January 18, 1999
To:Emergency and Protective Services Committee
From:Ron Kelusky, General Manager, Toronto Ambulance
Subject:Restrictions of Ambulance Access to Hospital Emergency Departments
Purpose:To provide information to the Emergency and Protective Services Committee on
the increasing restriction of access to hospital emergency departments.
Funding Sources, Financial Implications and Impact Statement:
There are no immediate financial implications or requirements related to this report.
Recommendations:
It is recommended that this report be received for information.
Council Reference/Background/History:
The Central Resource Registry (CRR) was established several years ago under the direction of
the Hospital Council of Metropolitan Toronto and is currently administered under Criticall
Toronto. The CRR allows hospitals to indicate their bed availability status to facilitate
inter-hospital transports and permits hospitals to indicate to the ambulance service that they
are experiencing temporary difficulties in accepting additional patients. Hospitals can request
either that only critically ill patients be brought to the emergency department, Redirect
Consideration (RDC), or that no patients, except for scheduled transfers, be brought to the
emergency department, Critical Care Bypass (CCB). The definitions of these categories were
established by committees which included wide representation from emergency departments
and other hospital representatives. Monthly reports of the utilization by Toronto area hospitals
are provided to all participants. A number of reviews regarding issues related to emergency
department access have included reference to the increasing utilization of restricted
emergency department access to ambulances. The most recent of these was the report prepared
by the Emergency Services Sub-committee of the Ontario Hospital Association at the request
of the Minister of Health following the dramatic increase in emergency department restricted
access in the winter of 1998.
Comments and/or Discussion and/or Justification:
The trend to increasing utilization of RDC and CCB by Toronto area hospitals has continued
through 1998. In previous years, a number of hospitals have endeavoured to reduce their
utilization of RDC and CCB with inconsistent and usually temporary success. Some hospitals
have by policy chosen to not utilize either or both statuses, for specific periods of time or on
an ongoing basis. For example, the Hospital for Sick Children, as the major tertiary pediatric
facility in the Toronto area, has never used either status. The monthly averages for RDC and
CCB utilization may not therefore accurately reflect the depth of the problem.
Graphs comparing 1996, 1997 and 1998 CRR utilization provided by the Central Resource
Registry are included as attachment #1. These display the continuing increase in restriction of
access to ambulances. The tables in attachment #2 demonstrates the level of utilization of
CRR by Toronto and area hospitals in ranked order during the months of September, October
and November from 1997 and 1998.
The hospitals in the northwest of the city and the adjacent hospitals in Mississauga and
Brampton are having the greatest current impact on Toronto Ambulance. The five fully active
emergency departments restrict access to their emergency departments 46.2% of available
hours. Hospital closure in this part of the city has included the closure of the former
Northwestern Hospital and the partial closure of the emergency department of the former
North York Branson Hospital. The difficulties being experience in the northwest are expected
to be further impacted when the former Queensway Hospital begins to partially close its
emergency department in the coming months. Patients from the northern part of the
Queensway catchment area may be transported to hospitals in the northwest area placing a
further demand on their resources.
Similarly, patients from the eastern portion of the Queensway catchment area may be
transported to St. Joseph's Health Care Centre rather than the Mississauga Hospital. St.
Joseph's currently restricts access to ambulances over 30% of its hours of operation. The
change in patient destination resulting from the Queensway closure may result in difficulties
in the southwest paralleling those in the northwest.
The hospitals east of Yonge Street, on average, restrict ambulance access more than 20% of
available hours. This may be further increased when the Wellesley Hospital closes its
emergency department. Patients are likely to be transported to St. Michael's, Sunnybrook or
the East General hospitals, possibly increasing their restricted status.
Conclusions:
Hospital restructuring appears to be one of the factors contributing to the increasing restriction
of ambulance access to Toronto and area emergency departments. Additional factors have
been addressed by the Ontario Hospital Association report and others. Data from the past
three years indicates an increasing problem. The northwestern part of the city is currently the
area of greatest impact on the delivery of ambulance services. The ability of Toronto
Ambulance to provide timely patient care and transport may be compromised unless system
improvements are made.
Contact Name:
Ron KeluskyPhone: 397-9241 Fax: 292-2115
Ron KeluskyBarry Gutteridge
General ManagerCommissioner
Toronto AmbulanceWorks and Emergency Services
