It’s been a month since a 49-year-old Bass River woman named April George experienced a heart attack and her husband waited 80 minutes for an ambulance to arrive. Sadly, George did not survive.
Sadly, the story of her husband calling 911 and waiting more than hour for paramedics to arrive in a rural community is not unique. On social media yesterday, the #CodeCritical launched by the union representing 1,200 paramedics in the province showed Hants, Colchester, and Cumberland counties had either no or low ambulance coverage at 1:15pm yesterday.
That was less than an hour before the province held a news conference to announce many changes which should improve emergency response times for critically ill patients like April George, and provide more opportunity for trained paramedics to use their skills where they are most needed.
Many of the policy changes are the result of a review and recommendations by Fitch and Associates conducted from October 2018 to November 2019. One of the report’s key findings was that paramedics were unable to respond to urgent calls because they were spending an average of 1.5 hours waiting to offload patients at emergency departments at major hospitals in Halifax.
“Significant ambulance time is spent in non-productive or non-emergency activities,” said the review. In fact, Fitch found that nearly half of paramedics’ time was spent driving people between different levels of hospital or nursing homes. Of those individuals being transferred between facilities, only 2% required the skills of a paramedic or the equipment in one of the province’s 180 ambulances.
“Total transfers represent 47 percent of all ambulance transports in 2018. Some 98 percent of these transports require only basic life support staffing and equipment. For that 98 percent, a medical necessity policy and procedure could be developed so that many of these transports could be handled by other transportation modes such as multi-patient buses, wheelchair vans, or car services. The use of ambulances is placing unnecessary stress on the system as in-hospital patients compete for the scarce resources in the field. This creates a paradoxical situation where patient movement is creating potentially negative outcomes on patients experiencing emergencies outside of medical facilities.”
-Fitch Report page, page 20
“How do we improve patient care and improve confidence in the system?,” asked newly minted Health Minister Zach Churchill, who previously was at Education. “Paramedics are spending more than 40% of their time doing non-urgent work, such as transporting patients between facilities and bringing patients who don’t need to go to emergency department to hospitals and then getting stuck in a bottleneck when it comes to offload times. We do have confidence that improving these system challenges will open up more time for paramedics to respond to emergencies and save peoples lives.”
Solution 1: Fewer people coming to Emergency
Starting April 1, paramedics will no longer be required to take every patient they assist to hospital. One of 64 of 68 Fitch recommendations accepted by the government will allow paramedics the flexibility to treat people at home or at the scene instead of being mandated to drive them to a hospital.
This is just one change to help reduce the flow to congested emergency departments. The Health Department has signed a new five-year contract with Emergency Medical Care Inc., which operates the ambulances and emergency health system. EMC will hire both a nurse and doctor to work at the Medical Communications Centre where 911 calls are answered. Their job will be to spend more time with less-urgent callers who may need advice but not necessarily a trip in an ambulance.
To free up more ambulances to respond to true emergencies, the Health Department has purchased four passenger vans to transfer people between hospitals and nursing homes. The “clients” will not require medical attention. The vans will be equipped with defibrillators and the drivers will have received first-aid training and remain in constant radio contact with the Medical Communications Centre.
Michael Nickerson, the head of the NS Paramedics Union, welcomed the change and would like to see the Health Department expand this pilot project quickly to reduce the pressure his colleagues have been experiencing.
“Right now, paramedics are going through hell knowing they cannot respond to calls when somebody needs an emergency crew and that weighs heavily on them,” said Nickerson. “I’m very happy that the government has finally released the Fitch report, that’s good. And I’m extremely happy they are willing to implement 64 out of 68 of the recommendations. ”
Nickerson hopes to find out what four recommendations were not accepted but parts of the $144,000 report remain redacted. Readers may wonder why the Liberal government waited more than a year to release the review of the emergency health service when it’s no secret emergency rooms in most regional hospitals have been overcrowded and ambulances sit for long periods of time waiting to off-load their patients.
Yesterday, Churchill was asked why the government didn’t act sooner on recommendations it received in the fall of 2019. Churchill claimed it was because the government needed buy-in from Emergency Medical Care Inc, the company that runs the LifeFlight and ground ambulance system in the province.
“The paramedics’ union wanted the report out,” acknowledged Churchill. “From the government perspective, and I agree with this approach, where the Fitch report was informing negotiations with the Emergency Medical Care contract, the release of the report to the public could have impeded progress on that contract. So we kept it confidential until the contract was negotiated and signed.”
Readers can judge that explanation for themselves. The province began negotiations last December and now has a five-year contract with EMCI at a cost of $165 million for the first year. Paramedics got a raise last year and, depending on their skill and experience, earn between $25 and $35 an hour.
Solution 2: Getting people out of hospital faster
Guillermo Fuentes, COO, of Missouri-based Fitch Associates, said Nova Scotia’s Emergency Health system “is built on a strong foundation which will allow it to make a transformation.”
Fuentes said the province-wide system with its Medical Communications Centre for dispatch provides an opportunity to implement a province-wide system for patient discharge from hospitals. At present, each hospital calls in to the Communications Centre and places an order for ambulance the same way you would call a taxi. There is no province-wide booking system or even prioritization for which hospital has the most urgent need. But that is about to change, according to Rollie King, the lead negotiator for the Department of Health on the contract with EMCI. New policies are coming
What is outside the purview of the EMCI and within the Department of health is a stubborn problem that create much of the backlog for ambulances waiting to offload patients at hospitals. That’s the fact that at most large regional hospitals the beds are full. With often as many as one in five patients waiting for a place in a nursing home or rehab or homeless shelter. Ambulances can’t leave Emergency until their patient has been admitted.
Yesterday, Churchill punted the ball to Nova Scotia Health to solve a problem it didn’t create. Churchill announced he had issued a directive to unload patients from ambulances within 30 minutes of their arrival at Emergency. Patients arriving at Emergency must be admitted or discharged within 12 hours. NSH Chief Executive Officer Brendan Carr must provide monthly reports.
If this sounds vaguely familiar, it’s because it is. Back in June 2019 — months before the government received the Fitch Report in November — then-Health Minister Randy Delorey issued the same directive with the same timelines. The lineup of ambulances at Emergency got shorter for a while but then crept back up.
Overcrowding at emergency departments and lack of beds because they are filled with people who have no place to go are longstanding issues.
A few months ago the Department of Health and Nova Scotia Health Authority worked together to move 73 people from the Halifax Infirmary to rooms in a hotel in Burnside where they are waiting for a place in long-term care. That’s a symptom of a system stretched to capacity.
Do we need to hire more paramedics to improve emergency health care? That’s not the solution, according to Dr. Andrew Travers, the medical director for Emergency Health Services at the Department of Health. He favours a re-design and a re-allocation of resources.
“If we can use our resources more effectively as identified by Fitch and identified by patient need and in collaboration with the Nova Scotia Health Authority, then we can probably have our existing teams respond to all 911 calls quickly and effectively.”
That would be an overdue change worth cheering.