Restrictions of Ambulance Access to

Hospital Emergency Departments

The Emergency and Protective Services Committee recommends that:

(1)Council reaffirm its support for the Toronto Paramedic Service being the primary service for medical emergencies in the City of Toronto; and

(2)the Mayor be requested to meet with the Premier of Ontario to discuss means of reducing the rates of Redirect Consideration and Critical Care Bypass at Toronto's emergency rooms.

The Emergency and Protective Services Committee reports, for the information of Council, having:

(a)requested Councillor Dennis Fotinos, Chair of the Emergency and Protective Services Committee, to invite the Provincial Minister of Health to appear before the Committee in order to provide a briefing on the Province's efforts to reduce the increasing restriction of access to hospital and emergency wards;

(b)requested the Commissioner of Works and Emergency Services, in conjunction with the General Manager, Toronto Ambulance, to convene a one-day meeting of representatives from Hospitals, the Canadian Medical Association, the Ontario Nursing Association, the Canadian Union of Public Employees, Locals 79 and 416, and other interested medical groups to:

(i)discuss the problem of Critical Care Bypass and Redirect Consideration of hospitals; and

(ii)review protocols for addressing these situations at the various hospitals;

and that Members of the Emergency and Protective Services Committee be invited to participate in the proposed one-day meeting; and

(c)referred the following motion to the Budget Committee for consideration:

"That Council further support the principle of parity between the Ambulance, Fire and Police Services."

The Emergency and Protective Services Committee submits the following report (January 18, 1999) from the General Manager, Toronto Ambulance:

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.

Recommendation:

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 No. 1. These display the continuing increase in restriction of access to ambulances. The tables in Attachment No. 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 percent 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 experienced 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 percent 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 percent 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 Kelusky

Tel: 397-9241/Fax: 292-2115

(A copy of each of the attachments referred to in the foregoing report was forwarded to all Members of Council with the agenda of the Emergency and Protective Services Committee for its meeting on February 9, 1999, and a copy thereof is on file in the office of the City Clerk.)

--------

The Emergency and Protective Services Committee reports, for the information of Council, also having had before it during consideration of the foregoing matter a communication (February 8, 1999) from Ms. Anne Dubas, President, Canadian Union of Public Employees, Local 79, in connection with the foregoing matter.

The following persons appeared before the Emergency and Protective Services Committee in connection with the foregoing matter:

-Mr. Ron Kelusky, General Manager, Toronto Ambulance, and gave a presentation with respect to Health Care Restructuring, Emergency Department availability, system utilization and staff impacts, and options to be considered; and

-Ms. Roberta Scott, Toronto Paramedic Association.