MINUTES

COMMUNITY SERVICES COMMITTEE

REGIONAL MUNICIPALITY OF OTTAWA-CARLETON

CHAMPLAIN ROOM

19 NOVEMBER 1998

1:30 P.M.

The Medical Officer of Health, Dr. R. Cushman, welcomed delegates from Cuba and Bolivia attending the Canadian Society for International Health Conference to the Committee meeting.

Replying to a question from Councillor L. Davis, Dr. Cushman indicated a report on the above-captioned matter will be presented at the next Committee meeting.

1. ASSOCIATION OF LOCAL PUBLIC HEALTH AGENCIES (ALPHA) CONFERENCE: "THE FUTURE IS NOW"

- Committee Co-ordinator’s report dated 02 Nov 98 and attachments

2. INDEPENDENT AUDIT OF AMBULANCE RESPONSE TIMES

The Medical Officer of Health, Dr. R. Cushman began by saying the independent report prepared by Mr. Alan Craig, Senior Emergency Services Planner, City of Toronto Ambulance Service, focuses on the quality of ambulance service in Ottawa-Carleton and substantiates the Region’s two initial contentions: that the Region of Ottawa-Carleton must have control of dispatch to deliver an effective ambulance service and that the funding provided, $12.5 million, is substantially under-costed. Dr. Cushman speculated that running a quality service will cost over $20 million. He reiterated his support for the men and women working in the ambulance service sector, saying there have been problems from the beginning and there will continue to be difficulties as the system re-defines itself. Dr. Cushman wanted to underscore the fact these are system problems, not people problems, and that the paramedics and dispatch operators are working as best they can within the existing system.

The following is a presentation made by Ms. Joanne Yelle-Weatherall, Director, Land Ambulance Services, on the findings of the independent audit:

Ms. Yelle-Weatherall highlighted three of the many components used to measure response times:

She noted that all good ambulance services in North America use fractile reporting, as it clearly illustrates what happens most of the time. While the Ministry of Health supports the use of fractile reporting, as stated in Section 42 of the Ambulance Act regulations, it reports ambulance response times in Ottawa-Carleton by using averages. This is not a good measurement since it only relates what happens half the time.

The acceptable standard response time in North America in urban communities is 8 minutes, 59 seconds or less at the 90^th percentile. This standard is based on response times for cardiac arrest, the most serious emergency situation, where if circulation is not restored within minutes, the lack of oxygen will cause irreversible brain damage. In the 1970s researchers found there were significantly higher, out of hospital cardiac arrest survival rates if first level response (Cardio-pulmonary resuscitation CPR) was initiated within 4 minutes and if Advanced Life Support (ALS) paramedics arrived on the scene within 8 minutes. These have since become the international "gold standard" for urban ambulance systems and are supported by both the Ontario and American Ambulance Associations. In Ottawa-Carleton, in urban centres, the response time is somewhere between 13.5 and 16 minutes at the 90^th percentile.

Ms. Yelle-Weatherall spoke about dispatch call taking times. She said that Section 56 of the Ambulance Act regulations indicates that, for life-threatening emergency calls, it should take no more than 2 minutes to alert an ambulance crew to respond to a call, 90 percent of the time. The current dispatch response time in Ottawa-Carleton urban communities is 3 minutes 48 seconds. An important consideration is when does the clock start recording time, and it starts at different times for different people:

Ms. Yelle-Weatherall indicated that, for the purposes of this report and for all future purposes, the Region of Ottawa-Carleton identifies response time as the time between the ambulance dispatcher’s first contact with the caller and the arrival of the ambulance at the address where the call originated.

She presented a diagram which illustrates the components of emergency ambulance response time, beginning with the transfer from 9-1-1 service to the ambulance arriving at the scene. The first link in the chain, the dispatch function, is the weakest, and it is imperative that Ottawa-Carleton gain control of this function in order to improve the system. In addition, technology upgrades, new policies and improved system design will be required.

Ms. Yelle-Weatherall concluded her presentation by saying two key ingredients will be required in order for the Region of Ottawa-Carleton to provide its citizens with good ambulance service at a reasonable cost, and to meet the Ministry of Health’s basic principles: these are the control of the dispatch function and the requirement for additional funding. The independent audit has confirmed the position of the Medical Officer of Health at the time the service was downloaded to the RMOC.

Mr. Alan Craig began by restating there was no need to personalize any of the report’s findings, as everyone involved in the ambulance business is hardworking and has a huge emotional investment, whether they are service providers or administrators. He pointed out that Ottawa-Carleton is far ahead of almost every other municipality in terms of the downloading of ambulance service and in wanting to take this opportunity to provide an excellent service; the data contained in the report should be treated as a starting point and as part of the foundation process.

Mr. Craig described the analysis as a standard base line analysis for any emergency medical system to be established, one that is run on a daily, weekly and monthly basis by every quality service in North America and beyond. The information will be a mandatory part of the Expression of Interest process to come, where it will be ascertained whether there are agencies, departments or private interests who think they can provide service delivery in the year 2000. It will be important for the proponents to know the scope of the expected work and to receive fair warning they are taking on a major metropolitan service. The analysis provides the required level of detail, as well as a benchmark all parties can look back upon saying this is where we were, this is where we are today and this is where we want to go.

Mr. Craig continued by saying the Ministry of Health supplied the data for all calls handled by the Ottawa Dispatch Centre beginning or ending in the Region of Ottawa-Carleton or handled by ambulance stations physically located in the RMOC in 1997. One hundred and thirteen thousand (113 ,000) records were available and analyzands ended up with approximately 70,000 records. Approximately 28,100 were excluded because they did not relate to patient care (vehicles going for gas or moving from one location to another); an additional 16,000 calls related to pick-ups outside the RMOC and a small percentage was excluded because of missing time stamps and illogical response times.

In instances with extremely long time intervals, system providers were given the benefit of the doubt in very case possible. Data from 1998 had originally been requested but data from 1997 was more readily available. It was felt this would have a minimal impact since the demand for ambulance service does not shift radically from year to year in a community which is not changing shape or size at a fast rate. In addition, there have been no fundamental emergency medical service changes since January 1 therefore the results are representative of the current situation. The data provided was good, clean data, with few exclusions required.

A numerical analysis was undertaken (how many calls, how many patients arose from all priorities, from non-emergency to life threatening situations): response times were an important issue. Researchers analyzed all possible intervals in every call and calls were broken down into 5 km and 1 km squares across the Region. This has generated much information for each of these areas and the data will be useful to the RMOC in the future. The analysis provided an extremely good understanding for the future system. The importance of this cannot be underestimated, as it is the foundation for the new system. Good response time mapping and good demand mapping was generated, and this speaks to how many ambulances will be required in the long term. Aside from across-border calls, the Region now has all the data it needs for systems establishment and to negotiate with the Ministry of Health.

Councillor L. Davis asked why the RMOC’s response time is 3½ minutes while the Ministry standard is 2 minutes. Ms. Yelle-Weatherall indicated part of the problem is antiquated technology and the fact that paramedics may not be readily available; she reiterated there are efficiencies to be made once control of the system is obtained. Councillor Davis opined part of the problem is ambulance diversion for higher priority calls. Mr. Craig pointed out that the analysis looked at the total response time from the moment the clock starts ticking until the vehicle gets to the scene, and he agreed that diverting ambulances does add to the response time. The Medical Officer of Health, Dr. R. Cushman, expressed the hope that ambulances were not being diverted in the case of life-threatening emergency calls. He added that, in the case of a multi-vehicle accident, the first vehicle to arrive might be the second one that was dispatched, but the vehicles would have been coded from the initiation of the call to the arrival on the scene.

Councillor Davis wanted to know whether 9-1-1 operators assess the degree of emergency or whether they automatically channel calls to the downstream agencies. Mr. Craig indicated the normal practice is to refer calls to the prime agencies, fire, police and medical emergency services. He added that, in a good 9-1-1 centre, operators try to get as much information about where the patient is located to get the ambulance on its way rapidly.

Councillor Davis wondered any new technology would be year 2000 (Y2K) compliant. Ms. Yelle-Weatherall agreed this is a serious concern, however she reiterated that the system cannot be changed, and new technology cannot be introduced before staff have a definitive answer from the Ministry about the dispatch function. A. Craig added that the Y2K compliance issue will be highlighted in the Expressions of Interest document. He pointed out that all dispatch systems currently available are Y2K compliant, but he could not say whether this is the case with the Ministry’s technology.

Councillor C. Doucet expressed his concern about the 9-1-1- service not having been included in Mr. Craig’s research. He related a recent experience with land ambulance service where it appeared to him the 9-1-1 operator and the caller spent a significant amount of time discussing details of the accident. The Councillor said he felt this should be factored into response times for the new system. Mr. Craig noted that, from a public health point of view, monitoring how long a transfer from 9-1-1 takes is an important consideration, but this is beyond the responsibility of the Ottawa Ambulance Centre, and possibly, in this instance, the caller had already been transferred to ambulance services.

Councillor D. Beamish asked how the numbers compare to those in Toronto and whether a different kind of deployment is used. Mr. Craig replied that, as of this week, in 87% of life-threatening emergencies, ambulances arrive in 8 minutes, 59 seconds or less; this is measured from the time the phone rings in the centre since Toronto has the technology to do it. This figure is for the Metro area and response times are even shorter in the downtown area. There is no difference in the deployment scenario for 9-1-1 operations in Toronto.

Replying to a question from Councillor D. Holmes, J. Yelle-Weatherall indicated the data requested from the Ministry was provided directly to Mr. Craig and was not obtained through a Freedom of Information (MFIPPA) request. Staff have requested additional information through MFIPPA and are still awaiting receipt of much of this material. She confirmed, in response to an additional question from Councillor Holmes, that the Province was refusing to provide some of the other information requested.

Councillor Holmes asked for an update on discussions with the abutting municipalities. Ms. Yelle-Weatherall indicated that the counties of Prescott-Russell and Stormont-Dundas-Glengary are interested in partnering in any area that represents savings. The County of Renfrew’s position is that the Ministry of Health should take back ambulance service therefore they are not interested in participating in any discussion. Lanark County has indicated it has a made-in-Lanark solution.

Councillor Holmes asked whether the cost of dispatch was included in the $12.5 million figure and if not, what do staff estimate the cost will be. Ms. Yelle-Weatherall replied in the negative, adding that the estimated cost is approximately $2.5 million, a figure provided by the Ministry. She could not say, in reply to further questions from the Councillor, how many vehicles the RMOC should have, since the system will be completely redesigned, and efficiencies will be sought.

Councillor Holmes noted that the cost of amalgamating police services in Ottawa-Carleton had been high, and she wondered whether the Ministry should be expected to pay capital costs before the Region accepts the take-over. Mr. Craig said this is a political matter that Council will need to address: clearly, the $12.5 million is substantially low in view of the information on the current level of service and that which might meet the Medical Officer of Health’s requirements.

Councillor W. Byrne asked whether the full assumption of responsibility by the RMOC included the dispatch function, or whether the Province intends to continue providing this service. Ms. Yelle-Weatherall indicated the Province maintains it will continue to control dispatch. Councillor Byrne wanted to know about the logistics of dispatch and why it was essential the Region control this function. Ms. Yelle-Weatherall reiterated the control of dispatch controls the level of service and thus controls costs. Under the current arrangement, dispatch is provided by a separate agency under contract to the Ministry of Health and the Ministry and other providers control the vehicles.

Councillor McGoldrick-Larsen spoke about having spent time at the ambulance dispatch centre as well as at the Queensway-Carleton Emergency room and at being shocked at what she discovered. She recommended other Committee members spend time with the ambulance industry to gain a better appreciation of what the transition team is trying to accomplish and she wanted those present to know that everyone she spoke to had high regard for the way the Region is approaching the issue. The Councillor asked for an update on discussions with the Ministry regarding the dispatch function. J. Yelle-Weatherall said Chair Chiarelli has written to the Minister and there is a commitment from the Minister’s Office to future discussions with staff on this matter. Ministry officials have said the dispatch function would be retained.

Councillor H. Kreling asked for clarification on the Ministry standard for response times. J. Yelle-Weatherall clarified the 8 minute, 59 second standard is an industry standard, not a Ministry standard. Councillor Kreling wondered whether the recent re-tender for the Osgoode Ambulance Service had included references to the dispatch function or to response times. Mr. Craig said there had been no requirement for response times, as control over this aspect lies with the dispatch function.

Dr. Cushman noted that one of the key elements of dispatch, in addition to time sequence, is deployment. The "gold standard" is widely accepted in the North American industry and is well-known to the Ministry, to the point where it gets into the Ambulance Act but without rigid regulations. Dr. Cushman said this was another justification for establishing a performance-based service in Ottawa-Carleton as opposed to a level-of-effort service.

Mr. Richard Lavictoire, Acting Manager,

Mr. Lavictoire said the CACC is aware it needs to upgrade and update its system and protocols. Since 1997 it has been awaiting the installation of new equipment such as an integrated radio-telephone system (to be in place by January 1999), a new computer-aided dispatch (Fall of 1999), a digital mapping system and additional staff. Currently staff are updating and revising all policies and procedures and are revising the way calls are taken, questions are asked.

Staff also participate on the regional committee comprised of ambulance operators and members of the ambulance centre to optimize present resources and to present submissions for enhancement. Mr. Lavictoire noted that, notwithstanding the delays attributable to the major restructuring of land ambulance services and the fact that communication centre staff and paramedics in the field are demoralized at this time, employees remain competent and efficient in managing and coordinating the delivery of pre-hospital care in the community.

Mr. Lavictoire presented the following statistics as a comparison with other jurisdictions:

No. of vehicles available per citizen;

Territory covered;

Number of calls per vehicle;

Mr. Lavictoire added that, as recently as July 1998, and as indicated in the OPALS study of base hospital statistics, patients suffering from cardiac arrest receive definitive care in under 8 minutes at 95.5% of the time. He concluded his presentation by saying that CACC staff will continue to work with other stakeholders to provide pre-hospital care for the citizens of Ottawa-Carleton and the surrounding municipalities. He invited those present to visit the call centre to see the overall system and to see that people work to the best of their ability. The Committee Chair, A. Munter, asked Mr. Lavictoire to convey the Committee’s appreciation to CACC employees for the excellent work they perform under difficult circumstances. Chair Munter added that some of the information provided by Mr. Lavictoire underscores the fact the Region has excellent ambulance staff but there are just not enough of them.

Councillor Beamish asked for a comment on Mr. Lavictoire’s statement regarding the findings of the OPALS study. Mr. Craig indicated base hospital numbers speak to the arrival of the first person capable or rendering any form of patient care, and does not speak to ambulance arrivals. In most cases, the number reflects the arrival of a fire department first response vehicle or of a basic life support ambulance, not to the arrival of a paramedic ambulance.

Councillor Beamish wondered why there was such a difference between what happens in Toronto and what happens in Ottawa-Carleton. Dr. Cushman asked whether Mr. Craig would comment on the disparities in the resources allocated for ambulance services across the Province. A. Craig pointed out that the Toronto ambulance program has been a municipal program since 1976 and, until January 1, 1998, there was a co-funding arrangement with the Province.

The Ministry set the number of ambulances it called "approved expenses" and this number was considerably lower than what staff knew was the number required to reach response time standards medically needed in the community. The Ministry paid approximately 50% of the bill and the municipality funded the rest from the municipal tax base. The cost of ambulance service in Toronto is $67 million, with $8.3 million from the Ministry for dispatch service.

Mr. Moloughney began by saying strong action must be taken to restore public confidence in ambulance service delivery in the RMOC. While public confidence has been damaged, OPSEU supports the release of the report and its findings. The Union has worked many years to try to affect change and to address the system’s shortcomings.

Mr. Moloughney continued by saying Local 413’s membership has been embarrassed and demoralized to some degree, but it has been offered a ray of hope. The shortcomings have been exposed and the RMOC is now in a position to address this matter. In addition, regional staff are being given an unique opportunity to redesign an essential, public emergency service.

Mr. Moloughney spoke about representations having been made to both Premier Harris and to the Minister of Health, requesting immediate corrective actions, and calling on the Province to relinquish control of dispatch to the RMOC. He highlighted the fact the Province does not insist on running dispatch for police or fire departments, but it does maintain regulatory authority in each of these areas. Mr. Moloughney posited there is no reason why the Province should run ambulance dispatch to maintain its regulatory authority over the service.

Ms. Lalonde began by saying the Association was founded in 1995 as the result of paramedics’ frustration that there was not a better way to answer the public need in accordance to the training they were getting. Some of the rules and policies that now paralyze the system have been changed. She spoke about the lack of consultation between the dispatching system and the ambulance system and she expressed the hope the worker on the street would be consulted to see if there was a better way of doing things. Ms. Lalonde said she agreed the rules should be changed before injecting the amount of money required into the new system, to ensure more efficiency. She added that currently, there is no logic in who answers a call, it is usually the vehicle closest to the situation, since dispatch doesn’t have the right to differentiate between situations and relocate another vehicle that could be better used. Ms. Lalonde said part of the response time difficulties lies with poor technology, a radio system that does not work well all the time, and difficulties contacting an ambulance because the driver is inside a hospital delivering a patient. Another problem is that, at times, not that many ambulances are available.

The satellite positioning system is part of the problem; if a has to ask five or six vehicles about their location before deciding which one to send, important time is consumed. Hospital restructuring has also contributed to these difficulties. Ms. Lalonde expressed the hope many of these problems will be rectified through the establishment of a new system.

Councillor Kreling asked whether, in the protocols used in Toronto or elsewhere, dispatchers are given the authority to use their judgment in assigning calls. Mr. Craig replied in the affirmative, adding that the new computer-aided dispatch software being launched proposes the closest three ambulances available and highlights them on a digital map thus empowering the dispatchers to make the determination.

Councillor McGoldrick-Larsen want to clarify she has every respect for the professionals working in the field who are really doing their best within the existing system. She pointed out that most of the paramedics moving to the advanced level are doing so on their own initiative, because they really love their jobs and want to improve the service to their patients. She asked whether Ms. Lalonde would comment on the frustration experienced by paramedics trying to find a hospital where they can take patients. Ms. Lalonde indicated that hospitals now and then update the dispatch centre about the status of their emergency rooms, about how many people they have and whether or not they are able to deal with life-threatening emergencies. This is a source of frustration and stress because it may be several kilometers farther to access emergency services and it makes vehicles and paramedics less available for the next patient.

Mssrs. Villeneuve and Martel are the Union representatives for workers in the dispatch centre. Mr. Villeneuve pointed out that the system has been under a lot of criticism lately, leading the public to believe the quality of ambulance service is far below the acceptable norm. He said he did not feel this was an accurate picture and it was not something that happened all of a sudden. While the references to delays in responding and the difficulties in assigning priorities are fairly accurate, the responsibility does not lie solely with the dispatch centre. There are problems with the number of providers, that is paramedics and dispatchers, and the fact that governing policies did not evolve with the increase in the number of calls. The introduction of paramedics has contributed to multiple levels of patient care being performed on the road. Dispatchers have not been assisted in dealing with new demands and standards. There are also problems with maintaining staffing levels in the communication centre, which is understaffed most of the time.

Mr. Villeneuve concluded by saying dispatchers are as valuable in the current system as any part of it; their expertise has not suddenly declined and they are efficient given the tools they have. Dispatchers are proud of the work they do, and would like to see the system enhanced to provide better service.

Mr. Berthiaume congratulated regional staff for retaining Mr. Alan Craig, whose quality of work and expertise are renowned. He is one of the few Canadian experts in ambulance service and the Region can be fully confident in the information he brings to this matter. Mr. Berthiaume noted that operators in Ontario have been aware of this information, and have brought matters to the attention of the Ministry. However, there was no willingness to look at the issues, the Ministry said the system was working and didn’t need to be fixed. The ambulance services association was aware there were opportunities to better serve the public, and is pleased to see the matter come to the table. The speaker said he felt the public should not be alarmed at this point, as the system is still functioning, but it can function better..

Dr. Justin Maloney, Director, Base Hospital, called the report credible and important; the depth of analysis is worthy of admiration. Many of the details highlighted, while alarming, are not necessarily new. Dr. Maloney said he was glad to see the level of frustration around the table, and he reminded Committee members the Region will soon own the system. He suggested Councillors familiarize themselves with the business, visit the dispatch centre, and approach the matter as the average citizen would. He reinforced earlier statements about this not being a people problem but a systemic problem, as there are really good people working in the field in Ottawa-Carleton. Dr. Maloney said he has been involved in training many of the paramedics, and they know the system’s failings. He emphasized that dispatch is the heart of the system, it controls resources and success rates at many levels. The Region is right it pursuing it but it will cost money to fix, i.e., new software and training for personnel.

Councillor D. Holmes wanted to ensure Council reiterate to the Ministry that, in spite of the difficulties foreseen, the Region is still interested in assuming land ambulance services. However, the Ministry must be asked to divulge the real cost of the service, and, to this end, Councillor Holmes put forward the following Motion:

Councillor Kreling expressed reservation about asking to appoint a mediator, inquiring whether all hope was lost of arriving at a negotiated solution with the Ministry. Ms. Yelle-Weatherall reiterated staff have a commitment from the Minister’s office for further discussion and will continue to work towards a win/win solution. Dr. Cushman added there is quality dialogue with the Minister’s Office, but this still has to happen with the Ministry’s ambulance branch. A mediator may not have to work too hard and this would underscore the importance of moving on dialogue. Chair Munter noted part of the problem is that there have been back and forth discussions with Ministry, and efforts are now being made to get the Minister involved to move beyond the Ministry/Regional staff box.

Councillor Kreling said he could support the Motion, given that it puts forward a process by which the Region can attain its goal. He spoke about comments made at an earlier meeting by some of the individuals present today, on how open and refreshing it was to deal with the Region in comparison to the Province. The Councillor said he hoped those present realized that same openness can have a double-edged effect when referencing problem areas; it makes all parties accountable and responsible for changing the situation, and for issues coming to a positive conclusion.

Councillor McGoldrick-Larsen said she wholeheartedly agrees the Region must control dispatch to make the system work; there is no question centralized dispatch would provide a seamless service. She asked whether staff could provide a notional figure for what the service might cost in Ottawa-Carleton. Mr. Craig pointed out that the first two to four minutes’ improvement in response times will come procedurally, not with money. In addition, the Region will describe the level of service it wants to provide and ask others how they will do it and at what cost. Another factor is the uncertainty about what the Ministry will hand over, and there are many unknown factors about capital expenditures.

He said his best guess would be somewhere between $20 and $24 million, and there may be efficiencies through exceptionally good responses at the Expressions of Interest and Request for Proposal stages. Councillor McGoldrick-Larsen opined it is crucial the costs become part of the dialogue with the Ministry and as the Region begins its budgetary process. It is also crucial that residents understand the importance of the information contained in the report as it provides a picture of where Ottawa-Carleton is compared to other cities and what the ultimate cost is going to be.

Councillor L. Davis related that, in her experience, most of the primary response has come from firefighters, and this is a source of concern to her. She said she did not believe that highly trained people should arrive at the scene after fire trucks arrive; they need to be deployed in other ways and this will be done by taking over dispatch. The ambulance service should be given the tools it needs to do its job, and this will only happen by providing it with funds. Councillor Davis said she would like to see the Region tally up what the costs will be and approach the Province before taking over, to hold the Province accountable and to secure the right amount of funding. She emphasized the need to be proactive in negotiating for the entire package.

The Committee Chair, A. Munter, began by saying it isn’t often in the municipal sector that politicians deal with life and death issues. He made reference to Dr. Maloney pointing out this will become the Region’s problem and, while Councillors can and should be indignant about what the Ministry of Health has done with the service in the past, in 13 short months it will be their job to fix it. Chair Munter thanked Dr. Cushman, Ms. Yelle-Weatherall and Mr. Craig for the hard work they have done, and the participants in today’s meeting for their candor in speaking out about the system. He said he was hopeful that reiterating the Region’s original position about adequate financial resources being required and needing local control of dispatch, and asking the Province to mediate on these issues, would bring about a resolution. Chair Munter noted that, while the Committee often complains about services being downloaded, he did not feel this was applicable to land ambulance service being at the local level, along with police, fire and 9-1-1 services. He said he supported the provincial decision, but it has to come with the appropriate funds and the tools necessary to protect the health and safety of residents of Ottawa-Carleton.

The Committee then considered the following Motion:

Moved by D. Holmes

3. SUCCESS BY SIX: A PREVENTION/EARLY INTERVENTION INITIATIVE FOR OTTAWA-CARLETON

CARRIED

LEGAL

- Committee Co-ordinator’s report dated 01 Nov 98

ADJOURNMENT

The meeting adjourned at 4:50 p.m.

NEXT MEETING

___________________________ ___________________________

CHAIR CO-ORDINATOR