Emergency department closures, staffing and retention issues, and ambulance offload delays are making working conditions “unbearable” for the province’s paramedics.
And while offload delays have risen “dramatically” across the province since August of 2020, initiatives to counter the problem have resulted in some improvement over the last six months.
Those were among the messages delivered to the legislature’s standing committee on health on Tuesday. The meeting’s focus was Emergency Health Services (EHS) offload times.
“Outside offers of better working conditions, increased benefits, and a better remuneration package have resulted in a dire loss of workforce who are a valued investment which this province must retain,” Kevin MacMullin, business manager for IUOE 727 (the union representing the province’s paramedics), told the committee.
“To keep training the top Canadian paramedics and have them leave the region is assuredly adding to the current state of health care. These issues are reducing staffing levels, and combined with offload delays, often make working conditions unbearable for the paramedics who have chosen to stay.”
Fallout from reduced emergency departments
MacMullin said emergency department closures across the province have led to increased demand, with regional facilities typically picking up the slack. He said illnesses, accidents, and medical emergencies don’t grind to a halt because emergency departments are closed.
Those closures, he said, place even greater demand on the emergency health system, and paramedics feel the pinch as need for their services spikes.
“Upon arrival at these ERs, paramedics face reduced nursing staffing, nurses who face similar challenges in their workforce,” MacMullin said.
With fewer nurses to look after patients in the emergency department, he said paramedics are forced to wait. MacMullin described the triage delay as “increasingly frustrating” for paramedics, nurses, and patients.
A shrinking stable of paramedics doesn’t help. MacMullin said of the province’s 884 active paramedics, 70 of them are over the age of 55. In the last year, they’ve hired 53 paramedics, although at least 30 are new graduates. While 53 joined the fold, they lost 49. Of those, he said 16 were advanced care paramedics.
In addition, MacMullin told the committee that close to 200 paramedics are off for various medical reasons. They’re also seeing an increase in operational stress injuries.
Emergency department closures can also result in paramedics spending more time on the road as they’re required to drive longer distances to get to facilities that are open.
“Our paramedics are stressed out. They’re leaving their area to transport to another area which is further away,” MacMullin said. “Now they are sitting there and looking at their screens and seeing, there’s nobody even in my area. So, how am I going to be able to respond appropriately to a call that may be one of my neighbours that I know, family, or whatever. So, it is a stressful situation.”
‘Need to fix offload delay issue now’
MacMullin said one team recently travelled 1,700 km in a single shift. He also hears from paramedics driving up to 700 km during a night shift.
“They may be in Springhill and the next thing you’re in Truro. You might be down to New Glasgow, then you’re down to Sheet Harbour, you’re up to Halifax,” MacMullin said.
“It’s a lot, and it’s wear and tear on these people…driving these successive hours late at night. It’s bad. So, we have to turn around and come up with a solution to fixing the offload delay.”
He told the committee long transfer times and even longer offload delays prove that paramedics aren’t being used efficiently or effectively.
“Paramedics want to avoid standing in hallways providing care for stable patients, knowing that they could be used in a more urgent and critical setting at that exact moment,” MacMullin said.
“We need to fix this offload delay issue now, not down the road some time…Working as a team and supporting one another, we can accomplish the goal of an improved health care system for Nova Scotia. This is a necessity, not a desire if we wish to successfully solve this crisis and provide the care and emergency support Nova Scotians deserve daily or in a life-and-death situation.”
‘Dramatic escalation of offload times’
Citing statistics obtained through a Freedom of Information request, the leader of Nova Scotia’s Liberal Party told the committee that ambulance offload times have dramatically increased across the province since August 2020.
“Despite all the initiatives and all the money that’s being spent, we’re still seeing a really dramatic escalation of offload wait times,” Zach Churchill said.
Churchill said the QEII Health Sciences Centre went from a 104-minute offload wait time in August of 2020 to more than 124 minutes in March of this year. Yarmouth Regional Hospital’s offload time has tripled in that same time period, from 21 minutes to almost 60 minutes.
Cape Breton Regional Hospital went from a 35-minute offload time in August, 2020 to a 135-minute wait time this year. Valley Regional’s 29-minute offload time jumped to 78 minutes, while South Shore Regional Hospital spiked from 37 to 90 minutes. Offload times at Cumberland Regional Health Care Centre also jumped, from 24 minutes on average in 2020 to 79 minutes this year.
“Where at one point (it was) only really a major issue at the QEII and Dartmouth General in Metro, we are now seeing offload wait times become a problem in every single emergency department across rural Nova Scotia as well,” Churchill said.
Starting to trend back down
Acknowledging that ambulance offload times are an issue for emergency departments across the province and that numbers have increased in rural Nova Scotia, Dr. Tanya Munroe said it’s important to consider the changing landscape from August 2020 to the present day.
“I am mindful that the emergency department demand looked different in August 2020, courtesy of the pandemic. We did have, at least in the zone in which I worked, there was a decrease in visit volumes year over year,” Munroe, co-lead for Nova Scotia Health’s Access and Flow Network, said.
“What we now see is increasing demand, perhaps even more than would have been there if we hadn’t just spent two years in COVID because there was delayed access to care and people chose not to present for care.”
Munroe said that meant some chronic diseases became more complex, leading to increased demand for — and a higher rate of patients who require — hospitalization.
“We have seen across the province that yes, wait times have been increasing. But they’re starting to trend back down,” Munroe said.
“The initiatives that we have ongoing within Nova Scotia Health, they recognize that solving the ambulance offload problem is not going to occur solely within the bricks and mortar of emergency departments.”
Munroe said the solution requires a whole system and community approach.
“I am encouraged that I am seeing some local trending down,” Munroe said. “I absolutely acknowledge we have more work to do, and that work is ongoing.”
‘More can and will be done’
Department of Health and Wellness Deputy Minister Jeannine Lagassé told the committee the entire health care system remains under pressure.
“This is not unique to Nova Scotia,” Lagassé said. “We are working hard to alleviate this pressure to ensure those with the most urgent needs get care sooner, improve ambulance response times, and offer more options for care.”
Echoing Munroe’s comments, Lagassé said health care issues must be tackled as a system. She pointed to several initiatives specific to paramedics.
Expanding the medical transport service and patient transfer units to low risk patients who don’t require medical oversight means paramedics now handle fewer than 20% of such transfers, down from 86%. She said nurses and physicians in the medical communications centre give advice over the phone, and new primary care options help divert patients who don’t need emergency care to “more appropriate places for the support that they need.”
The new Single Paramedic Emergency Advanced Life Support and Basic Life Support (SPEAR) program allows paramedics to respond to lower acuity calls without tying up ambulances. That initiative is set to expand this year, doubling from six units to 12.
Lagassé also pointed to the second air ambulance that will soon be operational. It’s capable of transporting several patients at a time to Halifax for routine tests and treatment.
She said more EHS transport operators have been hired, and a new fleet of ambulances are now on the road. More campuses are offering paramedic training and a rebate is available.
Lagassé told the committee the addition of patient advocates, physician assistants, and offload teams supporting patients in emergency departments are also helping ambulances get back on the road faster.
“While more can and will be done, ambulance offload times have been trending down over the last six months,” Lagassé said.
‘What we’ve done for years is send our SWAT team’
The executive director of provincial operations for Emergency Medical Care Inc. (EMC) also addressed the statistics showing a dramatic increase in offload times since 2020. Charbel Daniel said COVID created a ripple effect that peaked about six months ago.
“As you look at the data and all the changes that we’ve put in place, you’ll see the enhancements that as of six months ago to today are trending in the right direction,” Daniel said.
Prior to the introduction of the patient transfer service, EHS did about 55,000 transfers a year. More than 40,000 were completed by ambulances. Daniel said the expansion of the transfer service over the last two years reduced the number of ambulance transfers to fewer than 10,000.
Daniel said because 70% of calls are low acuity calls that don’t require an ambulance, initiatives directing patients to an appropriate care pathway are important.
“I use this example of mirroring what our police agencies do. They’ve got their SWAT teams and they’ve got their police cruisers,” Daniel explained. “What we’ve done for years is send our SWAT team to every call. And it’s not the best use of resources because it’s not required. They don’t need that.”
‘People are concerned for good reason’
NDP MLA Susan Leblanc wanted to know if the province was getting good value for the five-year contract it signed with EMC in 2021. That deal is worth about $165 million a year.
“We all know of some of the terrible stories that we’ve heard in the last couple of years. People are very concerned about their ability to get an ambulance,” Leblanc said.
“And, of course, we want to reiterate, always call 911. But people are genuinely concerned for good reason, and paramedics are doing their best under very difficult circumstances.”
Leblanc pointed out that despite being among the most highly qualified, Nova Scotia’s paramedics were among the lowest paid in the country. She asked when they could expect a wage increase.
Daniel told the committee they’re currently at the bargaining table with the union representing Nova Scotia’s paramedics.
“The focus on retaining paramedics is not only on the salary piece. It’s about the work environment,” Daniel said. “And we’ve heard concerns about that and it’s something that we are diligently working on always because the strain of the system will always impact frontline people more than anyone else.”
‘We want to see the system work better’
Daniel said they’ve also worked closely with the union to increase vacation approvals, which have increased by 300% over the last two years.
“We are focussed on the work environment, we’re focussed on making sure they have the right wages, and we’re at the table right now going through that negotiation process,” Daniel said.
Acknowledging that there have been system improvements that are helping, MacMullin said the paramedics his union represents want to see things move at a quicker pace.
“We’re the ones that get the 911 call. We want to be there right away. Everybody’s waiting. We want to see the system work better,” MacMullin said.
“That’s our big goal here, is to make sure that we concentrate on the delays so we can get our teams up there. We have highly qualified paramedics in this province, and they will show up and give the best care you can ever receive.”