1. ottawa paramedic service –– 2006 ANNUAL REPORT AND 2007 PERFORMANCE TRENDS

SERVICE PARAMÉDIC D’OTTAWA – RAPPORT ANNUEL DE 2006 ET TENDANCES DU RENDEMENT DE 2007

COMMITTEE RECOMMENDATION

That Council receive this report for information.

Recommandation du comité

Que leConseil reçoivent ce rapport aux fins d’information.

For the information of Council

The Committee approved the following direction to staff:

That Tony Di Monte, Chief of the Ottawa Paramedic Service and Community and Protective Services Committee Chairperson Deans to meet with Dr. Kitts, President and Chief Executive Officer of the Ottawa Hospital, Dr. Cushman, Chief Executive Officer of the Champlain Local Health Integration Network (LHIN) and the Provincial and Federal Ministers of Health, to discuss strategies to free up hospital beds to reduce hospital wait time for paramedics and report back to the Community and Protective Services Committee.

And that Chief Di Monte and Chair Deans be directed to go to a LHIN Board meeting to encourage them to exercise their power in this regard.

Pour la gouverne du Conseil

Le Comité a approuvé la directive suivante à l’intention du personnel :

Que Tony Di Monte, chef du Service paramédic d’Ottawa, et que madame Deans, présidente du Comité des services communautaires et de protection, rencontrent le Dr Kitts, président-directeur général de l’Hôpital d’Ottawa, le Dr Cushman, directeur général du Réseau local d’intégration des services de santé de Champlain (RLISS) ainsi que les ministres provincial et fédéral de la Santé, afin de discuter de stratégies permettant de libérer des lits d’hôpital et réduire le temps d’attente du service paramédic, et de rendre compte au Comité des services communautaires et de protection.

Et que le chef Di Monte et la présidente Deans soient chargés d’assister à une réunion du conseil d’administration du RLISS afin d’inciter ses membres à exercer leur pouvoir à cet égard.

DOCUMENTATION

1. Deputy City Manager, Community and Protective Services report dated 5 October 2007 (ACS2007-CPS-OPS-0002).

2. Extract of Minute, 18 October 2007.

Report to/Rapport au :

Community Protective Services Committee

Comité des services communautaires et de protection

and Council / et au Conseil

5 October 2007/le 5 octobre 2007

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 Di Monte@Ottawa.ca

City Wide/à l'échelle de la Ville

Ref N°: ACS2007-CPS-OPS-0002

SUBJECT:	ottawa paramedic service ––2006 ANNUAL REPORT AND 2007 PERFORMANCE TRENDS
OBJET:	SERVICE PARAMÉDIC D’OTTAWA – RAPPORT ANNUEL DE 2006 ET TENDANCES DU RENDEMENT DE 2007

REPORT RECOMMENDATION

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

RECOMMANDATION DU RAPPORT

Que les Services communautaires et de protection ainsi que le Conseil reçoivent ce rapport aux fins d’information.

EXECUTIVE SUMMARY

As part of the Coroner’s Inquest into the death of Alice V. Martin in 2004, a number of recommendations were directed to the City of Ottawa, specifically:

“That the City of Ottawa maintain, on an ongoing basis, adequate paramedic staffing levels in order to ensure that its target response times are met into the future as call volumes and requests for service increase”

“That the City of Ottawa continue to operate its EMS as a high performance system, continue to monitor itself in light of changes in the community, and maintain performance targets in line with benchmarked international standards”

In response to the recommendations emanating from the Coroner’s Inquest into the death of Alice V. Martin as well as the 2004 mid year report (ACS2004-CPS-OPS-0008), Council approved the addition of 52 paramedic FTEs over 2 years. The last 18 staff were hired in July of 2006. As part of the same report, the recommendation was approved “that staff report back to Committee and Council prior to budget each year on performance trends, mitigation strategies and associated financial impacts to ensure the service can maintain its baseline performance targets”.

The following report provides statistics for 2006 for call volume; response time and hospital wait time as directed by Council. It also identifies trends for 2007 and illustrates potential staffing strategies to address the growing problem over the next three year.

RÉSUMÉ

Dans le cadre de l’enquête du coroner sur la mort d’Alice V. Martin en 2004, un certain nombre de recommandations ont été formulées à l’intention de la Ville d’Ottawa, plus précisément :

« Que la Ville d’Ottawa maintienne, en permanence, des niveaux adéquats d’employés paramédicaux pour veiller à ce que les temps de réponse visés soient respectés dans le futur, compte tenu de l’augmentation du volume d’appels et de demandes de service.

« Que la Ville D’Ottawa continue de gérer ses services médicaux d’urgence comme un système à rendement élevé, qu’elle continue d’en assurer la surveillance en tenant compte des changements qui se produisent dans la collectivité et qu’elle veille à ce que ses objectifs en matière de rendement correspondent aux normes internationales repères ».

En réponse aux recommandations découlant de l’enquête du coroner sur la mort d’Alice V. Martin ainsi que du rapport semestriel de 2004 (ACS2004-CPS-OPS-0008), le Conseil a approuvé l’ajout de 52 ETP paramédicaux sur deux ans. Les derniers 18 employés paramédicaux ont été embauchés en juillet 2006. Le même rapport contenait également la recommandation suivante : « que chaque année, avant le budget, le personnel rende compte au Comité et au Conseil des tendances du rendement, des stratégies d’atténuation et des répercussions financières connexes de manière à s’assurer que le service puisse continuer d’atteindre ses objectifs de base en matière de rendement ».

Le rapport qui suit présente les statistiques de 2006 sur le volume d’appels, les temps de réponse et les temps d’attente à l’hôpital, selon les directives du Conseil. Il présente également les tendances pour 2007 et illustre des stratégies de dotation possibles pour faire face à la croissance au cours des trois prochaines années.

BACKGROUND

In October 2004, the Ottawa Paramedic Service reported to the former Emergency and Protective Services Committee and Council on call volume, hospital wait time and response time trends. That report indicated that in 2003 and 2004, rising call volumes surpassed the capacity of the service, resulting in increased response times in both the urban and rural sectors.

As part of the Coroner’s Inquest into the death of Alice V. Martin in 2004, a number of recommendations were directed to the City of Ottawa, specifically:

“That the City of Ottawa maintain, on an ongoing basis, adequate paramedic staffing levels in order to ensure that its target response times are met into the future as call volumes and requests for service increase”

“That the City of Ottawa continue to operate its EMS as a high performance system, continue to monitor itself in light of changes in the community, and maintain performance targets in line with benchmarked international standards”

In response to the Coroner’s Inquest into the death of Alice V. Martin recommendations as well as the 2004 mid year report, Council approved the addition of 52 paramedic FTEs over 2 years. The last 18 staff were hired in July of 2006.

As part of the same report, the recommendation was approved “that staff report back to Committee and Council prior to budget each year on performance trends, mitigation strategies and associated financial impacts to ensure the service can maintain its baseline performance targets”.

Each year, the Ottawa Paramedic Service reports on the historical, current, and projected trends for call volumes, hospital wait times and response times to code 4 calls. These reports are the mechanism by which the service provides council and the public with an indication of the service’s capacity and subsequent performance.

The Ottawa Paramedic Service reported to Committee and Council in September 2006 on their performance for 2005 however, reliable information for 2006 upon which they could project growth trends for the coming year was not yet available due to a recent implementation of a new Computer Aided Dispatch (CAD) system by the Province. The Ottawa Paramedic Service committed to returning to Committee once reliable data became available. The following report provides year-end results for 2006 as well as projects trends for 2007 as directed by Council and recommended by the Coroner’s Jury.

In addition, on December 22^nd, 2006, Ottawa experienced a significant ice storm. As a result of the sudden increase in the calls for service, Ottawa Paramedic Service experienced times during that storm where there was not enough paramedics to respond to calls – “Level 0”. Subsequent to the storm the Chair of Community and Protective Services Committee, requested that staff provide information with respect to the extent of “Level 0” in Ottawa, information about how that compares with other Canadian cities and the protocol invoked to deal with a “Level 0” situation. Staff have included the response as part of this report.

SYSTEM CAPACITY

There are four markers of system capacity. Two indicators are inputs of system capacity – call volume and hospital wait time. The other two indicators are results or outputs of the system effects – response time and paramedic availability. Since amalgamation, Ottawa has struggled with a rising call volume and hospital wait time – both, which effect system capacity. On the other side of the equation, response times have fallen indicating that paramedic resources are deployed in the best locations to provide an optimal response. While there have been improvements in response time due to the deployment practices of the Ottawa Paramedic Service there is no efficiency of practice that can accommodate the system redundancy necessary to address peak times when many calls can be received in a very short time period affecting paramedic availability.

Call Volume

Based on data available for 2006, call volume reached 92,55488,732, which is significantly higher than the assumption of the original system design of 65,000 requests for service per year with annual anticipated increases of 2% per year. While tWhilehe overall call volume between 2005 and 2006 went downup only marginally more than the projected 2%, the the total number of calls remains significantly higher than the projected 73,200 for 2006. number of code 4 calls (life threatening calls) rose dramatically by almost 22%.

Table 1: Call Volume

Call Volumes
Call Type	2001	2002	2003	2004	2005	2006	2007 Projected
Code 4	36,753	42,915	49,283	55,890	57,266	69,779	72,523
Code 3	20,662	22,601	21,569	20,974	22,200	12,409	12,879
Code 2	4,578	4,873	4,616	6,576	6,324	5,597	7,073
Code 1	10,457	9,467	7,335	6,618	4,350	3,011	2,592
Code 8	N/A	N/A	N/A	N/A	N/A	1,758[1]	2,272
Total	72,450	79,856	82,803	90,058	90,140	92,554	97,339
Source : MOHLTC

This increase in code four (4) can be attributed in part to the new Computer Aided Dispatch system implemented in 2006 and its new categorization of calls; however, it can also be attributed to population growth and its aging at a disproportionate rate with the elderly making use of the service far more often than younger people.

In 2006, stroke, heart problems, shortness of breath and falls – ailments normally associated with the elderly - accounted for approximately 30% of all calls. This represents an increase of approximately 3700 calls associated with the elderly in 2006. These code 4 calls require a more sophisticated and time consuming intervention by paramedics placing further demand on the paramedic system. Unlike lower priority calls (code 1 & 2), which can be planned and scheduled, the severity of these calls requires an immediate response depleting resources.

According to the Corporate Environmental Scan completed in 2006, the senior population (65+) in Ottawa will likely increase by at least 50% over the next 20 years, and will represent slightly over 16 % of total population in 15 years. The very elderly, 85+, will increase by 25% in the next five years, accelerating demands on paramedic services, health care, and long term care facilities.

The shortage of family physicians, long wait times for emergency rooms and the enhanced medical care provided by paramedics are all contributing to a public perception and reliance on the Paramedic Service as a provider of primary health care.

In 2006, the number of code 4 – life-threatening calls have increased sharply. The code 4 calls require a more sophisticated and time consuming intervention by paramedics placing further demand on the paramedic system. Unlike lower priority calls (code 1 & 2), which can be planned and scheduled, the severity of these calls requires the immediate response depleting resources. The shortage of family physicians, long wait times for emergency rooms and the enhanced medical care provided by paramedics are all contributing to a public perception and reliance on the Paramedic Service as a provider of primary health care. Despite these trends it appears that Ottawa is experiencing a levelling out of calls for service in 2005 and had a slight decrease in demand for service in 2006.

Hospital Wait Times

Although it was never achieved in Ottawa, when the paramedic deployment model was originally developed, the provincial standard for the return to service of a paramedic crew after arrival at hospital (hospital wait time) was twenty (20) minutes on average. Recently, a recommendation has been put forward from Dr. Brian Schwartz of The Hospital Emergency Department and Ambulance Effectiveness Working Group to change the provincial standard for hospital wait time to thirty minutes (30) at the 90^th percentile - a more stringent standard. Across Canada, Paramedic Services are experiencing an increase in hospital wait time. In Ottawa in 2006, the average wait time was 53 minutes and 31 seconds – an increase of 3 minutes and 36 seconds from the previous year. An increasing wait time negatively impacts response time and paramedic availability given that paramedic crews are not available for assignment or deployment until the patient has been transferred into the care of hospital staff.

The following tables illustrate increases in hospital wait times since 2001 both at the average and the 90^th percentile and indicate another potentially significant increase in 2007 based on data available for the first six months.

Table 2: Average Hospital Wait time

Average Hospital Wait Time (T6-T7)
	2001	2002	2003	2004	2005	2006	2007 Jan - June
Wait Time	00:36:44	00:39:17	00:42:27	00:49:00	00:49:55	00:53:31	00:57:38
Source: MOHLTC

Table 3: Hospital Wait time 90^th Percentile

Hospital Wait Time (T6-T7) at the 90^th percentile
	2001	2002	2003	2004	2005	2006	2007 Jan - June
Wait Time	1:04:49	1:07:02	1:10:07	1:12:14	1:15:52	1:15:48	1:20:24
Source: MOHLTC

Based on the tables above, Ottawa well exceeds the provincial standard for hospital wait times of 30 minutes at the 90^th percentile. In fact, in 2006 the hospital wait time was approximately 45 minutes above the standard, which accounts for approximately 4 ambulances which are routinely at the hospital and unavailable to receive the next call.

A number of initiatives have been undertaken to mitigate the lengthening hospital wait time in Ottawa. Participation on regional committees such as the Eastern Ontario Emergency Services Committee has resulted in the implementation of internal hospital procedures intended to expedite the transfer of patient care. As well, to provide for the equitable distribution of patients to health care facilities, the Ottawa Central Ambulance Communication Centre now directs Paramedic crews to particular hospitals in a structured manner designed to avoid the overload of any one emergency department (Patient Priority System). This system takes into account the hospital capacity and the acuity and type of care the patient requires.

Locally, the CEO of the Ottawa Hospital has recently announced a pilot project to begin in March 2007 at both the Civic and General Campuses of the Ottawa Hospital. The project will implemented separate areas staffed by nurses where paramedic crews can off load patients and return to service without waiting for an emergency room doctor to take care and control of the patient. Ottawa Paramedic Service is was hopeful that this pilot project will would prove successful and contribute to a corresponding decrease in hospital wait time at these facilities - which accounts for 52% of the Ottawa Paramedic Service calls. However, preliminary reports indicate that it is not proving effective as hospitals still struggle with capacity within their own organization.

Although solutions to the current hospital wait time is the sole responsibility of the hospital administration, it remains a contributory factor in paramedic availability and therefore negatively impacts service response time.

Response Time

Response time targets were developed for the City of Ottawa taking into account international industry standards, medical appropriateness, and community expectations. The performance targets are set at 8 minutes 59 seconds 90% of the time for life threatening calls in Ottawa’s high-density area and set at 15 minutes 59 seconds 90% of the time for life threatening calls in Ottawa’s low-density area[2].

These targets were reconfirmed by Council and reiterated by the recommendations of the Coroner’s jury into the death of Alice V. Martin.

In order to meet response time targets, there must be enough Paramedics available, assigned, and deployed according to strict parameters related to call demand (call volume), and call location (geography) – known as system capacity.

The following table demonstrates the relationship between historical call volume, number of paramedics and response time since amalgamation.

Table 4: Response time trends

Call Volume and Response Time 2001 - 2006
Year	Annual Call Volume	Number of Paramedics	High-Density Target	High-Density Actual	Low-Density Target	Low-Density Actual
Pre-amalgamation	65,000	157		14:35		22:41
2001	72,450	254	12:59	12:24	18:59	17:25
2002	79,856	268	10:59	10:50	17:59	16:30
2003	82,803	268	8:59	11:05	15:59	17:16
2004	90,058	276[3]	8:59	12:06	15:59	19:14
2005	90,140	296	8:59	12:00	15:59	18:18
2006	92,55488,732	312	8:59	11:3612:32	15:59	18:5746
Source: MOHLTC

In 2006, response time increased in both the high-density and low-density areas of the city, translating to the Ottawa Paramedic Service achieving the target 8 minutes 59 seconds or better in high-density areas to 64.5% % of cases and achieving the target 15 minutes 59 seconds or better in low-density areas to 79.6% of cases in 2006.This translates to the Ottawa Paramedic Service achieving the target 8 minutes 59 seconds or better in high-density areas to 71.6% of cases and achieving the target 15 minutes 59 seconds or better in low-density areas to 81.7% of cases in 2006.

The table below illustrates the percent rank that Ottawa Paramedic Service reached its target 8 min 59 seconds in the high density area and 15 minutes and 59 seconds in the low density area or better.

Table 5: Performance compliance

Year	2004	2005	2006
High density Percentile Rank 8:59	68.5%	68.3%	71.664.5%
Low Density Percentile Rank 15:59	70.4%	81.7%	81.779.6%

A total of 52 paramedic FTEs were hired since 2004, to address the rising call volumes and the increasing struggle paramedic services had in meeting demand for service. The final 16 paramedics were hired and deployed in January 2006[4] during peak call periods to maximize their effect. However, despite the increase in response time in the low-density areas in 2006, Council’s investment resulted in an overall improvement over the two-year investment period with an overall decrease of 42 seconds in the high-density area and 17 seconds in the low-density area. These improvements occurred despite a significant increase in code 4 – emergency calls over the same two-year period.

Despite the increase in staffing in the first part of 2006, response times increased due to the increase in call volumes and the significant increase in code 4 – life threatening and more time consuming calls.

In 2006, the ratio of code 4 calls to number of paramedics was the highest it has been since amalgamation; likewise, the urban response time was also the highest it has been since amalgamation (Table 6). In the early years after amalgamation, there was a reduction in response times, due to the improvements in deployment and programming such as the implementation of the Paramedic Response Units and the Patient Priority System. However, the positive effects of those changes have now been realized and the only recent improvement in response time was in 2005 when there was an investment in staff and a corresponding decrease in the number of calls per paramedic.

Table 6:

With call volume levelling out and potentially declining, hospital wait time being addressed with a promising Provincial solution and response time on the downward trend, only one other component of system capacity needs to be addressed – paramedic availability.

Year	Number of Paramedics assign to the Urban area	Number of Code 4 calls In the Urban area	Number of code 4 calls per paramedic In the Urban area	Response time in the urban area
2001	166	34,551	208	12:24
2002	180	40,340	224	10:50
2003	180	46,426	257	11:05
2004	188	52,537	279	12:06
2005	208	53,830	258	12:00
2006	224	65,592	293	12:32

Note: Since response time targets are based on only code 4 life threatening calls and not all calls, the table illustrates the relationship between staffing, number of code 4 calls and the corresponding urban response time at the 90^th percentile.

Despite the best efforts and optimal deployment, without continued investment to increase staffing, the rising call volume and specifically the anticipated rising number of code 4 calls will continue to surpass capacity and continue to result in rising response times.

Paramedic Availability

“Levels” is a term used to describe availability of paramedic units. For example, Level 15 denote that there are 15 ambulances available to respond to calls for service. Level 4 refers to the fact that there are only 4 ambulances available to respond. As ambulances are deployed to calls, the number of remaining available ambulances goes down and the level drops. As the level goes down, staff invoke protocols to ensure all staff are alerted and where appropriate attempt to take remedial action. The following table provides a high level overview of the protocols for dealing with a declining “level” of service.

Table 3: Tony we need more detail in the protocol section

Level

Protocol

The instances of “Level 0” are not recorded in the CAD system but are indicated by manual intervention through the Service’s paging system. Since the pager is not an analytical tool but rather a alerting system, analysis of the historical level 0 will be time consuming and manual based on the limited amount of stored data and capability of the tool. Staff will need to review records of calls in the CAD system manually for times of day that match the instance of “Level 0” still stored in the pager system. They will then need to analyze what was going on at the time to cause the reduction in service level. Ottawa Paramedic Service has assigned staff to this task and over the next several weeks will be working on this task exclusively. They will then be able to provide a detailed analysis of the instances of reduced services and recommendations to mitigate

The number of ambulances available to respond to the next call is ever changing given the random pattern of 911-call reception. Because of this unpredictable nature of emergency calls, extreme weather events, or a combination of these factors, the fleet may be engaged in its entirety, leaving no Paramedics to respond - referred to as “Level Zero”. It is understood that extraordinary situations like sudden ice storms such as the one experienced in Ottawa on December 22, 2006, can outweigh a system’s capacity for a short period of time, however this should be on an exceptional basis and should not be the norm. Likewise, one may not want to staff the system permanently for these situations as it would be cost prohibitive, but the system should be able to respond to the normal demands of the community.

Inter-municipal Comparisons

It is difficult to compare Ottawa Paramedic Service with other Paramedic Services in the country, as each service is unique in their collective agreements, scheduling practices and deployment models. Ottawa has a particular challenge due to its large geographic size requiring considerable more resources compared to other urban cities to achieve the same response time targets. In fact Toronto, Calgary and Edmonton combined could fit within Ottawa’s geographic boundaries.

Below is a table that shows comparisons between Ottawa and other municipalities. Ratios of paramedics to calls, population and sq kilometres have been used to allow for comparison purposes.

Table 7: Inter municipal Comparators

City	Geographic Area	Population	Number of Paramedics	Total number of Calls	Number of calls per paramedic	Number of citizens per paramedic	Number of sq kilometres per paramedic	Year
BC (Lower Mainland)	2,878	2,116,581	1,079	208,126	193	1961	2.7	2007
Toronto	642	2,600,000	892	293,215	329	2914	.7	2006
Montreal	744	2,240,000	884	266,362	301	2533	.8	2006
Calgary	726	974,000	348	96,442	277	2798	2.1	2006
Edmonton	700	740,578	319	63,791	200	2321	2.2	2006
Ottawa	2,700	877,280	312	92,554	297	2811	8.7	2006
Ottawa (Urban)	426	831,000	224	87,527	391	3709	1.9	2006

Both Edmonton and Calgary currently experience response times in the 8 – 9 minute range. However, as shown in the table above, each Ottawa paramedic responds to significantly more calls than Edmonton and Calgary in addition to being deployed over a significantly larger number of square kilometres. In all instances, other cities have one paramedic per one to two kilometres. Ottawa has one paramedic per approximately 9 km kilometres. There comes a point in time where sheer distance to travel is such that without sufficient resources, it is physically impossible to respond within the targeted time frame. The following charts graphically illustrates the comparison of Ottawa Paramedic Services with others in Canada.

Inter-municipal Comparisons

It is difficult to compare Ottawa Paramedic Service with other Paramedic Service in the country, as each service is unique in their collective agreements, scheduling practices and deployment models. Some services follow static and more costly deployment models as well. Likewise, Ottawa geographical makeup always makes deployment of a service more difficult given the vast area requiring coverage. However, conversations with other services indicated that that “Level 0” is experienced only during abnormal situations such as disasters or severe weather conditions and not part of regular operations due to their staffing ratio.

Staffing Ratio

The nature, frequency and timing of emergency calls are unpredictable by definition. Rarely are calls received in alignment with exactly when an ambulance returns to service after completing an assignment. Consequently, if Ottawa Paramedic Service deploys 10 paramedic units during the day and 10 calls are received in the first hour of the shift, there is no available ambulance to attend the 11^th call. Despite staffing appropriately to deal with busier times of the day, this situation does happen. In an effort to build in redundant resources to ensure sufficient availability except in extreme circumstances, the Paramedic industry developed a standard staffing ratio. In a static deployment model, staffing should be such that 2/3^rd of the on shift resources are in excess of what call trends would demand – therefore being available to deal with any inundation of calls. For example, if 10 calls per hour are normally received and each call takes an hour, there should be 30 ambulances on shift - Ten (or 1/3) ambulances to answer the first 10 calls, and twenty ambulances (or 2/3) to be available for subsequent calls.

The following chart indicates the number of calls received by Paramedic Service on an average day and the number of resources required to deal with the calls assuming a 2/3 redundancy.

Table 4:

As depicted in table 4, significant resources would be required over an above the normal call volume to ensure a 2/3 redundancy factor and mitigate the occurrence of reduced levels of service – “level 0”

Table 5 shows the calls received on an average day for Paramedic Service (bottom curve), the response capacity required to ensure 2/3 redundancy factor (top curve) and the current level of staffing available within existing Ottawa Paramedic Service resources (middle curve).

Table 5:

Although the curve of resources deployed (middle curve) is closely aligned with (calls for service) (bottom curve), which indicates that existing resources are deployed appropriately to address the somewhat predictable trends of calls, the response capacity to ensure a 2/3 redundancy factor is well above what currently exists in Ottawa. There are simply not enough available resources in Ottawa to deploy to this level of insurance. Currently there is little on shift surplus to respond to any random influx of calls. As a result Ottawa does find itself at level 0 not only as a result of extreme circumstances but unacceptably as part of a regular business day.

If Ottawa were to consider staffing to a 2/3^rd redundancy factor, significant additional resources would be required. Currently, each emergency call takes approximately 1 hour exclusive of hospital wait time. Assuming that hospital wait time is reduced to 30 minutes as a result of the new hospital pilot project which is higher than the original system design but lower than it has ever been in Ottawa since amalgamation, the time required to complete an emergency (code 3 or code 4) call in the future will be approximately 1 ½ hour.

Ottawa Paramedic Service receives approximately 10 calls per hour on average per day. Since calls take approximately 1.5 hours to complete, paramedics need enough staff to respond to 15 calls per hour ((10 X 90 min)/60 min = 15 calls per hour). Therefore, to achieve a 2/3^rd redundancy factor per industry standard, Ottawa would need to have 45 paramedic units deployed on average per day - 15 units to deal with current calls (1/3^rd) and 30 as a redundancy to deal with a potential influx of calls (2/3^rd). 15 of the remaining 30 will deal with the next 1.5 hours of calls with remaining 15 resources available to respond to an influx of calls. It is important to note that those 15 “redundant” resources would be expected to cover the entire City (2700 sq km) while the others are occupied on calls.

Currently, Ottawa has 27 paramedic units deployed on average per day (although distributed differently to address periods of the day that see more calls than others see Table 5). Consequently, Ottawa would require an additional 18 to meet these criteria with a static deployment model. This is not what is required in Ottawa. Since Ottawa utilizes a more efficient dynamic deployment model where resources are deployed based on location and trend of calls, a much lower redundancy factor is required. However, to determine the true requirement will take a period of time for staff to analyze the instances of level 0 and the causes for it as well as what type of redundancy factor would address the need in Ottawa.

Staffing Requirement

The City under a contract with the Province of Ontario runs the Central Ambulance Communication Centre (CACC). In January of 2006, the Province replaced the Computer Aided Dispatch system in Ottawa’s Communication Centre with a new application resulting in a new code 8 type of call - which are emergency standby calls received from Police and Fire where paramedics are required to attend a call and standby in case of required medical care.

Total call volume has increased by an average of 5% annually since 2001, with the total number of code 4 – time consuming calls – increasing by almost 14%. With this increase in calls anticipated to continue if not grow, Ottawa Paramedic Service will need to grow accordingly to maintain a current response times.

Based on a 14% increase in code 4 calls in 2006, a conservative increase of 38 additional staff (12%) will be needed to address the rising response time trends. For Council’s consideration, is a $3,150,000 pressure for the 38 paramedics along with a corresponding increase in provincial revenue of $1,575,000 (50% per the provincial funding agreement) resulting in a net pressure to the City of $1,575,000 – which has been identified as a growth pressure for 2008 and will be considered as part of the budget process. Funding in the amount of $880,000 will be required to purchase vehicles and associated equipment to support an additional 38 paramedics will be included in the paramedic 2008 Draft Capital Budget with a corresponding provincial revenue stream for 50% funding. With the approval of the budget pressure for 2008, Ottawa Paramedic Service would hire the initial 19 paramedics covered by the City’s investment immediately and would hire the remaining 19 paramedics once the provincial funding is received.

An investment of this magnitude ($3.1 million total) should result in not only maintaining existing response times per the Coroner’s direction in the inquest of Alice V. Martin but should assist the Ottawa Paramedic Service to reverse the recent upward trend of their response times and move toward the international standards originally set by Council. With increasing call volumes anticipated to continue, staff have identified the need for an additional 25 FTEs in 2009 and another 27 FTEs in 2010 as well as a corresponding capital investment to purchase sufficient ambulances and associated equipment. Furthermore, staff have received positive indications from their provincial counterparts that the Province will fund 50% of the costs associated with additional staff in both 2009 and 2010.

Provincial Cost Sharing

The Ottawa Paramedic Service receives a funding grant from the Province of Ontario to operate the Central Ambulance Communications Centre. The Central Ambulance Communications Centre is wholly funded (100%) by the Province of Ontario and operated under contract by the Ottawa Paramedic Service. The funding for the Central Ambulance Communications Centre (CACC) is separate and distinct from other funding for the operation of the Ottawa Paramedic Service.

Since 2003, the relationship between the Ottawa Paramedic Service and the Province has been a collaborative one. In fact, the Ottawa Paramedic Service received an additional $9.4 M in funding to bring the provincial/city cost share ratio to 50% for 2005/2006. Currently, the Province of Ontario and the City of Ottawa fund the Ottawa Paramedic Service in equal shares (excluding the 100% funding received from the province for CACC). For six years, the Ottawa Paramedic Service has encouraged the Province to meet their obligation and fund to 50 percent. The achievement of 50/50 cost sharing is a direct result of City Council's persistent dialogue with the Provincial government. The City's argument for 50/50 cost sharing has existed since the download of the service from the Province to the City (2001) and has been bolstered by the 50/50 cost sharing recommendation of the Alice V. Martin Coroner’s Inquest. Following the last Provincial election (2003), the Province of Ontario committed to getting all municipalities at the 50% funding level by 2009. Since, we achieved the 50/50 cost sharing in 2006, we believe that the Province of Ontario will honor their commitment on an on-going basis as the service increases to meet its service demands. Further, staff expect the Provincial cost sharing commitment will extend into 2009.

CONCLUSION

Despite the Ottawa Paramedic Service best efforts, call volume – especially number of code 4 calls – and a corresponding response time are increasing each year and the service expects the same will be true by the end of 2007 based on available data. Despite the Provincial announcement to implement a pilot project aimed at reducing hospital wait time, no improvement has been seen to date. With an aging population and with the elderly relying on the Paramedic Service more than the rest of the population, Ottawa can expect to see increases continue into the future. An ongoing investment in staff aimed at keeping up with the demand for service is required in order to maintain existing response times or reverse the recent upward trend.

Per the direction of the Coroner, in the inquest into the death Alice V. Martin, “[t]hat the City of Ottawa maintain, on an ongoing basis, adequate paramedic staffing levels in order to ensure that its target response times are met into the future as call volumes and requests for service increase”, staff have included a growth pressure in the 2008 budget that if approved will be used to hire additional paramedic staff to address the growing call volume and arrest the increasing response time. Assuming the province contributes their matched funding for operating and capital costs, the City could hire enough paramedic FTEs (38) to not only arrest the increasing response time but to actually reverse the trends downward toward the industry standard of 8 minutes and 59 seconds in the urban area and 15 minutes and 59 seconds in the rural areas of the City. Furthermore, additional required investment has been identified in the Long Range Financial Plan for 2009 and 2010 to deal with call volume growth in subsequent years.

CONSULTATION

As this is an administrative report, no public consultation was required.

FINANCIAL IMPLICATIONS

The Draft 2008 Operating and Capital Budgets will include the expenditure/revenue increases identified by this report for the 38 paramedic FTEs.

STRATEGIC DIRECTIONS

Response time targets were developed for the City of Ottawa in April 2002 (ACS2002-EPS-EMS-0001) taking into account international industry standards, medical appropriateness, and community expectations. The performance targets are set at 8 minutes 59 seconds 90% of the time for life threatening calls in Ottawa’s high-density area and set at 15 minutes 59 seconds 90% of the time for life threatening calls in Ottawa’s low-density area[5]. Council approved these response time targets, however, growth in the City and specifically in call volume since amalgamation makes further investment necessary. Currently the City receives funding from the province at 50% and the City should maximize the opportunity to access the provincial funding to address growth per the strategic direction to “[d]eliver agreed-to level of service at the lowest possible cost”.

DISPOSITION

The Ottawa Paramedic Service will report back in 2008 with 2007 year-end results as well as performance trends for the first six months of 2008.

OTTAWA PARAMEDIC SERVICE – 2006 annual report AND 2007 performance trends

SERVICE PARAMÉDIC D'OTTAWA - RAPPORT ANNUEL DE 2006 ET TENDANCES DU RENDEMENT DE 2007

ACS2007-CPS-OPS-0002 CITY WIDE / À L'ÉCHELLE DE LA VILLE

Chief Anthony Di Monte provided an overview of the report. A copy of his PowerPoint presentation is held on file. He also provided copies of a media release which spoke to the Premier’s announcement that Dr. Alan Hudson, a neurosurgeon and president and CEO of both Cancer Care Ontario and the University Health Network, had been appointed to develop a hospital emergency room (ER) wait time strategy. He added that he sits on the Expert Panel assigned to provide Dr. Hudson and the Minister of Health with advice on how to address the issue of hospital wait time.

Responding to questions posed by Councillor Chiarelli, Chief Di Monte indicated that the number of 911 call takers does not increase as a result of putting more ambulances on the road; there is a formula in their contract that provides for increasing the number of 911 call takers by 1 FTE for every 6500 calls received. He also noted that seven is the fewest number of dispatchers on at night and there have been no challenges with regards to receiving or delays in dispatching calls at the call centre. A performance report is provided to the province each month.

Councillor Bédard noted that the Eastern Ontario Emergency Services Committee has undertaken ways to reduce the hospital wait time and he asked what additional things have been done to address this issue. Chief Di Monte advised that the other initiatives that have impacted the delivery of ambulances include: delivering patients directly to the centres they need (e.g. heart institute, stroke centre, et cetera) instead of a hospital emergency room. This ensures that every partner in the health continuum of care can support and understand the pressures that the other has, and work together to find long-term solutions.

Chair Deans noted the budget pressure the City would be facing to hire the 38 paramedics and she asked what impact this would have on response times. In addition, she inquired what assurances the City has that the province would pay their share (50%) of the costs associated with those positions. Given the growth and the dynamics of what is happening to the response time, the Chief explained that the addition of 38 paramedics will complement and close the gap of growth and should improve response times. With regards to the commitment from the province, he confirmed there are no guarantees, although he indicated that he has had discussions with the province and they have indicated they would fulfill their financial responsibility. When asked, he suggested he might be able to get a clear indication from the province, prior to budget deliberations.

The committee received the following delegations:

Marlyn Martin, daughter of Alice Martin referred to a pilot project at the Civic and the General hospital campuses, which began in March 2007, whereby paramedics could leave their patients and get back out onto the road. She observed that this is obviously not going as planned and suggested it would be less costly to have two people to take over the patients at the hospital, thereby allowing the paramedics to get back out. She noted that rescue workers from their fire department are no longer allowed to assist when a 911 call is sent, despite the fact they have the necessary training and could provide assistance until the ambulance arrives or if needed, get the patient to the hospital in a timely manner. She noted that this would be of great help to paramedics in low-density areas when their ambulance may not be available. She believed there was a direct relation between the shortage of paramedics and the slow response time.

Cory Couturier, grandson of Alice Martin did not want anyone else to have to go through what they have been through, wondering whether a loved one could have been saved if paramedics were on time and if they had the right equipment. He called on those who had the power, to do what is necessary to improve this situation.

Responding to the comment about rescue firefighters no longer being able to assist, Mr. Kanellakos explained that in the rural areas, there are volunteer fire departments that have to assemble and come from different places when a call is placed. This results in a longer staging time for them to get to a scene.

In response to Ms. Martin’s suggestion to station two paramedics in emergency rooms, Chief Di Monte indicated this had been explored several years ago, but was met with challenges. Essentially, paramedics have been providing care to the patient and when they arrive at the hospital, the continuity of care should continue with that team. The suggestion could be made to have two medics in the ER and when the paramedics arrive with the patient, those two medics would get in the ambulance and go back out into the community. However, that would mean that the paramedic service would be staffing the ER when in fact perhaps the better solution is to have two nurses there, with an appropriate number of beds in the ER. He also indicated that in Ontario, paramedics do not have the right to practice in an institution. The Chair indicated that the pilot program involved having nurses taking the patients and she asked why this was not effective. The Chief advised that while it is a challenge to get nurses in any case, on a daily basis when they are required, they are generally the first ones called upon to help elsewhere in the ER.

Dr. Louise McNaughton-Filion, Emergency Department Head, Champlain LHIN made the following comments on the initiatives undertaken by the LHIN:

· they have been trying to improve services in the pre-emergency department, the emergency department and, in the post emergency department and one of the pilots that has now become almost institutionalized is the off-loading of ambulances to the waiting room; people who are stable enough are taken to the waiting room, thus allowing paramedics to return to the road;

· other pilot projects include nurse practitioners in long term care centres whereby the nurse, who would be affiliated with the hospital, would be responsible for stabilizing the patients so they do not have to call the paramedics or have to go to a hospital

· other pre-emergency initiatives being piloted in Ontario or suggested to be done, is to allow the paramedics to decide whether or not a patient has to go to emergency or whether they can go elsewhere, depending on the nature of the matter

· the LHIN is also doing what it can to ensure everyone has a family doctor so they do not deteriorate to the point where they have to go to emergency

· there are new initiatives for chronic illness care and if they are able to be dealt with and cared for in a timely manner, they do not have to go to emergency

· the Emergency Services Committee have trialed a ‘no consideration study’ whereby patients are brought according to the care they require but using a numeric system, i.e., patients are distributed to the different hospital campus emergency rooms so that not one emergency department gets overloaded with patients

· the Canadian Institute for Health Information will be releasing a report about emergency room overcrowding and she believed this report would help to a certain extent to try and determine what the solutions will be; each emergency department will need to collect statistics so they can find where the delays are because each is different and each has it’s own challenges

· in the post emergency department, there is a shortage of long term care beds; over 20% of acute care beds in hospitals are occupied by people awaiting placement for long term care; when this occurs, those patients are not getting the care they need and the acute care patients who are admitted cannot get up to the beds because they are occupied; in turn the beds in the ER are full of people who are admitted.

Dr. McNaughton-Filion closed by stating that the province has signalled that emergency department waiting time is a priority and the Champlain LHIN will be working together with other ED representatives to come to the solutions, which need to be made.

Councillor Chiarelli recognized that there has been a problem for years and he wanted to know what the LHIN is actually doing to help the City eventually release their paramedics from the hospital. Dr. McNaughton-Filion advised that there is not one quick fix, but offered the following suggestions:

· decreasing the actual flow coming in (suggestions given previously)

· making it more efficient when they arrive by ensuring there are enough stretchers and hands available to take their patients

· there should be a way to measure their times to increase their efficiencies

She also noted that they have been mandated to have an Emergency Department Information System in each hospital and will have to submit reports of how long the waiting time actually is, and other indicators, such as length of stay in the emergency department; this will hopefully identify where efficiencies can be gained and what each hospital can do to improve efficiency so the admitted patients can go up to the floor so the paramedic’s patients can be seen.

Councillor Cullen indicated the LHIN is designed to coordinate health care within a specified district and has control over budgets including hospitals (involving the hiring of nurses) and making recommendations to the Minister. He felt that the LHIN is the key point to reorganize the system and expected therefore, that the LHIN would use those powers to correct this problem. Dr. McNaughton-Filion confirmed that hospitals have the funding to hire more nurses, but there is a shortage of nurses right now. The councillor suggested that if they were offered the right price, they would be found and the LHIN has the responsibility and leadership because it has the power to do this. Dr. McNaughton-Filion reminded the councillor that the wages of nurses are set by negotiations with the province and the Ontario Nursing Association and hospitals are not allowed to pay above and beyond what those negotiations require. The councillor reminded her however, that the LHIN provides advice to the Minister to deal with those issues and is the proactive leadership the City expects from the LHIN.

On a closing note, the councillor indicated his appreciation to Dr. McNaughton-Filion if she would agree to come back to the Committee in the future to advise what the LHIN is going to do about this directly. The doctor agreed to this request.

Chair Deans thanked Dr. McNaughton-Filion for taking the time to address the committee and recognized that the concern here is for paramedics and how service is being adversely impacted by the crisis in health care and the crisis in the emergency room. She indicated that the City is a willing partner to the extent it can be in looking for lasting solutions to a complex and difficult set of problems.

Catherine Gardner expressed concern about the number of people waiting in the hospitals to be transferred back to their homes. As a patient having to wait in the emergency ward, she has witnessed people waiting for the paramedics to come back and transfer them back to their long-term care facility. She did not believe this was a good use of paramedic services and suggested that if they no longer require help and are just going back to a nursing home or back to their own home, a shuttle service of sorts should be developed to return them to the community. She suggested that something be done to eliminate this high-cost service and to put the expertise of the paramedics where it is required.

When asked to comment on her concerns about paramedics transporting patients back to their homes, Chief Di Monte explained that while that may have been the arrangement a few years ago, hospitals have contracted out to a company that drive private vehicles that look like ambulances and whose drivers are dressed in a similar uniform to that of paramedics.

In considering the report, Councillor Bédard believed this was not just a problem with the paramedics and that the global problem must be addressed. He recognized that the solutions are more health care solutions and as the Board of Health, Council needs to address the more global issue. He proposed the following:

That the Community and Protective Services Committee direct Tony Di Monte, Chief of the Ottawa Paramedic Service and Community and Protective Services Committee Chairperson Deans to meet with Dr. Kitts, President and Chief Executive Officer of the Ottawa Hospital and Dr. Cushman, Chief Executive Officer of the Champlain Local Health Integration network (LHIN), to discuss strategies to free up hospital beds to reduce hospital wait times for paramedics and report back to the Community and Protective Services Committee.

He believed the City has to ask for a broader solution to what is a much bigger problem. He added that some of the issues that would have to be examined include:

· The problems in hospitals

· The numbers of doctors involved in emergency services

· The number of nurses

· The number of bed spaces, overcrowding

· Prevention, i.e., long term care and what goes on there and what can be done in order to deal with the issue of pre-emergencies.

Councillor Holmes believed that this issue is as a result of major provincial cuts to health care over the years and suggested that the above-noted direction also include meeting with the senior Ministers of Health. Councillor Bédard accepted this amendment.

Councillor Cullen suggested that direction be given to staff to put together a presentation package and have the Chair or Vice Chair of this Committee, together with staff, attend a LHIN Board meeting and make the case. Their purpose would be to encourage the LHIN to exercise its powers because it is there to coordinate health care services in the community and there is a series of disconnects in that community causing stress, which the LHIN needs to take responsibility for resolving. Councillor Bédard agreed to include this additional direction to his Motion.

If the City did not have to deal with the delays at the hospitals, Councillor Chiarelli inquired how many fewer paramedics would have to be hired and what would the dollar value on that be. The Chief advised that the 38 paramedics are required specifically to address growth. He added however, that 48 extra staff would be required to address the hospital wait problem as it stands today. He indicated total costs for those positions, plus the associated equipment (ambulances) would be about $4M. The councillor indicated the enormous cost to the property tax when it should not be. Chief Di Monte indicated that 50% should be covered by the property tax.

Chair Deans agreed that putting on more paramedics to address a complex hospital problem is not going to solve anything and the issue is to solve it at the source (in the ER and the whole hospital system behind it). When asked, the Chief confirmed that he is not recommending that the City address the hospital wait time problem by adding new paramedics. He went on to state that he would also not recommend that the City fund the replacement of the equivalent number of ambulances that are lost in hospitals. He noted that the hospital wait problem has to be solved, but recognized it is complex and will take some time.

Chair Deans believed the province is signalling their intention to address the health care and hospital problem now and she believed there are some indications that this will be a priority for the province. She indicated that the Motion presented by Councillor Bédard is important because the City needs to send a loud and clear signal to it’s provincial partners that the City wants this complex issue dealt with in an expeditious manner because it is having an adverse affect on paramedic services. She further stated that the City wants to ensure it has an efficient paramedic service and while Council will continue to do it’s part in that regard, what is needed is for the province to address this issue.

Moved by G. Bédard

That the Community and Protective Services Committee direct Tony Di Monte, Chief of the Ottawa Paramedic Service and Community and Protective Services Committee Chairperson Deans to meet with Dr. Kitts, President and Chief Executive Officer of the Ottawa Hospital, Dr. Cushman, Chief Executive Officer of the Champlain Local Health Integration Network (LHIN) and the Provincial and Federal Ministers of Health, to discuss strategies to free up hospital beds to reduce

hospital wait time for paramedics and report back to the Community and Protective Services Committee.

And that Chief Di Monte and Chair Deans be directed to go to a LHIN Board meeting to encourage them to exercise their power in this regard.

CARRIED

Councillor Feltmate requested that staff prepare for next year’s report some analysis of the impact of this growth in seniors and some modelling or research in terms of how this is going to impact the City in the next few years. Chief Di Monte agreed to this direction.

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

RECEIVED

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[1] In January of 2006, the Province replaced the Computer Aided Dispatch (CAD) system in Ottawa’s Communication Centre with a new application resulting in a new code 8 type of call - which are emergency standby calls received from Police and Fire where paramedics are required to attend a call and standby in case of required medical care. Historically, these types of calls (now categorized as code 8) were considered code 4 calls and as such were reflected in the code 4 numbers in previous reports.

[2] High and low density areas refer to call volume in relation to a geographic area. High-density areas are defined as areas with greater than 24 calls per sq km per year in groups of not less than 6 contiguous sq km and low density areas are defined as areas that do not meet the high density area criterion.

[3] Following the Coroner’s inquest into the death of Alice V. Martin, City Council directed that fourteen (14) Paramedics be hired immediately. Consequently, fourteen (14) paramedics were hired in December 2004. Concurrently, the Advanced Care Paramedic Training Program (within capital project 901047) that had funded six (6) paramedic positions concluded, resulting in the net addition of eight (8) new paramedics in 2004.

[4] The final 2 FTEs approved by Council were Equipment and Supply Technicians (EST) positions required to support the additional front line staff.

[5] High and low density areas refer to call volume in relation to a geographic area. High-density areas are defined as areas with greater than 24 calls per sq km per year in groups of not less than 6 contiguous sq km and low density areas are defined as areas that do not meet the high density area criterion.