STAFF REPORT

December 22, 1999

To: Community Services Committee

From: Barry H. Gutteridge, Commissioner, Works and Emergency Services

Subject: Response by the Minister of Health to Emergency Department Overcrowding Within the City of Toronto

Purpose:

The purpose of this report is to inform City Council of the ten-point plan recently announced by the Minister of Health to alleviate pressures on the health care system, inclusive of Toronto Ambulance within the City of Toronto.

Financial Implications and Impact Statement:

Toronto Ambulance will receive approximately $3.2 million of the $23 million announced by the Minister of Health on December 20, 1999. This funding will be targeted for programs that will be the responsibility of Toronto Ambulance as part of its role in addressing some of the system-wide issues that effect the availability of health services within the City of Toronto. It is understood that all funding associated with the Minister's announcement will be targeted for program areas to be detailed within the body of this report and will not form part of the current funding arrangement between the provincial government and the municipality. Toronto Ambulance will be responsible and accountable to the Ministry of Health and Long-Term Care for the management and administration of this funding as it relates to the program areas identified. As a result of this announcement, the 2000 Operating Budget will be updated to include this $3.2 million item on a net zero basis.

Recommendations:

It is recommended that:

(1) The Community Services Committee be advised that the 2000 gross Operating Budget for Ambulance Services will be increased by $3.2 million as offset by $3.2 million in revenues to be received from the Ministry of Health and Long-Term Care for a net zero impact.

(2) City Council endorse the initiatives proposed by Toronto Ambulance to assist the Ministry of Health and Long-Term Care in dealing with emergency departments and health care pressures within the City of Toronto; and

(3) Appropriate City officials be given the authority to give effect thereto.

Background:

On December 20, 1999, Health and Long-Term Care Minister, Elizabeth Witmer, announced a $23 million, ten-point action plan for emergency care in Toronto and the Greater Toronto Area region. Over the past 5 years there has been a measurable increase in the use of restricted status by emergency departments within the Toronto area. This has been caused by a number of system-wide issues, including higher demand for emergency care and, in part, as a result of transitional issues resulting from health care reform initiatives taking place within the health care system in Ontario. It should be noted that pressures effecting the health care system and emergency departments is not restricted to only the City of Toronto, as it is a nation-wide issue facing most urban centres. Of late, seasonal demands have added additional pressures on the emergency care system, inclusive of Toronto Ambulance requiring immediate action on the part of the Ministry of Health and Long-Term Care in order to enhance and improve the delivery of health care within the existing structure.

Prior to the announcement by the Minister of Health, Toronto Ambulance was invited to submit proposals to assist the Ministry of Health and Long-Term Care in dealing with the immediate and long-term issues associated with emergency department overcrowding. The proposals submitted by Toronto Ambulance were designed to pay special attention to the need for immediate interim solutions and to the dual needs of hospitals within the City of Toronto and the Greater Toronto Area at large. In total, 5 proposals were submitted.

Comments:

Improved Detail in Emergency Department Capacity Information:

At present, hospitals report only two statuses, other than "Normal". Designed 15 years ago, these two ("Redirect Consideration [RDC] and "Critical Care Bypass [CCB]) now fail to convey the full depth of information required to optimally allocate ambulance patients. Toronto Ambulance proposed the following changes be implemented immediately:

Each hospital would report any change in the following three patient care classes:

The above proposal would ensure that Toronto Ambulance did not divert an ambulatory patient across the city, when a closer hospital could in fact treat the patient, but may be on Critical Care Bypass because its ICU is full. Toronto Ambulance also proposed to receive and manually track the improved status indications until appropriate modifications are to be made to the CritiCall computer software.

The value to patients and to the system at large of this simple amendment should not be underestimated.

Toronto Ambulance Hospital Load Management Facilitator:

In order to facilitate the clearing of overcrowded hospital facilities, and to better allocate ambulance patients to available hospital resources, Toronto Ambulance proposed adding a Load Management Facilitator to its communications centre. This 24 hour/seven-day-per-week position would be responsible for actively communicating with each emergency department to achieve the following:

· Determine how our ambulance resources could assist in clearing backlogs in facilities that declare reduced emergency department availability. This could include immediate assignment of a non-emergency ambulance to discharge a patient from an admitting bed, or from an emergency stretcher back to a nursing home, to clear emergency department capacity.

· Determine whether an emergency department could accommodate individual patients during times of reduced availability, such as a patient with an extensive relevant medical history at the facility, or a minor patient who can clearly await treatment in a public waiting area.

· Track and balance the allocation of ambulance patients amongst hospitals in the neighbouring areas of the city.

· Improve co-ordination with other GTA hospitals and ambulance services to ensure that the maximum possible resources are brought to bear to clear hospitals, and allocate patients. This dispatch position would be equipped with GTA-wide radio capability and a computer dispatch terminal connected to the other GTA ambulance dispatch centres.

Cost Estimate: $ 380,000 per annum (salaries and benefits)

Immediate Full Dedication of Critical Care Transport Program Ambulances:

Toronto Ambulance currently operates the province's only paramedic-based Critical Care Transport program as an add-on to our Advanced Life Support program. The program is an active partnership with Sunnybrook and Women's College Health Science Centre, who provide our medical direction and clinical quality management. CCTU ambulances remove the need for a sending facility to provide physician, specialist or nursing escorts and critical care equipment for these complex patients. All critical care interventions normally provided in an Intensive Care Unit are provided in these specially equipped units.

While Toronto Ambulance is sensitive to the principle and desirability of providing full critical care services on-site for every patient arriving at a hospital, our program recognizes the reality that the sending hospital's ICU or CCU may be temporarily full or that a patient's condition simply warrants transport to a regional centre.

Toronto Ambulance proposed to dedicate two fully equipped Critical Care Transport Units on a 24-hour/7-day-per-week basis to undertake all critical care transfer calls in the GTA. This program earned an excellent reputation among hospitals throughout the GTA who have been using its limited services since July, 1998, and have been asking for some time for a major expansion of its capacity. In addition, Toronto Ambulance proposed to add full paediatric services to this program during the Year 2000.

In order to offer a full-dedicated service, Toronto Ambulance needed to backfill the regular municipal Advanced Life Support program to prevent degradation of "on-street" ambulance services. At present, the CCTU ambulances spend only a portion their work day in inter-hospital duties, and the balance in regular emergency municipal ambulance service with patients arising from 911 emergency calls. As part of the proposal, Toronto Ambulance needed to ensure the CCTU ambulances are optimally equipped for the increased patient load.

Cost Estimate: 1.90 million per annum (salaries, benefits and equipment)

Dedicated Hospital-Clearing Non-Emergency Ambulances:

Toronto Ambulance proposed providing the hospitals with one additional dedicated non-emergency ambulance per quadrant of the City to operate at the disposal of the Load Management Facilitator to solve immediate and urgent needs. These units would be exempt from regular ambulance traffic in order to ensure their immediate availability to remove a patient from an overcrowded emergency department, or to facilitate a discharge from hospital to clear an admitting bed.

Toronto Ambulance based this proposal on the success of such units through the relationship with St. Michael's Hospital in managing the pressures arising from their twin sites in downtown Toronto.

It was proposed that these units be available 12-hours per day, seven days a week.

Cost Estimate: $900,000 per annum (salaries and benefits)

The Future: Linking Patients with Appropriate Alternatives to Emergency Department Visits:

Toronto Ambulance will shortly propose to the MOHLTC a pilot project to provide telephone-based assistance to patients considering going to their local emergency department for other than life-threatening emergencies. Such medically safe programs have proven highly effective in other jurisdictions in the United Kingdom and elsewhere in reducing reliance upon emergency departments as primary care substitutes.

The Emergency Care Ten-Point Plan will Include:

q establishment of 4 emergency service networks and regional co-ordinating hospitals;

q create flex beds and additional critical care capacity;

q extend and enhance interim long-term care beds and expedite the establishment of permanent long-term care beds;

q improve intensive care unit patient flow;

q expand discharge planning services;

q expand ambulance services;

q expand CritiCall bed information system;

q audit hospital use of redirect and critical care bypass;

q establish provincial emergency system monitoring officer.

This ten-point plan was developed based on recommendations from hospitals, the Ontario Hospital Association, and Toronto Ambulance Services. These measures were developed to annual peak periods of emergency department use and will be used each year during peak periods until larger system changes such as the expansion of emergency departments and permanent long-term care beds are completed.

Establish Four Emergency Service Networks and Regional Co-ordinating Hospitals:

The basis for this proposal will include the following:

New emergency services networks in Toronto will be created to co-ordinate the emergency care services of local hospitals, Toronto Ambulance and CritiCall in the central, east and west regions of the City of Toronto. A fourth network will co-ordinate paediatric emergency care. The co-operation between hospitals in each network will ensure that one hospital in each network will always be able to accept ambulance emergency patients. Each regional co-ordinating hospital (RCH) will improve co-ordination in its network and better maintain a responsive emergency care system in Toronto to handle emergency care pressures and improve patient access to care through ongoing review and monitoring. The regional co-ordinating hospital and the central region will be St. Michael's Hospital. In east Toronto the regional co-ordinating hospital will be Sunnybrook and Women's College Sciences Centre. In west Toronto, the regional co-ordinating hospital will be St. Joseph's Health Centre and the Hospital for Sick Children will be the regional co-ordinating hospital for all paediatric care. Included in the announcement, regional emergency services co-ordinators will be hired to monitor and improve emergency care in each of the networks.

Additional Critical Care Capacity:

The government announced funding that would allow hospitals in each network to open and staff additional beds during peak periods of emergency department use and will allow patients to move out of emergency departments into flex beds. This will ease pressure on the emergency departments and increase emergency care capacity during the busiest times of year.

Extend and Enhance Interim Long-Term Care Beds and Expedite New Permanent Beds:

Enhanced nursing and personal care for interim long-term care patients across the province will allow more long-term care patients to be cared for interim long-term care beds rather than inappropriately occupy an acute care bed. Hospitals within the Toronto area have told the government they need additional resources to meet the higher care needs of long-term care patients. Interim long-term care beds will provide a higher level of care and this will free up more acute care beds for patients entering the hospital through the emergency department and help reduce pressures in emergency departments across Toronto. The Ministry of Health and Long-Term Care has indicated that it will speed up the construction of new permanent long-term care beds by streamlining the capital approval process and reducing any red tape. In addition, the Ministry of Health and Long-Term Care will be offering assistance to municipalities to remove any barriers that could delay construction.

Improve Intensive Care Unit Patient Flow:

The government has announced the establishment of ICU medical directors to improve the co-ordination of intensive care and emergency care for critically ill patients. This is designed to improve patient flow and bed management in intensive care units and will ensure that critically ill patients have beds in an Intensive Care Unit that can be moved out of the hospital's emergency department.

Expand Discharge Planning Services:

Through the expansion of Discharge Planning Services to 20 more hospitals in Toronto and the Greater Toronto Area will allow the establishment of better working relationships with community care access centres to assist in the transfer of patients from hospital into appropriate long-term care and community care services. The ability to admit patients to an emergency department is reduced is patients who can be safely discharged occupy some of the hospitals/critical care beds. The lack of hospital discharge planning staff, particularly on Friday evenings and weekends, prevents hospitals from being able to discharge patients who are well enough to leave the hospital and be cared for in another health care setting or in their own home. Discharge planners are health professionals who oversee a patient's entire staff in the hospital, as well as identifying and arranging for the type of care each patient will need after discharge.

Expansion of Ambulance Services:

Based on proposals submitted by Toronto Ambulance, there will be an expansion of the critical care transport system for adults and children in Toronto. Specially trained paramedics will move critical care patients between hospitals in their network and not require a doctor or nurse to accompany the patient during transport. This will further free up ICU beds and will allow the physician and nurse to remain in the hospital and care for patients.

In addition, ambulances will be specifically allocated to improve interfaculty transfers of non-emergency patients especially those that are able to be discharged from emergency departments and/or within the hospital to other appropriate long-term care and community care services.

Additional ambulance dispatchers will also be hired to meet the needs of patients calling for ambulance service, as well as co-ordinate with hospital emergency departments, discharge planning services and CritiCall in order to improve the flexibility of the system. Patient care co-ordinators will also ensure that patients being transported are not unnecessarily being redirected away from a hospital that could actually accept the patient due to low patient activity or because the patient has a history with the hospital of choice.

Expand Critical Care Bed Information Systems:

The expansion of the CritiCall bed information system to all Toronto and GTA hospitals will ensure full compliance with standards for Ontario hospital emergency units providing ambulance access. CritiCall will provide hospitals with instant information to assist them in finding the most appropriate care for critical patients.

Audit Hospital Use of Redirect and Critical Care Bypass:

Based on the recommendation of the Ontario Hospital Association and concerns raised by some hospitals, an expert team of emergency care professionals and the Ministry of Health and Long-Term Care will audit hospitals that are more frequently turning away ambulance patients. The audit will assess the hospitals compliance with RDC and CCB guidelines and review the hospital's emergency department policies, practices, and procedures with an eye towards providing concrete recommendations on how to safely reduce the hospital's use of RDC and CCB. The Ministry of Health and Long-Term Care has committed to work with the Ontario Hospital Association and Toronto Ambulance to monitor how hospitals are dealing with ambulance patients and will keep track of the hospital's use of RDC and CCB activity.

Encourage Flu Vaccines for Health Care Workers:

The Ministry of Health and Long-Term Care has committed to provide free flu vaccines to hospitals, long-term care facilities, home care agencies and emergency services staff (fire, ambulance and police), so they can vaccinate their staff.

Establish Provincial Emergency System Monitoring Officer:

A new provincial emergency systems monitoring officer will work with hospitals and Toronto Ambulance to implement the emergency care ten-point plan. The officer will report to the Deputy Minister of Health and Long-Term Care.

Conclusions:

The ten-point plan announced by the Minister of Health and Long-Term Care was a co-operative effort between the Ontario Hospital Association, lead hospitals, hospitals within the Toronto area and Toronto Ambulance. The $23 million announcement is designed to provide flexibility within the system to address the transitional pressures that currently affect the health care system within the City of Toronto. The $3.2 million earmarked for Toronto Ambulance has been incorporated into the announcement as part of Toronto Ambulance's contribution to assist the health care system in dealing with increasing demand and structural blocks that have created backlogs within emergency departments within the City of Toronto. The funding will provide additional resources for both the Toronto Central Ambulance Communications Centre and the land ambulance service division of Toronto Ambulance. The funding is separate from the existing shared funding arrangement that currently exists between the City of Toronto and the Ministry of Health for the provision of land ambulance services within the City of Toronto. It is important to note that the Ministry of Health and Long-Term Care has recognized the value and contribution of Toronto Ambulance as part of the integrated health system within the City of Toronto. The role of Toronto Ambulance will be expanded to include representation on co-ordinating committees within the regional co-ordinating hospitals and at the local level, to be able to better co-ordinate and improve operating protocols within the health care system. As these systems evolve, additional reports will be tabled before Community Services Committee in order to inform and update City Council regarding developments within the health care system within the City of Toronto.

Contact:

Ronald L. Kelusky, General Manager

Phone: 397-9240

Fax: 392-2115

Ronald L. Kelusky Barry H. Gutteridge

General Manager, Ambulance Services Commissioner, Works and Emergency Services