3. OTTAWA PARAMEDIC SERVICE – 2008 HOSPITAL WAIT TIME REPORT

SERVICE PARAMÉDIC D’OTTAWA – RAPPORT CONCERNANT LES PERIODES D’ATTENTE A L’HOPITAL 2008

Committee RecommendationS

That Council receive this report for information.

RecommandationS du Comité

Que le Conseil prenne connaissance de ce rapport à titre d’information.

Documentation

1. Deputy City Manager's report Community and Protective Services dated 6 October 2008 (ACS2008-CPS-OPS-0004).

2. Extract of Draft Minutes, 16 October 2008. (This item and item 2 were addressed concurrently and reflected in the minutes under this report.)

Report to/Rapport au:

Community and Protective Services Committee

Comité des services communautaires et de protection

and Council / et au Conseil

6 October 2008 / le 6 octobre 2008

Submitted by/Soumis par: Steve Kanellakos, Deputy City Manager/

Directeur municipal adjoint,

Community and Protective Services/Services communautaires et de protection

Contact Person/Personne ressource : Anthony Di Monte, Chief / Directeur

Ottawa Paramedic Service/Services paramédic d’Ottawa

(613) 580-2424 x22458, Anthony DiMonte@Ottawa.ca

City-wide/ À L'échelle De La Ville

Ref N°: ACS2008-CPS-OPS-0004

SUBJECT:	ottawa paramedic service – 2008 HOSPITAL WAIT TIME REPORT
OBJET :	SERVICE PARAMÉDIC D’OTTAWA – RAPPORT CONCERNANT LES PERIODES D’ATTENTE A L’HOPITAL 2008

REPORT RECOMMENDATION

That Community and Protective Services and Council receive this report for information.

RECOMMANDATION DU RAPPORT

Que le Comité des services communautaires et de protection et le Conseil prennent connaissance de ce rapport à titre d’information.

EXECUTIVE SUMMARY

Since 2003, Hospital Wait Times (HWT) has continued to stress paramedic service delivery across the province. The original system design assumed a 20-minute wait time to check-in patients at hospitals. In Ottawa however, hospital processing times have hovered at around 1 hour over the course of the past decade.

HWT are the responsibility of the hospital administration and the Ministry of Health and Long-term Care (MOHLTC). The Ottawa Paramedic Service (Paramedic Service) has actively collaborated and participated in numerous provincial and municipal initiatives, as described in this report, to attempt to mitigate the situation over the past 5 years.

As part of the 2008 budget deliberations, Council directed: “that a steering Committee be established to develop an innovative plan to address hospital wait times in Ottawa. One of the first solutions to address in 2008 is the feasibility of using other health care practitioners to support emergency departments. The steering committee has been asked to present recommendations to Council prior to considerations of the 2009 and 2010 City budgets.”

The motion directed by Council was very timely and proactive. It is clear, however, that the province has recognized the impact of lengthening hospital wait times on paramedic services. A clear commitment has been made and the province has begun to actively address the issue through a number of initiatives including, most recently, the hiring of nurses to care for patients who arrive at ERs by ambulance to ease ambulance offload delays.

The Ottawa Paramedic Service has been an active and ongoing participant in these initiatives and the OPS is satisfied that the establishment of a new steering committee with its own terms of reference is not required at this time.

RÉSUMÉ

Depuis 2003, le temps d’attente à l’hôpital (TAH) continue de mettre en évidence la prestation de services paramédics partout dans la province. Le projet d’origine prévoyait un temps d’attente de 20 minutes pour l’enregistrement des patients à leur arrivée à l’hôpital. À Ottawa par contre, les délais de traitement des hôpitaux tournent, depuis les dix dernières années, autour d’une heure.

La responsabilité du TAH incombe aux administrations des hôpitaux et au ministère de la Santé et des Soins de longue durée (MSSLDO). Au cours des cinq dernières années, le Service paramédic d'Ottawa (Service paramédic) a collaboré et participé activement à de nombreuses initiatives provinciales et municipales, comme le décrit le rapport, en vue de stabiliser la situation.

Dans le cadre des délibérations sur le budget de 2008, le Conseil a demandé « qu’un comité directeur soit créé pour élaborer un plan novateur destiné à résoudre le problème du temps d’attente dans les hôpitaux d’Ottawa. L’une des premières solutions à prendre en compte en 2008 a trait à la faisabilité de faire appel à d’autres pr aticiens de la santé dans les services d’urgence. Le comité directeur a été chargé de présenter ses recommandations au Conseil avant l’examen des budgets de la Ville de 2009 et 2010 ».

La motion présentée par le Conseil était très opportune et proactive. Il est évident, en revanche, que la province a reconnu les répercussions sur le service paramédic des temps d’attente toujours plus longs dans les hôpitaux.

Un engagement clair a donc été pris et le provincial a commencé à s’attaquer activement au problème avec certains projets comme, tout récemment, le recrutement d’infirmières chargées de prendre soin des patients arrivant aux urgences en ambulance, afin de réduire les retards de transport chez les ambulanciers.

Le Service paramédic d’Ottawa participe activement et continuellement à ces projets et le SPO se réjouit que la création d’un nouveau comité permanent ayant son propre mandat ne soit pas nécessaire pour le moment.

DISCUSSION

The discussion portion of this report highlights Hospital Wait Times history and related initiatives since 2003.

2003

In 2003, HWT were beginning to impact service delivery for paramedic services across the country. The Ottawa Paramedic Service began to endeavour to work with its partners at the hospitals to ensure that timely quality care is provided to patients as part of the overall medical system. As result, the Champlain Emergency Service Network (CESN) was established under the administration of the Local Health Integration Network (LHIN). The CESN brings together local health care stakeholders in order to build solid primary health services, and customize services to area realities.

2004

In 2004, HWT continued to increase. The Paramedic Service participated in a number of initiatives to mitigate lengthening hospital wait times in Ottawa. The Paramedic Service participated on regional committees such as the Eastern Ontario Emergency Services Committee and has resulted in the implementation of internal hospital procedures intended to expedite the transfer of patient care. As well to provide for equitable distribution of patients to health care facilities, the Ottawa Central Ambulance Communication Centre (CACC) implemented a system that directs Paramedics crews to particular hospitals in a structured manner designed to avoid the overload of any one emergency department (ED). It is called the Patient Priority System (PPS).

2005

In 2005, hospital wait times continued to strain the paramedic response time performance across the country.

In March 2005, the Minister of Health and Long-Term created a special task force to investigate hospital wait times in response to issues raised by stakeholders such as Emergency Medical Service and municipal officials in Ottawa and Toronto. Dr. Brian Schwartz headed the Hospital Emergency Department and Ambulance Effectiveness Working group. The group membership was comprised of Doctors, Paramedic Chief's and various stakeholders. The City of Ottawa participated on this task force.

The group’s mandate was to review recommendations of other task forces and committees, best practices from Ontario, Canada and abroad and available public research. The working group presented the MOHLTC with a report on September 16, 2005, outlining 15 recommendations as to the patient’s journey through the emergency health care system, the three following themes emerge:

l System Commitment: Commitment from all stakeholders is the fundamental requirement for improvement in emergency department overcrowding and ambulance off-load delays. Many previous initiatives have failed because they addressed only the emergency department component of the problem. Hospitals and communities must recognize that ED overcrowding is a symptom of systemic issues and must be a high priority for change. Moreover, integration with other initiatives in the transformation agenda such as Primary Care reform and the Wait Time Strategy will help to ensure sustainability of the improvements.

l Accountability: Stakeholders must be accountable to each other and the citizens of Ontario for the emergency patient care. The design and collection of key performance indicators will allow tracking of progress. Implementation, by the ministry, of incentives and disincentives for hospitals and ambulance services will guide the evolution of the system improvements.

l Capacity: Resource requirements generated by admissions to the hospitals from ED's can be predicted daily, seasonally and regionally. Based on objective modelling methodologies, capacity should be defines and expanded through efficiencies, rescheduling of other services and innovative solutions; and finally, with addition to acute care beds only under circumstances in which all other means have been exhausted. Further, expanded capacity can be created in the community consistent with the government’s agenda to allow patients to stay in their community for care.

Essentially, the report submitted by the task force outlines a hospital system re-engineering. It clearly indicates that HWT are not created by one problem but by the sum of many issues needing to be addressed with key stakeholders.

The recommendations brought forward by the working group can be classified in 4 groups:

l Pre-Hospital Environment

l Recommendations for ED's

l Recommendations to improve patient flow out of the ED to definitive care or follow-up

l Oversight and accountability, including key performance indicators, benchmarks and recommendations to stakeholders accountability for achievement of the benchmarks.

The Critical following recommendation for ambulance off-load was the outlined as follows:

l That benchmarks for the flowing Key Performance Indicators (KPI's) of Ambulance Offload Delay and Emergency Department Overcrowding become part of the hospital accountability framework:

� Time from ambulance arrival to place on ED stretcher

� Time from patient on ED stretcher to admission to in-patient or discharge

The Report of the Hospital Emergency Department and Ambulance Effectiveness Working group will be reviewed by the Minister of Health and Long-Term Care with regards to its recommendations.

2006

In January 2006, the McGuinty government acted on the report submitted in 2005. The Minister of Health and Long-Term Care announced $96 million in funding for a comprehensive action plan as he released publicly the 2005 report of the Hospital Emergency Department and Ambulance Effectiveness Working Group. The report recommends ways for the hospitals and ambulances to transfer patients more efficiently from ambulance paramedics to the hospital ED. In response, the government provided funding to Toronto's hospitals and unveiled the government's new Critical Care Strategy, which in conjunction with the recommendations from Dr. Schwartz’s task force is designed to help ease emergency room pressures across the province.

Expert Panel

As a result of the 2006 funding announcement, an Expert Panel was established and chaired by Dr. Alan Hudson. The mandate of the expert panel was to explore and implement HWT strategies. The membership comprised of the Medical Association, Hospital Associations, Nurses Associations, Hospital CEOs, MOHLTC staff and 2 EMS Service Chiefs from Ottawa and Toronto. The EMS Chief’s from Ottawa and Toronto developed the “off-load” nurse strategy and presented the project for approval under the funding envelope.

2007

In 2007, the CEO of the Ottawa Hospitals announced a pilot project to begin in March 2007 at both the Civic and General campuses of the Ottawa Hospitals. The project implemented separate areas staffed by nurses where paramedic crews can off-load patients and return to service without having to wait for an emergency room (ER) doctor to take care and control of the patient. The Paramedic Service was hopeful that this pilot project would prove to be successful. Unfortunately the preliminary reporting indicated no improvements and hospital wait times in 2007 jumped considerably from 2006.

This initiative had practically no impact on HWT because the nurse was employed by the hospitals. When staffing levels for nurses were low in the hospitals the “off-load” nurse would be re-located within the hospital to cover off other department’s shortages.

2008

In May 2008, the Ministry of Health acknowledged the hospital wait time problem and is presently actively attempting to mitigate its impacts via a multi-faceted approach. The province has recognized this issue as a challenge and is addressing it directly. Hospitals are now required to provide directly to the ministry an Emergency Department Reporting System (EDRS). This initiative has been implemented and holds the Boards and CEO’s of hospitals accountable for performance criteria that must improve over a defined time frame.

Other initiatives that the government has announced and implemented are:

• Performance Fund targeting Ontario’s 23 poorest performing emergency rooms, IT enhancements and coaching teams to enhance hospital efficiency.
• Increase home care and personal support and homemaking services and enhanced integration between hospitals and Community Access Centres.
• New priority funding for Ontario’s 14 Local Health Integration Networks (LHINs) to invest in local solutions to further address ALC pressures
• Hiring of nurses to care for patients who arrive at ERs by ambulance to ease ambulance offload delays.
• New nurse-led outreach teams to provide more care to patients in long-term care homes to avoid transfers to the ER

The Ottawa Paramedic Service is directly affected by the funding for off-load nurses in ER’s. The 4.5 million dollar funding will be distributed among 14 municipalities in the province of Ontario, which includes Ottawa, and will be dedicated to putting in place nurses solely to care for patients who have arrived by ambulance at hospital. Although the 2007 hospital nurse initiative was not successful, in 2008 the significant difference is that the nurses are specifically contracted to off-load patients. This contract clearly outlines the nurse’s responsibility and mandate within the ED at the Ottawa Hospital. This initiative will allow paramedics to return more quickly to the community and be available to respond to another call. This is an effective short-term solution to help reduce HWT. The Paramedic Service is confident this funding will positively impact offload delay in the targeted hospital emergency rooms.

Ottawa Implementation Strategy

The Ottawa Hospital ED’s have been challenged with long ambulance off-load times due to several factors. The Emergency Departments of the Ottawa Hospital general and civic campuses will pilot an ambulance off-load initiative starting September 29, 2008 using Off-Load Nurses. The total cost of the project will be $350,008 100% funded by the MOHLTC and within the funding envelope of the Paramedic Service for this specific purpose.

The overall goal of this initiative is to reduce ambulance off-load delays in order to improve return to service times. The proposal identified the nursing staff employed by the hospital as being a health care professional to receive and be responsible for ambulance off-loads to the General and Civic Emergency Departments.

Ottawa Hospitals in 2008

Numerous initiatives have been implemented in the Ottawa Hospital as the first steps towards health care re-engineering:

• Trial of Waiting room nurse to offload CTAS 4 & 5 patients, begin assessment & treatments in Waiting Room
• Successful trial of Geriatric Emergency Nurse at Civic – to expand to General in January 2009 – to reduce admissions
• Successful trial of Patient Flow Manager at Civic to improve patient flow from ED to inpatient units – to expand to General with Pay for Performance funding
• Implementation of Full Capacity Plans (to send a patient to floor when an inpatient is admitted but not gone yet – used to expedite transfers of 483 patients Oct - April) and Over Capacity plan (to send a patient to an inpatient unit when no bed is available to stay in hallway – used to expedite transfers of 83 patients Oct – April)
• Implementation of new ED Patient Tracking system at both campuses
• Trial of Nurse Practitioner in Long Term Care Facilities to reduce transfers to an from – successful trial and now have applied for ongoing funding to continue & expand
• Process Transformation Project in 2006 to review processes & improve efficiencies.
• Implementing trial of Clinical Decision Unit at Civic Campus September 2008

Made in Ottawa Solution

As part of the 2008 budget deliberations, Council directed: “that a steering Committee be established to develop an innovative plan to address hospital wait times in Ottawa. One of the first solutions to address in 2008 is the feasibility of using other health care practitioners to support emergency departments. The steering committee has been asked to present recommendations to Council prior to considerations of the 2009 and 2010 City budgets.”

The motion directed by Council was very timely and proactive. It is clear, at this time, that the province has recognized the impact of lengthening hospital wait times on paramedic services. A clear commitment has been made and the province has begun to actively address the issue. The re-engineering of the health care system will continue over the next 5 years. In the interim, the province has provided paramedic services across the province with temporary short-term funding to allow for the implementation of the longer-term re-engineering initiatives.

The Paramedic Service is a member and is convinced that the hospitals and provincial government are doing all they can to resolve the issue therefore the establishment of a new steering committee with its own terms of reference is not required.

CONCLUSION

In March 2005, the Minister of Health and Long-Term created a special task force to investigate hospital wait times in response to issues raised by stakeholders such as Emergency Medical Service and municipal officials in Ottawa and Toronto. Dr. Brian Schwartz headed the Hospital Emergency Department and Ambulance Effectiveness Working group.

The group membership was comprised of Doctors, Paramedic Chief's and various stakeholders. The City of Ottawa participated on this task force. The group’s mandate was to review recommendations of other task forces and committees, best practices from Ontario, Canada and abroad and available public research. It has been made clear that HWT are a symptom of a larger systemic issue in hospitals. The re-engineering of the health care system presented by Dr. Schwartz’s report will allow for culture change and change in the way the hospitals to business. The province has accepted responsibility and has committed to fixing the problems.

Moving forward it is clear that Hospital Wait Times are a Ministry and Hospital administration issue. With all initiatives mentioned earlier on in this report, it is clear the Ministry of Health and Long-Term Care has accepted responsibility and is continuing to actively address the issues. The re-engineering efforts will continue to be implemented in Hospitals in 2009.

CONSULTATION

There was no consultation undertaken as part of the preparation of this information report.

FINANCIAL IMPLICATIONS

There are no financial implications associated with this report.

DISPOSITION

Community and Protective Services Department, Paramedic Service Branch will action any direction received as part of consideration of this report.