B. C. Ambulance chief defends dispatch changes
‘ It’s not about saving money. It’s about better patient care,’ Dr. William Dick says
There are only three medical emergencies for which rapid ambulance responses are proven to make a difference to the life or death of a patient, according to B. C. ambulance leaders: cardiac arrest, respiratory arrest, and total airway obstruction.
“Those are the big three where you can get big saves,” says Dr. William Dick, an emergency room physician at Surrey Memorial who is vice- president of medical programs for B. C. Emergency Health Services ( B. C. Ambulance).
He acknowledged that cases involving severe trauma, strokes, anaphylaxis ( life- threatening allergic reactions), chest pains, and some others are also treated with the same kind of urgency. But scientific evidence has singled out the “big three” as being the most critical when it comes to the proven benefits of fast response times.
The “big three” account for less than one per cent of the 373,000 ambulance calls in B. C. each year.
In a wide- ranging interview to address controversies related to ambulance service changes and complaints from municipalities that too many calls have been downgraded and ambulance response times slowed, Dick said changes that took effect last year through what is called the Medical Priority Dispatch System ( MPDS) are based on an internationally recognized system used in almost 3,000 jurisdictions, including Toronto and Winnipeg.
“It isn’t to save money. It’s about better patient care, getting to critical calls faster,” he said.
“The rationale is to triage cases and rank them in priority, just like they do in hospital emergency departments so that we can get to certain types of cases more quickly. It’s an evidencebased, data- driven, decision- making emergency medical system,” he said.
The rationale is to triage cases and rank them in priority, just like they do in hospital emergency departments so that we can get to certain types of cases more quickly. DR. WILLIAM DICK VP MEDICAL PROGRAMS FOR B. C. AMBULANCE
“In some cases before, we were overresponding and in others we were under- responding,” he said, referring to the fact it is expected there will be a 54- per- cent increase in “cold” responses — ambulances sent to calls with less urgency and no lights and sirens.
That should translate into 800,000 fewer kilometres driven using lights and sirens by ambulances and fewer associated accidents involving collisions between ambulances and other cars, according to information contained in nomination documents for an award to George Papadopoulos, director of BCEHS quality and patient safety. Papadopoulos helped execute the ambulance service changes and was recently nominated for a Leadership in Quality Award from the B. C. Patient Safety and Quality Council for his work in transforming the service. Winners are expected to be announced next month.
The changes implemented by Papadopoulos, Dick and others at the ambulance agency were subjected to an external review. The April 2014 final report of the review by Alan Craig, the retired deputy chief of Toronto Emergency Medical Services, lauds the “sophisticated” new system and says it was based on more than 630,000 ambulance transfers and paramedic patient care reports.
A separate report, to be completed in the spring of 2015, will show the effect of the changes. As well, the B. C. health ministry has granted permission for access to patient files so research can determine if changes have in any way negatively impacted health outcomes of patients transferred to hospital by ambulance.
“We are looking to get the complete, utterly undeniable truth,” Dick said. The proposed research will compare patients transferred before the changes to patients transferred since the system took effect a year ago.
Linda Lupini, executive vice- president of Provincial Health Services Authority and BC Emergency Health Services, said harsh criticism of the changes, expressed mostly by several Lower Mainland mayors, is ironic because it was mayors complaining about the frequency of first responder use that prompted changes.
“Yes, there are times when first responders ( firefighters) are getting to calls faster than ambulances and they’re saying, ‘ What took you so long?’ But that’s their choice to go there. They can do that because they aren’t spending as much time fighting fires as they would like.”
Dick said firefighter first responders can and do make a huge difference in some cases — by doing chest compressions, attaching defibrillators, extricating people from vehicles and ventilating patients.
“That’s when you get huge bang for the buck.”
Dick admits that first responders and hospital emergency personnel have been submitting examples of cases where paramedics should have got to calls faster. Dick said he has recently reviewed 170 such cases, mostly in the Lower Mainland. Each review took four or five hours since he also listened to 911 calls.
“I haven’t found one case yet that was wrong,” he said, referring to how the call was triaged.
But Dick and Lupini acknowledged it’s not just firefighters and mayors who have been complaining about the ambulance service. In the past two years, more than 1,000 complaints have been lodged by patients, their family members, health professionals, ambulance personnel and others. Complaints about the ambulance service can be made by contacting the Patient Care Quality Office of the Provincial Health Services Authority — 1- 855- 660- 2757.
In the most recent Patient Care Quality Review Board annual report, most of the cases about health care complaints in PHSA were about the ambulance service.
Lupini said complaints about the changes, being documented day by day in the news media, are “raising public anxiety needlessly” and ambulance leaders recognize they need to do a better job on public education.
Part of the messaging she wants people to hear is that ambulances are not taxis and the service shouldn’t be abused. She cited a case recently in which an individual who was bleeding from the site of a wisdom tooth extraction called for an ambulance. The caller described the bleeding in the mouth as profuse. Dispatchers can’t ignore any calls, so paramedics went to the residence and were obligated to transfer the individual to hospital. It was a case that required neither an ambulance nor a hospital, she said.
Individuals can refuse a transfer to hospital in which case the service call would cost $ 50 for those with Medical Services Plan coverage. But if transferred to a hospital, the charge is $ 80, a heavily subsidized fee since, as Lupini points out, the actual cost to taxpayers who fund the system is $ 550, if all capital and operating costs are taken into account.
Lupini said the ambulance service is now considering changes in which paramedics could “treat and release” clients, avoiding an unnecessary transfer to hospital.