outcome of this process.

Contact Name:

Ronald L. Kelusky

Phone: 397-9240 Fax: 392-2115

Ronald L. KeluskyBarry Gutteridge

General ManagerCommissioner

Toronto Ambulance Works & Emergency Services

TORONTO AMBULANCE -- APPENDIX A

SUMMARY OF CHANGES TO THE AMBULANCE ACT OF ONTARIO

Part I : Definitions

The definition of an ambulance has been narrowed and is more specific than previously, and may have significant implications for service delivery. The definitions have been expanded to include air ambulance services, delivery agent, designated area and upper-tier municipality which are dealt with in the Act. More specific definitions of emergency medical attendant and paramedic are included, which encompass both employees and volunteers.

Part II : Provincial Responsibilities

This part details the functions and powers of the Minister. Significant changes have been made related to the training of personnel for ambulance services and communications services, the establishment of regions and districts, and the designation of base hospitals. The Minister can establish and operate, alone or cooperatively, institutes and centres for training. This may have implications for the well developed and accredited educational activities of Toronto Ambulance.

Part III : Responsibilities of Upper-Tier Municipalities

This part deals extensively with the responsibilities of upper-tier municipalities, including Toronto, and provides details regarding the two year protection period, operator selection, licensing by the Ministry, authority of the municipality to pass by-laws related to ambulance services and the responsibility for payment. Upper-tier municipalities may assume responsibility for the provision of land ambulance services in the municipality during and following the protection period.

Part IV : Delivery Agents

Delivery agents may be designated by the Minister in areas which do not form part of an upper-tier municipality. Such a municipality can itself be designated as a delivery agent for other areas and may present an opportunity for Toronto Ambulance. This part also details the roles of the Minister and the responsibilities for and payment of the delivery agent.

Part V : Licences

This part identifies the requirement for a licence to operate an ambulance service, the grounds for refusal to issue a licence and the grounds for revocation. As well the role, responsibilities and function of the Health Facilities Appeal Board related to ambulance services are described.

Part VI : General

This part addresses the appointment and powers of inspectors, confidentiality, and the prohibition of user fees. The authority and expanded scope of the regulations which can be made by the Minister in relation to ambulance services is detailed. Also included in this part are sections related to the apportionment of costs in upper-tier municipalities. The authority to create different classes of ambulances, ambulance services and operators with different requirements, standards or conditions is broad and may have implications for the level of service and care to be provided to the citizens of Toronto.

SUMMARY OF THE CHANGES TO THE REGULATIONS UNDER THE AMBULANCE ACT

Introduction:

The regulations under the Ambulance Act have not been substantially revised in almost twenty years. Therefore, a number of antiquated sections have been updated and, existing standards and components of the ambulance system not currently provided for in the regulations, have been incorporated into the regulations (for example, air ambulance services and first response teams). Also, a number of regulations have been deleted in order to provide municipalities with more flexibility and decision-making power, and to eliminate red tape. Most importantly, the regulations have been revised to reflect the 'Who Does What' decisions respecting ambulance services.

The following is a summary of the changes made under each Part of old Regulation 19 under the Ambulance Act:

PART I : Definitions

Definitions for programs, persons and vehicles that currently exist in the system have been added (i.e., "aeromedical transportation", "air ambulance", "first response team members", "midwife", "registered nurse in the extended class" and "emergency response vehicles").

Three classes of paramedic are defined, each with a different scope of practice: primary care paramedic, advanced care paramedic and critical care paramedic. The primary care paramedic is equivalent to the Toronto Ambulance Level I paramedic. The Department's Level III paramedic, however, has a skill set beyond the scope of the advanced care paramedic and less than the critical care paramedic, as defined in the regulations. The difference in scope of practice may have significant implications for the type of licence applicable to Toronto Ambulance, as well as for its ability to meet the requirements of the regulations for staffing of ambulances.

The definition of a communications officer has been expanded to permit the receipt of calls and the dispatch of other emergency and non-emergency services. This has implications for the ability of the Department's control centre to receive requests for, and to dispatch to, such services as home-care.

Among the new definitions, the addition of the 'first response' vehicle has significance for the Department. This validates the operation of such services as the emergency response units, and may provide an opportunity for an expanded role for single paramedic response services. This parallels the revised definition of a 'patient' which permits first aid, emergency and other medical care to be provided without the requirement for transport.

Finally, definitions have been updated to improve the language or to make the language consistent with Bill 152 and other legislation.

PART II : Ambulance Service Licences

Four classes of licences are created by this regulation. They reflect the level of care to be provided and the level of the scope of practice of the providers in each class - emergency medical attendant, primary care paramedic, advanced care paramedic and critical care paramedic. The requirements for each licence are detailed, including the application process and the conditions of licensure.

A regulation was added requiring that land ambulance service operators present proof of an agreement with a municipality before the operator is issued a licence or an operator's licence is renewed. This lets the Ministry know that the municipality has evaluated that operator and that the two parties have made decisions respecting the proper management, operation and use of ambulance services. Where the municipality is the operator, such agreement is not required.

PART III : Qualifications of Persons Employed in Ambulance and Communication Services

The basic qualifications required of emergency medical attendants and paramedic are detailed. Specific additional requirements for full-time employees, part-time employees and volunteers are detailed for emergency care attendants, primary care, advanced care and critical care paramedics. The paramedic levels all require documentation regarding authorization from the base hospital medical director to perform controlled acts as listed in the schedules appended to the regulations. This requirement raises issues related to scope of practice of the different levels of paramedics as defined by the schedules, and the scope of practice currently in place for Toronto paramedics, specifically levels II and III.

The required qualifications for communications officers are also provided. New requirements for officers employed after January 1, 1999 include completion of a communications officer training program and a pass standing in an emergency communications examination. To date, Toronto Ambulance has not been advised of the training program nor the examination process.

PART IV : Continuing Education and Training of Persons Employed in Ambulance and Communication Services

This part details the requirements of the operator - as a condition of the operator's licence - to ensure that the training and continuing education requirements of both the Director and the Base Hospital are met. Remedial training requirements for emergency medical attendants and paramedics are defined. Re-qualification examinations may be required every three years, at the direction of the Director.

The addition of training and continuing education requirements to the regulations supports the importance of an in-house education and training program capable of meeting the standards of the regulations. In addition, there is an opportunity for the Emergency Medical Services (EMS) education program to be enhanced to provide additional training and continuing education programs to external (non-Toronto) operators, beyond those which are currently offered. This may lead to additional opportunities for training-based revenue generation.

Under this Part, the Director may require that a person take a re-qualifying examination if the person has not taken any such examination in three years or if the Director has reasonable grounds for belief that the person may not be competent to perform, with reasonable skill, the duties normally required for his or her position.

PART V : Standards of Care for Emergency Medical Attendants and Paramedics

The addition of standards of care requirements under the regulation is welcomed. The standards being used, however, are those published in 1995 by the Ministry of Health (Basic Life Support - Patient Care Standards manual). Concerns have been identified that advances in out-of-hospital care may not result in sufficiently prompt changes to the standards of care described in the manual. No provision for doing so is outlined in the regulations, and may be a limiting force in the progress of out-of-hospital care.

PART VI : Functions and Duties of Base Hospitals

The functions and duties of the Base Hospitals have been added to the regulations. These additions define the role of the Base Hospital and its relationship with an ambulance service.

The requirement for the Base Hospital to provide training for all emergency medical attendants and paramedics within the Base Hospital's jurisdiction is of concern. It is unclear whether the provision of such training will be a direct function of the Base Hospital, or whether it will best be accomplished in collaboration with the EMS education program already well established at Toronto Ambulance, as is the current situation. As well, the authority of the Base Hospital Medical Director to determine if the patient care skills of the emergency medical attendant or paramedic are deficient may be a source of contention as there may be confusion between the standards of care outlined in Part V and the Medical Director's own determination of patient care skill deficiency.

PART VII : Standards, Maintenance and Repairs of Ambulances, Emergency Response Vehicles and Equipment

This part requires the operator to ensure that standards set by the Ministry are met. It references documents detailing the minimum standards required for land ambulances and emergency response vehicles, as well as the document for minimum provincial equipment standards.

As the equipment standards are minimum standards, local ambulance services may exceed them, and are no longer required to carry specific manufacturer's products. This will enable Toronto Ambulance to seek efficiencies in equipment and supply selection beyond that previously permitted. Operators and/or municipalities will also be able to carry additional equipment on their ambulance vehicles; however, the permission of the base hospital medical director will be required to carry any additional equipment that is used by paramedics to perform controlled acts.

The requirements for the maintenance of ambulances and emergency response vehicles are defined as is the requirement to maintain repair and maintenance records for a period of three years. The purpose of this regulation is to ensure that operators have a preventative maintenance program in place and that evidence of such program is available. At present, operators are required to follow preventative maintenance schedules established by the Emergency Health Services Branch of the Ministry of Health.

Regulations requiring that operators have each ambulance and emergency response vehicle inspected at a motor vehicle inspection station every six months have been deleted. This will allow municipalities to specify a vehicle inspection schedule that best meets their needs and requirements.

A regulation was added requiring that an operator immediately notify the communication service when an air or land ambulance or emergency response vehicle has been withdrawn from service for maintenance and repair, and when it is back in service. Regulations were also added to require that an operator make available each land ambulance and emergency response vehicle in the operator's service for an annual inspection of the communications equipment in the vehicles, to be arranged by their communication service.

Requirements for emergency medical attendants and paramedics regarding the sterilization and disinfection of equipment, cleaning of the patient compartment of ambulance vehicles, restocking of vehicles and the responsibility to safely and properly store accessories and patient care equipment is detailed. The operator is required to establish procedures relating to sterilization and disinfection of equipment.

PART VIII :Reports and Records by Ambulance and Communication Services Employee Register

This part limits the requirements for maintenance of a register for employee qualifications. The skills inventory currently maintained by Toronto Ambulance meets this requirement and provides an additional source of continuing education activity.

The 'incident reports' requirement for operators of communications services are defined. Previous requirements to submit incident reports have been removed, although copies are to be maintained for a period of three years.

The existing regulation requiring that an ambulance call report be completed by an emergency medical attendant or paramedic "with respect to the call" has been modified to clarify when a call report shall be completed. It is current policy that a call report be completed: (1) whenever a response to a request for ambulance service is initiated and, (2) with respect to each person for whom patient care is provided, regardless of whether the patient is transported by ambulance. This policy has been incorporated in the legislation. A retention period for the call reports was also added, since these reports may be essential, for example, in subsequent Ministry investigations and inspections or for litigation purposes.

PART IX : Accounting System and Report by Ambulance and Communication Services

This part details the requirements for accounting system and reports to be provided by operators who receive funds from the Province of Ontario. Municipalities who assume responsibility and funding of ambulance services will not be required to provide reports to the Ministry, since they can specify the accounting system and types of reports they require of an operator.

Toronto's Ambulance Communications centre, however, may be subject to the Ministry's reporting requirements.

PART X : Insurance

The Ministry currently holds the policy for automobile insurance for all ambulances owned by the Province. There are only a few ambulances across the Province that are not owned by the Ministry. For non-Ministry vehicles, operators are required under the current legislation to obtain and maintain a contract of automobile insurance with minimum liability insurance in the amount of $1,000,000. This section in the regulation has been modified: (1) to apply to only those operators who receive funds from the Province, allowing municipalities to specify the municipality's insurance requirements in other cases and, (2) to update the amount of insurance that must be obtained to bring it in line with more recent damage awards. The proposed minimum is $2,000,000.

This section has also been modified to require that every communication service, base hospital and land ambulance service operator who receives funds from the Province obtain and maintain a contract of general liability insurance in the amount of $2,000,000. By Ministry policy, land ambulance service operators are currently required to obtain liability insurance in this amount.

As a result, this is not a new cost and it is included in the $228+M in land ambulance service costs being transferred from the Province to municipalities. However, the requirement for liability insurance for communication services and base hospitals is new, although many already have such insurance. The cost of this insurance will be borne by the Ministry.

PART XI : Management and Operation of Ambulance and Communication Services

This part establishes requirements for the staffing of ambulances, and has broad implications for Toronto Ambulance. The staffing requirements are linked directly to the type of licence held by the operator. As noted in the comments regarding Part I, none of the definitions appear to apply to the level of paramedic currently provided by Toronto Ambulance.

There is no provision apparent for the hybrid Level III paramedic which the Department and other ambulance services now employ. Even if our current Level III paramedics were deemed equivalent to one of the paramedic levels under the regulations, the requirements of Part XI that each vehicle be staffed by at least one paramedic of the level of the operator's licence could not be met by current Level III trained staff. Alternatively, it is unclear if the Toronto Ambulance should therefore apply for a primary care licence, whose requirements we meet now, and in so doing possibly create a risk management issue by providing a service which exceeds the scope of the licence.

Specific standards for response time performance are set for the operator of an ambulance service in an upper-tier municipality based on the 90th percentile of 1996 performance of the operator. In other words, all operators of ambulance service must in 1998 achieve standards at least consistent with standards achieved in 1996.

There has been a modification to the regulations regarding the destination of the transported patient. The new regulations require that in the absence of direction by a communications officer, the patient shall be transported to the nearest facility which provides the type of care required for the patient. Previous regulations were less explicit, requiring only that the patient be transported to the nearest facility 'apparently' able to provide care.

The current hospital restructuring process will result in hospitals with varying individual capabilities and capacity. Situations of this type already exist in some Toronto hospitals, and will undoubtedly become more prevalent. This will necessitate that Toronto Ambulance enhance its liaison activity with the hospital community and provide the leadership, development and training to ensure that staff are able to determine which facility is appropriate for the patient receiving care. This may require enhanced diagnostic skills for paramedics, as well as triage guidelines for many conditions parallelling those currently in place for trauma triage.

A limitation on the ability of a physician or midwife to direct the destination of the patient is imposed on the communications officer. The communications officer will direct the ambulance elsewhere if the facility cannot receive the patient. This would appear to be linked to the current Central Resource Registry System but this is not specified and may be open to much wider interpretation by the receiving hospital as well as the communications officer. Attention to this area will be required to ensure that communications and hospital staff are interpreting this section in an equivalent manner.

A new requirement to the regulations has been added regarding submission of deployment procedures to the Director for approval. The approval is predicated on the response to calls being efficient, accurate and timely, which appears to permit any level of response standard or any deployment plan deemed appropriate to be imposed on the operator.