Off-loads put paramedics at ‘level zero’

In the first seven months of this year, the Ottawa Paramedic Service lost an average of 151 hours every day waiting to transfer patients to hospital, says a city report.

Off-load delay is a measure of the time paramedics spend in area hospitals waiting to complete transfer of patient’s care to a hospital.

The industry standard for transferring patients is 30 minutes. That covers the time when paramedics arrive in the emergency department to the time the patient is off-loaded from the ambulance stretcher to the care of emergency department staff.

In the first seven months of 2019, the 90th percentile time was 79 minutes and 30 seconds for all Ottawa hospitals, and 95 minutes for the Civic and General campus of The Ottawa Hospital, according to the report.

“This creates a risk in the community where the Paramedic Service is at ‘level zero,’ which means it has no ability to transport patients,” said the report. When this happens, Ottawa paramedics have to rely on paramedic services from surrounding municipalities, a state of affairs that has caused past friction between paramedic services.

In the first eight months of 2019 there were 329 “level zero” incidents in Ottawa totalling more than 138 hours, including one in June that lasted more than 71/2 hours, according to the report.

In total, paramedics spent 32,126 hours in off-load delay.

The figures come less than five months after the city’s general manager of emergency and protective services, Anthony Di Monte, said emergency rooms in the city “are a disaster and there’s no excuse.” Di Monte called the emergency room of the Civic campus of The Ottawa Hospital the worst offender. In response, the hospital’s vice president of innovation and quality, Dr. Alan Forster, argued that long wait times are a symptom of a larger health-care overcrowding crisis, and said it was unfair to place the blame on emergency departments.

Ambulances account for about a quarter of all emergency-room arrivals. The paramedic service maintains that the root cause of the issue is the internal processes and operation standards of hospitals and its mandate is to provide out-of-hospital care and respond to emergencies. Delays are an emergency room issue and solutions are within the purview of the hospital, said the report, which noted that the paramedic service and The Ottawa Hospital entered into an agreement last December to off-load patients upon arrival.

“To date, The Ottawa Hospital has not been able to achieve the objectives outlined in the agreement.”

There are already a number of mitigation strategies aimed at offload delays:

■ The Paramedic Response Unit is a strategically-placed vehicle staffed by a primary care paramedic that provides rapid response to emergency calls and initiates patient care as soon as possible. The unit can downgrade or cancel an ambulance call to free up the transport crew for higher priorities.

■ There are several programs devoted to diverting patients from hospitals. These include community paramedicine, a pilot program funded by the province with a community paramedic assigned to conduct home visits; “targeted engagement diversion,” which brings vulnerable and homeless people with substance abuse issues and those with mental health issues to a specialized clinic and the influenza program, which helps mitigate the surge of patients in flu season.

■ The paramedic service also has been collaborating with hospitals on a series of strategies, including a $1.5 million-a-year pilot project funded by the province to transfer care of a patient to dedicated off-load nurses in emergency rooms. However, the program has been affected by the availability of off-load nurses and the types of patients the nurses can treat. The province announced another $424,000 for the program last month.

■ The paramedic service and the Ottawa Hospital introduced “vertical patient criteria” at both the

General and the Civic campus starting May 1. Vertical patients are transported by ambulance, but do not require hospital beds and are off-loaded to a waiting room. It has been estimated that about 10 per cent of patients could be diverted to the waiting room daily.

■ Amendments to the Ambulance Act of Ontario will create new regulations that allow alternate patient destinations and treat-and-release programs. The province has been holding consultations on the matter.

■ City staff are on consultation with hospitals to change the agreement that governs the “patient distribution” system to allow the paramedic service to deliver lower-priority patients to hospitals with shorter wait times.

The report noted that there are some new projects in the works. The paramedic service and the hospital are in discussion about a pilot program that would dedicate a community paramedic in the hospital to care for up to five patients at a time, said the report.

In a statement, The Ottawa Hospital’s head of emergency medicine, Dr. Guy Hebert, welcomed the report, saying it shows that by working together, better solutions could be found to decrease off-load times and provide the best care possible for patients.

“With more nurses being hired to work with paramedics, and other innovative solutions such as contracting paramedics to care for patients when they are dropped off at emergency departments, this report shows that there remains a lot of hard work ahead even as we implement these new measures.”