Report To: Program Planning Committee
From: Paul Myre, Chief of Paramedic Services
Date: June 14, 2022
Re: Paramedic Services Recommendation 2 - Option A - Issue Report
Background
Paramedic Services staff have explored Recommendation #2 - Option A to provide a comprehensive report back to the Board. This issue report will detail the processes utilized during the in-depth analysis and further provide the Board with 2 possible options for future consideration.
Understanding the sensitive and complex nature of this issue, staff have applied a predictive and prescriptive analysis approach for our detailed analysis of Recommendation #2 - Option A. Staff also applied the tenets of LEAN methodology and undertook a modicum of a 4 Step Problem Solving exercise to look at elements such as root cause, cause & effect, and countermeasure(s) confirmation. Many parallels can be drawn by comparing LEAN 4 Step Problem Solving and the analytic process which fortunately worked in staff’s favor and simplified workflows. Staff finally embarked on a “pro & con” comparison to ensure this report provides the Board with fulsome and objective information for future decision making. Staff have completed their analysis on Recommendation #2 - Option A and are pleased to submit the following comprehensive report and recommendations attained from that process.
Current State
Prior to looking at the outcomes of our analysis and recommendations, it is important to understand how staff utilized a predictive and prescriptive analytic approach for this very important but complicated issue. For a predictive analysis, the process has a goal to provide insight on what is likely to happen if we were to implement Recommendation #2 - Option A. For the purposes of this report, the predictive analysis would be the “Why, What and When?” of the recommendation. From the onset, three important elements were established to help guide staff through the predictive analysis process.
The three elements’ staff needed established were:
Fortunately, much of this work had already been undertaken by virtue of the previous reports presented to the Board in September 2021, February 2022 and March 2022 and could be easily and repeatedly referenced throughout our work. The greatest limiting factor when conducting these types of analyses is that they rely on forecasting and predictions that are based on the data on hand at the time this work was undertaken. One of the inescapable realities of the dynamic and fluid nature of Paramedic Services is that some of the data utilized in this analysis has already evolved or may now even be outdated.
The prescriptive analysis component takes the information from the predictive process and now assess how we would benefit from the predictions and further assess all the impacts, known and unknown, should a decision be made to operationalize Recommendation 2 – Option A. The limitation to this process is that again, due to the very nature of the Paramedic profession, real time experimentations on their own can pose a risk to public safety and if not properly structured, may in fact be unethical. Real time experimentations are additionally cost prohibitive and can be extremely disruptive to the prehospital emergency system. There is a saying in the Paramedic realm that you “never experiment on patients.” Therefore, “tabletop” exercises/scenarios and theoretical simulations were the only methods available that could safely and ethically be utilized for this analysis.
Finally, staff reviewed all our stakeholder feedback including the many emails, letters, petitions, and voicemails submitted from residents, politicians, concerned family members, etc. These were most valuable in providing a social, collegial, and human factors context to our analysis and findings.
Findings and recommendations
As noted in the March report to the Board, the recommendations proved indeed very controversial and garnered much media attention. Despite the public and political opposition to the recommendation, staff forged ahead utilizing an unbiased approach to provide the Board with the most fulsome and unfettered report for consideration. For the purposes of this report, it is important to review Recommendation #2 - Option A as it was presented in the March report to the board:
“Recommendation #2: Estaire and/or French River (Bigwood)
Staff see this recommendation as very important but acknowledge it would necessitate a significant investment to operationalize. If approved, a full Paramedic crew working a 12-hour day and 12-hour “on-call” rotation would incur a minimum $500,000.00 annual impact to the budget or approximately a minimum of $250,000.00 for the municipal share; not including all other operational costs in deploying an extra resource such as a new station which could cost as much as $1,200,000 for a 2,400 square foot building utilizing current cost estimates for capital infrastructure at $500.00 per square foot. The other possibility is a lease at $30 per square foot which would be $72,000 per year. As call volumes are projected to rise in some areas and to dampen the financial burden of operationalizing this recommendation, it may become necessary to consider alternate deployment options to better position assets in the areas likely to provide a greater response capability as described in the report.
For recommendation #2, staff submit three viable and mutually exclusive options for consideration:
a. The call volumes in the Foleyet station were 90 calls in 2021 with 89 of those calls being priority 3 or priority 4 calls. The call volumes in the Killarney station are at 125 calls for 2021 with 119 of those calls being priority 3 or priority 4 calls. If necessary, the Board could consider altering staffing patterns in the two lowest call volume stations to a single response Paramedic. This would see a Paramedic Response Unit (PRU) stationed at the Killarney and Foleyet bases providing a combination of Paramedic Services in those communities. These PRU’s could be deployed as Community Paramedicine resource in Foleyet and in Killarney, while also responding to 911 calls in the communities. The Community Paramedics would schedule appointments and/or hold clinics in the community as a realistic and cost-effective means to support both communities’ health care needs in partnership with their current primary health care providers. This also has the potential to reduce 911 calls as the Community Paramedic would make regular visit to the frail and vulnerable in the community. Ordinarily, we would not consider using Community Paramedics to respond to 911 calls as there is a risk that the Community Paramedic is with a patient or performing a procedure when a 911 call comes in. However, in the communities of Foleyet and Killarney with one call every 3 to four days, based on past call volumes, we believe this risk to be manageable. The Killarney and Foleyet ambulances could then be redeployed per the plan. While manageable, this option does present some risks as Paramedics stationed in these remote communities would be alone on calls for service for extended periods of time while transporting units respond.
This option would permit the staffing of a transporting unit without incurring the additional minimum of $500,000 in annualized staffing cost for a new station in the Estaire and/or French River (Bigwood) area. In addition, the existing 3 ambulances (Foleyet & Killarney) would be re-deployed; two (2) to the new station and one (1) ambulance would be eliminated which would save approximately $25,000 annually which would be used to pay for the two (2) new fully equipped PRU’s which would cost $10,0000 each annually.”
As previously noted, this recommendation provided much of the information for the predictive analysis component. The single greatest benefit from this model would be addressing the gap in equity of access to Paramedic Services across our region. What often gets lost in public or political discourse is the difference between prehospital health care (PHC) equality and equity. PHC equality means that our entire region has equal access to any of our 12 Paramedic Stations and resources at any given time. PHC equity means that each community has a different circumstance and we, as much as reasonably possible, must do our best to allocate the exact same resources and opportunity for access to achieve equal outcomes. This is the most important concept when considering a “balanced emergency coverage” model. What we know is that our large geographical, sparsely populated region has PHC equity gaps when it comes to response times for our highest acuity emergency calls. For example, the data demonstrates that areas with a greater population density such as Manitoulin West and French River/Estaire, do not have equitable access to Paramedic Services as areas such as Foleyet and Killarney. When applying a predictive analysis approach, staff are faced with an obvious prediction that an area with a denser population will undoubtedly have a greater chance for and higher frequency of emergency calls. The struggle then becomes how to justify having a fully staffed ambulance in an area less likely to be utilized all while witnessing ever increasing call volumes in a more densely populated area with no ability or agility to narrow our response time gaps. The deployment of a Community Paramedic in a Paramedic Response Unit in low call volume areas and redeployment of transporting unit to higher populated hence higher call volume areas on a tabletop, addresses some but admittedly not all those gaps.
Staff further hypothesized that deploying a Community Paramedic in Foleyet and Killarney could in fact be an increase in service and a system optimization measure by having a specialized resource available to respond to the most frequent emergency calls many of which may not actually require transportation to a hospital. This idea was grounded by the fact that our hospitals are continually experiencing high admission rates and are dealing with the ever-present Alternate Level of Care (ALC) patient crisis. These two elements are contributors in the overcrowding of our hospitals which inevitably creates a “bottle neck” in our system. This “bottle neck” leaves community hospitals with no choice but to try to decant into other regional hospitals that are experiencing the exact same pressures. This “back log” then creates increased wait times and Emergency Department surge pressures which then backs up into the Paramedic Services in the shape of Ambulance Offload Delays. Fortunately, our service has been able to avoid lengthy offload delays, but the current mitigation strategies are fragile and will not sustain without an innovative and “out of the box” change of course when it comes to prehospital healthcare. The majority of our remote communities would benefit from a medical response system that involves deploying a highly trained Community Paramedic to provide an initial “in home” assessment and then with the consultation of a Primary Health Care (PHC) provider, establish a care plan that sees the patients recover and convalesce at home rather than be transported great distances to a hospital Emergency Department; waiting long hours only to be discharged home with orders to follow up with their PHC provider. This idea worked well during hypothetical scenarios utilizing the types of calls encountered in Killarney and Foleyet.
However, staff predicted that in some rare instances, patients requiring urgent Emergency Department care or lifesaving surgical interventions could very well face a significant delay in accessing definitive care by re-deploying both the Killarney and Foleyet transportation units. This was a significant stalling point during deliberations and one that kept reappearing regardless of the many suggested theoretical countermeasures.
Staff also realized through industry partner conversations that while redeploying our transport units would maximize our ability to provide PHC equity within our current funding constraints, this move could impose an unanticipated and unbudgeted pressure on a neighbouring service. In discussions with our neighbouring leaders and under “seamless” provisions of Paramedic service mandates from the Ministry of Health that stipulate “the closest, most appropriate ambulance in time responds to emergencies at any time, to/from any jurisdiction;” it would appear that the closest unit in time to respond to Foleyet would in fact be from Timmins and not Chapleau. Based on our current call volumes and from discussions with leaders at the Cochrane DSSAB, this option could represent an incurred cost to the Cochrane DSSAB of up to $250,000.00 per year. While unintentional, this would not be well received by our neighbors and truly is not reflective of the intent of this modelling.
Through consultations with the Ministry of Health Emergency Health Services Division, the recommendation was discussed and was found to have some significant risks if some of the options were pursued. One of the most limiting risk factors identified by the Central Ambulance Communications Centre (CACC) is related to the “seamless” mandates and the positioning of a resource in the community of Estaire. The proximity of this theoretical resource to a denser populated urban center would expose it to be pulled into the city and utilized to respond to higher acuity calls as a primary resource. This was confirmed during tabletop scenarios, mapping, and data set comparisons. As an Estaire unit would be frequently utilized to respond to Urgent/Emergent calls for service, it would effectively negate the purpose of deploying an Estaire unit in the first place. Additionally, in discussions with the Ministry of Health’s EHS Northeast Field Office, we are on the precipice of having the Medical Priority Dispatch System (MPDS) software implemented which would reduce the burden of high priority call assignments and enhance service operators’ ability to dictate intended use of resources.
The alternative explored to manage our French River response time gaps was positioning the Paramedic unit in Alban. During tabletop and scenario discussions, this countermeasure addressed a good portion of the response time gaps while providing a stable emergency coverage for that area. Therefore, positioning a resource in Alban is a favorable countermeasure to our response time gaps in the French River area.
Finally, Staff read all the letters, email and petitions submitted by the public and politicians. Our communities value the important service Paramedic Services provide and are steadfast in protecting the current level of service. Many stories were shared about experiences and life altering encounters with our Paramedics which certainly amplified the message that rural-remote communities desperately need emergency health services now more than ever.
Given the information before Staff, the options for consideration are as follows:
Recommendation:
Option 2A was based upon managing identified emergency response gaps within the current DSB budget and not having to increase the municipal levy. Based on the public and political response to the proposed changes in the Foleyet and Killarney area, it is clear this is not a straightforward decision. Before the board is asked to select an option, staff are recommending that the Board first lobby the local Members of Provincial Parliament and the Minister of Health to address the needs of the residents of the DSB. The Board would request one time funding for new Paramedic stations and new Ambulances for the French River (Bigwood)/Estaire area and the western end of Manitoulin Island. This request would also include the provision of ongoing annualized operating funding for full-time paramedic staffing at both stations.