“It is taking ambulances longer, on average, to respond to emergency and urgent calls, putting Nova Scotians at risk.”
These words from Nova Scotia auditor general Kim Adair’s review of ambulance response times in 2022-23 support her conclusion that the emergency health system is in “a critical state.”
The auditor general’s report continues:
This is true for ambulance responses in large urban areas such as Halifax and in the rural parts of the province as well. In 2022, it took paramedics in Nova Scotia on average 25 minutes to reach patients, including those suspected of having serious medical issues such as heart attacks, strokes, or breathing issues. Of particular concern is the rapid 79% increase in response times during 2022 (from 14 minutes in 2021 to 25 minutes in 2022).
In the contract between the Department of Health and Wellness and Emergency Medical Care Inc. (EMCI), which employs close to 1,000 paramedics, the performance standard for emergency response times for urban areas is within nine minutes of getting the call, 80% of the time. For rural areas, the standard is within 30 minutes, 80% of the time. For suburban areas, it’s 15 minutes, 80% of the time.
In the more than two years since EMCI signed its contract with the Houston government, the auditor general said those performance standards weren’t met.
Adair told reporters the length of time it takes ambulances to get to an emergency call is no longer being measured.
“One of the things we found concerning is Emergency Health Services (EHS) — a division within the Department of Health — actually stopped tracking response times back in August 2022. That’s because of the delays in offloading patients at emergency departments and it was agreed the Department of Health would not hold the service provider accountable,” Adair said.
“We felt you need continue to measure in order to know if the initiatives being put in place are making a difference. Otherwise, it’s hard to know if they are making headway.”
Reinstate tracking of ambulance response times
One of the auditor general’s 14 recommendations is that the Department of Health and Wellness order EHS and EMCI to reinstate the tracking of ambulance response times. Adair also recommends the government start using the penalty clause in its contract with EMCI to levy $10,000-a-month fines if the company continues to fail to meet the performance standards.
Minister of Health and Wellness Michelle Thompson had this to say in a news release issued after the AG’s report:
“The report confirms what we already know: There are system pressures and challenges affecting ambulance response times that must be addressed. Since 2021, we have made significant improvements in emergency care across the province by investing in people, equipment, technology and changes in policy,” Thompson said.
“We will do more and that starts by accepting all 14 recommendations in the Auditor General’s report. Some of these recommendations are already complete, others are in progress, but all will be implemented.”
Thompson said her department has recently hired a contract compliance officer to sort out when delays in response times to 911 calls are a company issue that could trigger fines — for example, EMCI was unable to staff daily shifts 23% of last year — and when delays result from circumstances beyond the company’s control.
The report found that the wait time to discharge patients at emergency departments across the province grew from 60 minutes to 90 minutes on average last year, with the Halifax Infirmary averaging a three-hour wait. Paramedics spent one-quarter of their working hours waiting at emergency departments to offload their patients last year at an estimated cost of $12 million to the system.
Dartmouth North MLA Susan Leblanc, who is the NDP’s health spokesperson, had this to say about the auditor general’s report:
“I think if we address the paramedic working conditions part of the AG’s findings, we could make some headway. One of the issues is we know the paramedics are off because they’re burnt out, they’re underpaid, and overworked. They’re leaving, leaving the province to go work in other jurisdictions, they’re leaving the profession, and they’re off sick,” Leblanc said.
“All of this is quite damning for a government that was elected to fix health care. Things are getting worse and we’re not seeing the government taking the proper steps to address the issues.”
Accountability lacking, AG says
The reasons for the bottlenecks and pressures on emergency department are well known and cited by the auditor general: a shortage of long-term care beds for frail and elderly Nova Scotians, not enough registered nurses or access to primary care, and the closure of small emergency departments in towns such as Digby and Middleton.
Two previous directives from health ministers resulted in short-term improvements but they didn’t last. Adair said while the health minister is ultimately accountable for improving the flow of patients through the emergency department, the real issue is around who or what part of the health system oversees the daily running of emergency departments.
“Who is responsible at the working level, the day-to-day operational level, to ensure offload delays are addressed in the emergency departments? It’s about assigning responsibility. Who within Nova Scotia Health is responsible to make sure that the offload delays don’t continue and who within the Department of Health is responsible to monitor what’s happening?” Adair said.
The Examiner put that same question to Health and Wellness Minister Thompson, whose response boiled down to “we’re working on it.”
Adair said the situation would be more critical if the government hadn’t acted to introduce patient transfer vehicles and change rules so paramedics can treat and release people at the scene of an accident without taking them to hospital.
She’s also pleased to see more openness around the reporting of emergency department wait times through the introduction of an online reporting tool.
The auditor general wrote to paramedics asking for their input and received 240 responses. Adair said at any given time over the past few years, 15% of the workforce has been off on sick leave or long-term disability. Recruitment is not keeping up with retirements, and compared with five years ago, paramedics are now leaving early, after eight years compared to 12 years.
Unsurprisingly, with more than 200 vacancies, the bill for paid overtime has increased 28% over five years. Adair said while salaries are on par with those paid elsewhere in Atlantic Canada, she doesn’t know if paramedics are leaving because they can earn more money in Ontario and further west. The contract with paramedics expires at the end of October.
One of the auditor’s 14 recommendations is for EMCI to carry out formal exit interviews with people who are leaving the province or leaving the profession.
Finally, the auditor general recommends the health minister develop a plan to audit the costs incurred by its contractor, EMCI, to see if they are reasonable. The department has agreed to have an audit plan in place a year from now, in September 2024.
Here are some of the areas of “financial risk” the auditor general suggests the province consider:
• Actual costs not being valid and accurate
• Actual costs being inflated to increase management fee
• Salaries and benefits of paramedics being paid at inappropriate rates
• Fuel and maintenance costs of ambulances being inaccurate
• Inappropriate bonuses paid to EMCI management
Adair said the purpose of her audit of the ground ambulance service was to discover if the service is meeting the needs of Nova Scotians in a cost-effective way. Adair said she has no problem with the $147 million annual cost.
However, she said her concerns are around how the service is being managed, and whether it is effective considering the growing wait times for ambulances and subsequent delays at emergency departments, which are putting more people at risk.