EMERGENCY AND PROTECTIVE SERVICES COMMITTEE

MINUTES EPSC-2008-2

The Emergency and Protective Services Committee met on Thursday, September 4, 2008 at 9:43 a.m., in the Council Chamber, Regional Administrative Headquarters, 10 Peel Centre Drive, Brampton.

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* See text for arrivals
¨See text for departures

Chaired by Councillor P. Palleschi.

1. DECLARATIONS OF CONFLICTS OF INTEREST - Nil

2. APPROVAL OF AGENDA

RECOMMENDATION EPSC-3-2008:

That the agenda for the September 4, 2008 Emergency and Protective Services Committee meeting be approved.

3. DELEGATIONS/PRESENTATIONS

a) Peter F. Dundas, Director, Peel Regional Paramedic Services, Janette Smith, Commissioner of Health Services, Regarding the System Pressures Update of the Peel Regional Paramedic Services

Received

Peter Dundas informed the committee that the Peel Region Paramedic program has received the three-year certification from the Ministry of Health and Long-Term care. This certification allows the Region to continue providing land ambulance service through to 2011.

Peter Dundas, Director, Peel Regional Paramedic Services, provided an overview of the Systems Pressure Update of the Peel Regional Paramedic Services

Peter Dundas stated that there are three basic system drivers that are used to measure the Paramedic Services system:

• Productive Time, which is the amount of time paramedics spend responding to calls, travelling to hospitals and up to thirty minutes at the hospital. It is driven by call growth, traffic patterns and deployment plan;
• Offload Delay, which is the time in excess of thirty minutes that paramedics have to stay with patients at the hospital. It is driven by hospital patient processing within the emergency department and is directly related to the broader healthcare issues throughout the country;
• Total Coverage Hours, is the number of service hours that Regional Council approves at budget time. It is driven by council approval and the requirements to deal with population growth and offload delays.

Peter Dundas advised that Unit Hour Activity combines Productive Time, Offload Delay and Total Coverage Hours, to provide a high level system analysis of paramedic services. The ideal performance measure is .320 and .380. Peter Dundas reported that from 2003 to 2006 the Region of Peel was able to remain within the Unit Hour Activity, ideal performance range by adding service hours. In 2007, offloading time grew dramatically, the UHA increased to .430 and for 2008 he predicts it will increase to close to .500 which is a critical service marker to deliver the service to the community. Peter Dundas indicated that Peel Region has one of the highest Unit Hour Activity services in Ontario.

Peter Dundas noted that the Region of Peel faces a number of challenges that directly affect the level of paramedic services. These include:

• Population growth within the region adds 24,000 people annually;
• An aging population;
• A large immigrant population;
• A social attitude that a 911 call will receive faster service at the hospital;
• A lack of family doctors;
• Abuse of the 911 system; and
• Patients are returned home from hospital earlier, leaving families overwhelmed.

Peter Dundas advised that in 2007 there was an annual growth of ten per cent of call volumes and the projection for 2008 is 80,000 emergency responses. Peter Dundas also stated that there will be approximately a 36 per cent increase in Offload Delay time for 2008. The Offload Delay time is primarily responsible for the increase in the Unit Hour Activity in the Region of Peel.

Peter Dundas highlighted the community impact of an increase of Unit Hour Activity:

• The wait times for ambulances are longer for both emergency and non-emergency calls;
• An increasing frequency when, there are no Peel ambulances available in the Region of Peel to respond to 911 calls; In 2007 there were 78 occurrences of Code Capacity (an instance when there are no paramedics available to take the next emergency call) and to this date in 2008 there have been 39 of these events; and
• Paramedics taking calls are subject to chronic stresses and this may have an effect on overall citizen satisfaction with the service.

Peter Dundas noted the every day paramedic impact of an increase in Unity Hour Activity as follows:

• 9 paramedics do not get lunch;
• 30 paramedics are held past the end of their shift on paid overtime;
• 36 paramedics experience an offload delay of more than two hours;
• 10 of the 36 paramedics experience an offload delay of more than four hours;
• 6 of the 10 paramedics experience an offload delay of more than five hours.

Peter Dundas reported that the increase in offload times have a direct impact in that they increase hospital wait time, decrease system performance through an increase in response times and code capacity which increase costs.

Peter Dundas outlined the following offload strategies:

• Community Referral by EMS (CREMS);
• Transfer of Care protocols;
• Increasing the patient to paramedic ratio;
• Developing waiting room protocol;
• Real time negotiation with hospital Emergency Department staff;
• Implementing Patient Destination Software;
• Hospital Nursing Program; and
• Investigation of billing hospitals for lost time and recovering the $45 billing fee.

Peter Dundas stated that 2900 patients across Ontario are waiting daily in hospitals for alternative level of care placement. These patients take up acute care beds while waiting for placement in locations such as rehabilitation, home care, long-term care or hospice. In the Region of Peel 80 patients daily wait in hospitals for placement. The result of this situation is an increased pressure on the traffic of hospitals which increases offload times for paramedics. He noted that in order to deal with challenges in Ontario hospital emergency departments, Dr. Alan Hudson who was tasked by the Ministry of Health and Long-Term Care to develop a provincial emergency room strategy over the next three years. One of the goals of this emergency room strategy is to reduce offload times. Peter Dundas outlined recent announcements to support the emergency room strategy. These include the addition of acute transition beds, programs to help seniors to move from the hospital to the community, daily living support for seniors in the community who are at risk of hospitalization and assigning nurse practitioners to long-term care homes to prevent transfer to emergency rooms. Peter Dundas stated that he expects it will take five years for this emergency room strategy to begin to reduce offload times.

Peter Dundas advised that the Region of Peel has two options for dealing with the increase in call volume and offload time growth;

• Increase service hours only;
• Expand the hospital nursing program and reduce service hours need.

Peter Dundas outlined the steps needed in order to expand the Hospital Nursing Program. Execution of agreements with hospitals and the provincial government must be in place in order for the Region of Peel to participate in a program that is currently funded by the Ministry of Health and Long-Term Care. He further noted that local hospitals would also have to support the program as well as have the physical space. Peter Dundas stated that if the Region of Peel were to implement this program, would be a need to have a system in place to capture one hundred per cent of offload nursing hours.

Peter Dundas advised that even with the Hospital Nursing Program, there will be a need to add more service hours in the 2009 budget in order to deal with a ten per cent growth in call volume and an offload growth of thirty per cent. He added that without the Hospital Nursing Program, the Region of Peel would need to fund 70,000 service hours next year maintain service levels. Peter Dundas also advised that the implementation of the Hospital Nurse Program would mean a reduction in the increase in service hours for growth in call volume. As provincial wait times are reduced through the Ministry of Health and Long-Term Care emergency room strategy, the service hours spent with offload can be redeployed into the system to address response time and phase out of the expanded nursing program. Peter Dundas advised that this would lessen the financial impact on future regional budgets.

Peter Dundas concluded his presentation by outlining the current activity and next steps which need to be taken:

• Finalize negotiations with hospitals for the current provincial Hospital Nursing Program;
• Explore hospital willingness for an expanded Hospital Nursing Program;
• The EPSC endorse a Peel-funded, enhancement of the Hospital Nursing Program to commence in the fall of 2008;
• Advocate with the province to get assurances that they will continue with base funding for the current nursing program;
• Request 50/50 funding from the province for an enhanced Hospital Nursing Program.

Councillor Morrison asked Peter Dundas if the Central Ambulance Communication Centre (CAC) considers all 911 calls emergency calls. Peter Dundas responded that there is a limited triage system in place so the majority of 911 calls are considered emergencies.

Councillor Morrison commented that there are people calling 911 for non-emergency situations and that this mater must be dealt with in order to reduce the stress on the emergency system.

Councillor Morrison asked about the responsibilities of paramedics if their patients condition deteriorates while waiting at the hospital. Peter Dundas responded that paramedics are responsible for treating the patient in such situations but would also notify hospital emergency room staff.

Councillor Morrison asked if there was any way the Region of Peel could charge a fee for non-emergency 911 calls. Peter Dundas responded that through the Ambulance Act, the region is not allowed to bill patients for ambulance calls.

Councillor Morrison stated that adding service hours along with funding the Hospital Nursing Program were the best solutions to address the increase in call volume and the growth of offload time.

Councillor Morrison questioned if the Region of Peel agrees to fund the Hospital Nursing Program, how the region can ensure that the funds will not be used to supplement services for patients in neighboring regions. Peter Dundas responded that within the agreements of the neighboring regions there is reciprocal language to ensure that Peel is offloaded if first in to one of their area hospitals.

Councillor Morrison asked if the Region of Peel is going to put nursing care in local hospitals, what will happen if these nurses are used for other duties. Peter Dundas responded that there will be a pay for performance system in the agreement where, if the hospital uses the nurse for alternate duties, they will not receive funding for those hours.

Councillor Morrison asked if there will be out clauses in the agreement if the program does not produce results. Peter Dundas confirmed there will be out clauses in the agreements with local hospitals.

Councillor Morrison stated that a previous meeting with the Minister of Health and Long-Term Care was productive and that the Regional Chair and the three Mayors should meet with the new Minister to discuss these issues. Peter Dundas agreed that a meeting with the Minster of Health and Long Term Care would be a good opportunity to make the case for provincial support.

Chair Kolb congratulated Peter Dundas and staff for the work undertaken to prepare the presentation. Chair Kolb stated the next EPSC meeting should explore further details related to the Hospital Nursing Program now that the agreements with the hospitals are almost in place.

Chair Kolb reported that he and Janette Smith, Commissioner of Heath Services had recently met with the new CEO of the Credit Valley Hospital and discussed issues related to the presentation today. The CEO of Credit Valley Hospital expressed support for the issues raised today.

Chair Kolb stated he supported the idea meeting with the Minister of Health and Long-Term Care regarding funding for the Hospital Nursing Program.

Councillor Paterak requested details on how the funds from the $45 ambulance charge are distributed. Peter Dundas responded the fee is allowed under the Ambulance Act, the hospital retains a portion of the fee and the remainder is returned to the provincial government.

Councillor Paterak asked if there would be provincial funding to reward hospitals that improve emergency room service. Peter Dundas responded that there are incentives for hospitals based on performance so it is in the best interest of hospitals to improve emergency room service. Janette Smith, Commissioner of Health Services added that this is one of the first times that there will be paid per performance for hospitals for ER wait times. Janette Smith reported that in 2009, the public will have access to emergency room statistics through a Ministry of Health and Long-Term Care website.

Councillor Paterak questioned whether the increase in offload time caused additional stress on paramedic staff. Peter Dundas responded that paramedic staff are dedicated to their work and experience stress knowing they are better served out in the community taking additional calls.

Councillor McFadden asked if a 911 call is received and it is not emergency call, will the ambulance still respond. Peter Dundas responded that in accordance with the Ambulance Act, if a call for service is made, paramedics must respond.

Councillor McFadden commented that abuse of the 911 system ties up emergency staff. Peter Dundas responded that over fifty per cent of 911 calls are not emergencies.

Councillor Palleschi asked what the shortfall in funding is for 2008 expanded Nursing Program.. Peter Dundas responded that the shortfall for this year is $80,000 and that the Region of Peel would have to add an additional $400,000 for 2009. Janette Smith stated that the additional $80,000 is available under the current budget and for 2009 there would be a request for the additional $400,000.

Councillor Palleschi requested for further details on how offload time impacts response time. Peter Dundas responded that he would bring forward more details at the next meeting. Councillor Palleschi proposed that these statistics on the effects of offload on response time would be useful in a future meeting with the Minister of Health and Long-Term Care.

Councillor Palleschi questioned why there is an increase in transporting low priority patients.

Peter Dundas responded that the Region of Peel continues to transfer patients from hospitals to long-term care, rehabilitation and hospice facilities despite the increase in private transport companies. Peter Dundas reported that there are currently eight to ten hour delays in responding to the transport requests. Councillor Palleschi stated that long-term care facilities operated by the Region of Peel should use private transport companies in order to ease stress on regional paramedic services.

4. REPORTS - Nil

5. COMMUNICATIONS

 a) Member Communication - Alert: Association of Municipalities of Ontario (AMO), dated August 11, 2008, Advising of the New Local Land Ambulance Response Time Standards to be Established (Referral to Health Services recommended)

Received

6. IN CAMERA MATTERS - Nil

7. OTHER BUSINESS - Nil

8. NEXT MEETING

Thursday, November 27, 2008
9:30 a.m. to 12:00 p.m.
Council Chamber, 5 th Floor
Regional Administrative Headquarters
10 Peel Centre Drive
Brampton, Ontario

9. ADJOURNMENT

The meeting adjourned at 11:23 a.m.