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1 Emergency Service Planning Emergency Medical Services

2 This document has been produced by ORH Ltd for British Columbia Emergency Health Services (BCEHS) on 10 th November This document can be reproduced by BCEHS, subject to it being used accurately and not in a misleading context. When the document is reproduced in whole or in part within another publication or service, the full title, date and accreditation to ORH Ltd must be included. This document is intended to be printed double-sided. As a result, some of the pages in the document are intentionally left blank. Disclaimer The information in this report is presented in good faith using the information available to ORH Ltd at the time of preparation. It is provided on the basis that the authors of the report are not liable to any person or organisation for any damage or loss which may occur in relation to taking, or not taking, action in respect of any information or advice within the document. ORH Limited is the trading name of Operational Research in Health Limited, a company registered in England with company number Accreditations Other than data provided by BCEHS, this report also contains data from the following sources: HERE All rights reserved. Her Majesty the Queen in Right of Canada, Queen's Printer for Ontario

3 Contents Page Executive Summary i 1 Introduction Report Context BCEHS Report Structure Terms of Reference Overview of Requirement Detailed Specification Methodology Overview of Approach Project Timetable, Activities and Consultation Data and Analysis Modelling and Appraisal Current Service Demand Resources Response Standards First Responders Service Appraisal Resource Use Improving Efficiency Improving Effectiveness Demand Projection Overview of Methodology Metro-wide Projections LHA-level Projections Modelling Preparation and Validation Introduction Model Preparation Model Validation... 23

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5 8 Modelling for Introduction Creating the Base Model Modelling Options Achieving the Shadow Targets in Modelling 2017 and Modelling for Modelling for Alternative Scenarios Station Configuration Modelling Station Database Configuration Modelling Results Sensitivity Modelling Introduction Sensitivity Modelling Results Summary Overview of Review Current Service Profile Future Service Development Options Meeting the Shadow Targets... 48

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7 Figures Opposite Page ORH Modelling Approach Review Timetable Modelling Scenarios Demand Profile Summaries Resourcing Summary Performance Profile Summaries Participating Fire Services Records Received (2014) Participating Fire Services Time Fields Supplied Resource Use Key Statistics Proposed Improvement in Activation and Mobilization Times Shift Timings Shadow Targets Proposed for Response Times Delta/Echo Response Time Percentiles Comparing Categories and Targets Forecast Annual Patients by Age Band Population-based Demand Projections Modelled Life Cycle of an Incident Top 25 Additional 24/7 Ambulance Deployment Locations Adding ALS-skilled PRUs Summary of ALS PRU Results Response Performance Gap to Shadow Targets New Locations Required by and 2020 Response Performance Standards Average and 95 th Percentile Response Times First Responder Waiting Times by Scenario Potential Hub and Spoke Locations and Vehicle Additions for 2020 Targets Comparing Future Scenarios on

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9 Appendices A B C D Current Service Profile Service Appraisal Summaries Demand Projection Model Validation E Modelling 2014 and 2015 F Modelling 2017 and 2020 G H I Station Configuration Modelling Sensitivity Modelling Summaries Glossary

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11 i EXECUTIVE SUMMARY 1. This review of Metro Ambulance Operations has involved detailed analysis of the 2014 service profile, enabling a model of emergency cover to be prepared, validated and used to assess a range of options for change. Progress Reports throughout the 20-week review were presented to a BCEHS Steering Committee and discussed in detail with a Working Group. 2. An appraisal of current service provision was undertaken, highlighting where efficiency and effectiveness needed to improve. This was supported with some benchmarking comparisons. This appraisal informed the identification of options for modelling. 3. In 2014 Metro Ambulance responded to an average of 827 incidents per day: 714 emergency response and 113 transfers. Mainland Metro accounts for 86% of this demand, and Metro Island 14%. The highest acuity Delta/Echo incidents make up a quarter of emergency responses, with Bravo/Charlie 43% and Alpha/Omega, the least acute category, 31%. Red and Yellow transfers account for about 30% of transfer workload, with 70% categorized as Green or Blue (the least urgent). 4. There are 37 ambulance stations, most at or close to capacity, and 36 crossover points used for standby. Six annexes are also used for unit deployments. ALS units are deployed to 13 stations (2,520 unit hours deployed per week), BLS units to all stations (11,251 unit hours per week), and Transfer units to 11 stations (560 unit hours per week). 5. The utilization of ALS units is 30.5%, which is relatively low for a metropolitan area, and BLS units are 52.1% utilized (broadly average). This tiering structure between ALS and BLS does not give good ALS cover to the Metro area. For example, 21% of incidents require an HLA response but, of these, only 25% receive a first response from an ALS unit. ALS respond to only 45.7% of Delta/Echo incidents, usually arriving after the BLS unit. 6. Fire Service First Responders (FRs) are used extensively, responding to 243 Metro incidents per day (across 17 Fire Services covering Metro Vancouver); the RAP identifies 29% of incidents as FR appropriate (87% of Delta/Echo). 7. It takes over two minutes on average for BCEHS to notify the First Responder. Their response is very quick (93% within 9 minutes from time notified), and they most often (75.5% of the time) have to wait for the first BCEHS unit to arrive (eg, average waiting time when an FR responds to a Bravo/Charlie call is 9:29). It was agreed between BCEHS and Municipality representatives that reducing this waiting time should be an area of focus. 8. Analysis has highlighted very long activation times (the assignment time from Call Answer to Vehicle Assign) and mobilization times (the chute time from Vehicle Assign to Vehicle Mobile). For example, a Delta/Echo incident takes 4:13 to assign and mobilize. These times are definite outliers when benchmarked. Significant improvements are required in this time to allow unit resources to be used more efficiently. A phased programme of improvement in

12 Figure A: Shadow Targets Proposed for Response Times Category 9 minutes 15 minutes 30 minutes 60 minutes Delta/Echo 75% (51%) 95% (86%) Bravo/Charlie 75% (64%) 95% (90%) Alpha/Omega 75% (81%) 95% (95%) (Current achievement at these time thresholds in brackets)

13 ii these average times for Delta/Echo incidents of 80 seconds by 2020 has been set and agreed, with expected improvements for all calls. 9. This review has excluded the Control function. It is recommended that a Control review is undertaken with a scope that includes: call handling; dispatching practices; staff levels; dispatch desk jurisdictions; systems used; protocols followed; and the use of the RAP. Such a review would need to be set in the context of increasing demand and resource levels. 10. Response times are measured from the time the call is answered to the first vehicle on scene. A nominal target of 90% within 9 minutes has been set for Delta/Echo calls (currently 51.2%), and a more formal target of 75% in 9 minutes for Red Flag incidents (currently at 65%). Realistic targets need to be set based on best practice to allow resource plans to be developed. 11. There is significant variation in response performance between districts (eg, from 41.1% to 67.1% on the 9-minute Delta/Echo standard), and there is a requirement within the review objectives to set appropriate minimum levels. 12. Whereas the first on scene 9-minute response percentile from Call Answer to Delta/Echo incidents is 51.2%, for ALS response to Delta/Echo it is only 39.9%, and just 27.8% when they respond to HLA incidents. ALS units respond to 75% of Red Flag incidents (the highest acuity needing their skills) but with a 9- minute response percentile of just 37%. As well as an overall improvement in response times it is also necessary to raise the ALS response standard to higher acuity calls, ie, Delta/Echo, HLA and Red Flag. 13. In consideration of these issues and the need to give a basis for the modelling of options, ORH proposed a set of shadow targets for emergency response based on best practice elsewhere and some comparative benchmarking. For Delta/Echo incidents the 9-minute response target is set at 75% between the 51.2% currently being achieved and the 90% nominal target set. These targets, with current achievement, are shown in Figure A. 14. Emergency demand levels were projected forward to 2020 based on demand rate trends coupled with forecast population growth by age/sex group and by LHA. Transfer demand was assumed to reflect recent trends and the overall Metro population growth. This gave a 6.1% per annum increase in emergency demand and a 2.0% per annum increase in transfer demand distributed by LHA. This demand profile was used for modelling the future. 15. Once the model was validated against the 2014 service profile it was used to test a range of operational measures to test their impact on the efficiency and effectiveness of cover. The projected improvement in activation and mobilization times gave significant response time improvements. It was found that there was only marginal benefit in changing shift patterns (some were identified for the weekend). It was assumed that the average time at hospital would be held at current levels and that there would be no change in the conveyance rate (80%), nor in the time crews spend on scene.

14 Figure B: Average and 95th Percentile Response Times Year Activation Time Reduction Additional Resources Average Time for BCAS 1st Response (D/E Calls) 95th Percentile for BCAS 1st Response (D/E Calls) 2015 No Change No Change 10:17 19:54 No Change No Change 11:27 22: seconds No Change 11:03 21:54 30 seconds ALS PRUs Only 09:12 19:39 No Change No Change 15:07 30:05 80 seconds No Change 13:54 29: seconds ALS PRUs Only 10:41 25:02 80 seconds Full Resources For Shadow Targets 07:09 14:44 All times in minutes : seconds Note: Core emergency demand projection of 6.1% per annum assumed here

15 iii 16. Resourcing options were assessed. Increasing the size of the Transfer fleet is not an efficient measure. Introducing mixed crewing, ie, crewing units with an ALS and a BLS crew member, gave good outcomes in terms of extending the coverage of ALS skills, but this would be very challenging to implement given commitments made to the union. Also it would not improve first on scene response times. The most positive outcomes for improving cover cost-effectively is to deploy single-staffed ALS PRUs which would extend ALS coverage and improve first on scene response times. 17. The combination of improved activation/mobilization times and deploying ALS PRUs makes a significant impact on Delta/Echo response times, but to meet the extra demand projected and to improve response standards towards the shadow targets proposed will involve additional BLS units. 18. To meet the targets set by 2020 will involve achieving the reductions in activation/mobilization time by that year and deploying 1,344 ALS PRU hours per week (42 ALS FTEs and a peak deployment of 12 cars) and 3,792 additional BLS unit hours per week (235 FTEs with an increase in peak BLS unit deployments of 29). Seven of the existing cross-cover points will need to be upgraded to station locations with facilities, and there is significant potential to develop hub and spoke systems of cover in five areas, and this would be an efficient measure for ensuring sufficient capacity. 19. The benefits of investing in these resources and station configuration changes alongside the efficiencies identified are considerable: First on scene response standards will be in line with best practice, and the minimum district response standard raised (eg, Fraser Valley Delta/Echo from 42% within 9 minutes to 60%). ALS coverage will be extended to most of the Metro area, allowing these skills to reach 83% of HLA cases (currently 58%) with a 9-minute response time percentile of 50% (currently 28%). The First Responder waiting times will be reduced (eg, for Delta/Echo incidents from an average of 4:37 to 3:11). The reconfigured deployment locations will allow staff and vehicle resources to be accommodated appropriately and used efficiently. 20. A phased programme of change has been proposed aiming for a 30-second improvement in activation/mobilization times by mid-2017 and completing the introduction of ALS PRUs (42 FTEs) and some BLS units (35 FTEs). 21. Figure B illustrates the impact on the average and 95 th percentile Delta/Echo response times for alternative scenarios to the development path summarized above. If no changes were made by 2020, the average Delta/Echo response time would rise from the 2015 level of 10:17 (minutes:seconds) to 15:07, and the 95 th percentile response time would rise from 20 to 30 minutes. The First Responder average wait time on Delta/Echo incidents would rise from 4:37 to 5:53 in 2017 and 8:08 in 2020.

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17 iv 22. Alpha/Omega standards would fall very significantly by 2020 for options involving no new resources as the higher acuity calls take priority and there will often be insufficient units available to service these calls as the demand increases. Whilst the ALS PRU only option shown improves Delta/Echo response by 2017 and minimizes the response fall by 2020, Bravo/Charlie and Alpha/Omega response standards decline progressively. 23. Sensitivity modelling looked at testing a few of the assumptions made. If time at hospital were to reduce to 30 minutes this would lower the staffing requirement in 2020 by 47 staff. If the demand projection were to be lowered - 4.2% per year rather than the 6.1% used then this would reduce the staffing requirement in 2020 by 57 staff.

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19 1 1 INTRODUCTION 1.1 Report Context Operational Research in Health Limited (ORH) was commissioned to undertake a demand analysis and modelling review for British Columbia Emergency Health Services (BCEHS) in February 2015, and review work began in mid- March. The scope covers service delivery for both Metro Ambulance and Air Ambulance Operations This is the Final Report for the demand analysis and modelling review for Metro Ambulance. A succession of Progress Reports were produced and discussed with BCEHS over a 20-week review period, and this report now focuses on the results and conclusions reached, supported by quantitative evidence A brief overview of BCEHS is given below before describing the report structure in sub-section BCEHS Organization Overview British Columbia Emergency Health Services (BCEHS) is supported by the Provincial Health Services Authority (PHSA). BCEHS is mandated to provide provincial ambulance and emergency health services under the Emergency and Health Services Amendment Act, S.B.C BCEHS is currently responsible for two (2) operating entities. BC Ambulance Service (BCAS) provides emergency health services and ambulance services throughout the province of British Columbia. The BC Patient Transfer Network (PTN) is responsible for planning and coordination of all inter-facility patient transfers. BCAS Overview Created in 1974 the BCAS is tasked with the provision of public ambulance services across the province. BCAS is the largest provider of emergency medical services in Canada and one of the largest in North America. BCAS serves over 4.4 million British Columbians and responds to calls for emergency 911 and inter-hospital transfer services across six health authorities covering 944,700 square kilometres In 2013/14, BCAS responded to more than 515,000 events throughout the province 425,000 pre-hospital (911) events, and 90,000 inter-facility transfers. BCAS also transported an additional 6,600 patients by air ambulance. BCAS employs 4,486 staff 3,881 paramedics and dispatchers and 605 physicians, nurses, management and support personnel. BCAS operates from 184 ambulance stations, five administration offices, and three dispatch centres. BCAS has a fleet of 577 vehicles, including 510 ambulances and 67 support vehicles and dedicated ambulance aircraft.

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21 2 1.3 Report Structure The terms of reference as taken from the original tender document are reproduced in Section 2, and the approach taken by ORH in undertaking the work is described in Section The current service profile is exemplified in Section 4, covering the demand met, resources used and standards achieved (including a description of the contribution made by First Responders). Section 5 then provides an appraisal of this quantified profile, highlighting potential efficiency measures and identifying target response standards The time horizons taken for the projections in this review are to 2017 and Section 6 sets out the methodology and results for projecting demand to these years The simulation model of Metro Operations was built and validated using activity data from the 2014 calendar year, and this process is explained in Section 7, along with providing modelling results from the 2015 base year. The main deployment results for the two forward years are then set out in Section Section 9 focuses on modelling results related to the station configuration, and Section 10 shows the impact of changing some of the key assumptions made in the main modelling Finally, the results and conclusions reached are summarized in Section A glossary of terms provided throughout the report is provided in Appendix I.

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23 3 2 TERMS OF REFERENCE 2.1 Overview of Requirement BCEHS would like to see forecasted impacts on service delivery, response times and patient care as a result of: call patterns; station locations; staff deployment; skills mix methodology; and population growth and/or changes to demographics BCEHS, at the end of this project would like to have information to move forward with effective and efficient service delivery to meet changing demands. Initially, BCEHS is looking for specific evaluations and recommendations in Metro operations and/or Air Ambulance operations with options to conduct further detailed analysis in other service delivery areas. BCEHS has no preference as to whether this is achieved by utilizing a commercial off the shelf (COTS) software and/or through a consulting service contract. The solution needs to provide the analysis, service delivery planning recommendations and implementation plans. BCEHS may award one or more contracts at its discretion that best meets current and future needs The expectation is that the service or software solution will enable BCEHS to: a) gain an in-depth knowledge and understanding of current BCEHS service delivery resources; b) identify any inefficiencies within the current BCEHS service delivery; c) identify any inconsistencies in resources and demand matching; d) identify potential to optimize current BCEHS resources; and e) determine response times that could be achieved with optimization of the current system taken as a whole and the incremental cost to improve appropriate response times. 2.2 Detailed Specification Business Requirements From this project, BCEHS will require the ability to: a) Determine the most appropriate service delivery response model that achieves the proposed emergency response time standards.

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25 4 b) Determine the most appropriate service delivery response model including but not limited to: i. Location of vehicles, air ambulance aircraft and stations. ii. iii. iv. Type and number of shift schedules. Paramedic staffing by type and number and optimal configurations. Recommended best practices and deployment methodologies from other jurisdictions. c) Determine reasonable system costs to achieve the service delivery standards. d) Determine the reasonable considerations that should be accounted for in setting service delivery standards (for example specific to the Downtown and the Fraser Valley areas of Metro Operations). e) Revisit analysis in subsequent year(s), after implementing some or all recommendations. Outcomes BCEHS should, from this project, be able to: a) Determine and recommend the most appropriate service delivery model (considering the appropriate model of care based on call demand, location and patient acuity) that achieves the desired emergency response time standards, including: i. inventory of resources (ALS/BLS, CCP, Ambulance, aircraft); ii. iii. iv. location and deployment of resources (appropriate type, mix and number, priority lists, staffing pattern & levels); unit hours for both Ambulances and 1st response resources; and phased 12- to 24-month implementation plan. b) Determine and recommend resource thresholds for proposed deployment model with parameters for adding resources. c) Identify how any approach is consistent with the current RAP and flexibility for RAP changes in subsequent reassessment. d) Suggestions on Management/Performance Information requirements to implement and measure impact of changes. e) Estimate capital and operating cost impact of each recommendation proposed.

26 Figure 1: ORH Modelling Approach Validation Ensuring the model accurately reflects the current situation Optimization Identifying the best solutions given known constraints Simulation Modelling future scenarios and answering what if questions Sensitivity Modelling to check that identified solutions are robust and future-proof

27 5 3 METHODOLOGY 3.1 Overview of Approach The ORH consultancy approach to supporting service development and tackling complicated resource planning problems related to emergency ambulance cover involves a combination of analysis and modelling: analysis of demand, performance and resource use to allow the model of the service area to be populated and validated, and to inform an appraisal of potential options for change; and identifying and modelling options that aim to improve the effectiveness, efficiency and equity of service provision Analysis for operations is based upon inputs from CAD-derived workload and emergency ambulance vehicle resourcing data, including both the resource plan and the actual deployments made. External data are also analyzed where appropriate; for example, census data is used to support demand projections The relationship between the demand profile, the resources deployed and the performance achieved for an emergency ambulance service is complex. This is particularly the case with multiple call categories, different vehicle types and staff skills, and various response time targets. Given this complexity, a modelling approach is required to inform resource planning decisions Figure 1 opposite illustrates the overall modelling approach taken. The two key types of modelling used by ORH are: Simulation modelling the process of creating and analyzing a digital version of a physical model to predict performance in the real world. Optimization modelling finding the best possible choice from a set of alternatives, by using a mathematical expression of a problem to maximize or minimize some target function or goal ORH uses information specific to the Service to populate the models. This requires analysis of CAD data to provide information about such factors as demand, call locations and job cycle times. Service data are also used to determine resource numbers, types, deployment locations and dispatch times. In addition to these data, ORH develops a detailed travel time model of the service area using commercially available software calibrated against information on journey times measured from the CAD data The model is validated by comparing the model outputs with actual Service performance data. A fully validated simulation model will accurately produce outputs which correspond to the actual performance, utilization and vehicle workload experienced by the Service Once populated and validated, the models can be used to answer a wide variety of what if questions. Sensitivity modelling helps to provide confidence in the results by illustrating the degree to which performance changes as the value of input parameters alters.

28 Week No Week Commencing 16-Mar 23-Mar 30-Mar 06-Apr 13-Apr 20-Apr 27-Apr 04-May 11-May 18-May 25-May 01-Jun 08-Jun 15-Jun 22-Jun 29-Jun 06-Jul 13-Jul 20-Jul 27-Jul Progress Reports 6 & 7 Progress Report 8 4 Figure 2: Review Timetable a) b) Data Collection, Analysis and Benchmarking Stakeholder Engagement and Reporting c) Setup and Validate Models d) Demand Projections e) Scenario Modelling Reporting Project Initiation Report Progress Report I Progress Report II Interim Report Progress Report 3 Progress Reports 4 & 5 Visit Scheduled Phone Calls

29 ORH uses its optimization model (OGRE Optimization by Genetic Resource Evolution ) to identify optimum deployment locations. OGRE is set up with parameters taken from the simulation modelling inputs, and additional constraints are established in consultation with the Ambulance Service (eg, sites which will always be used). The locations found using OGRE are then input to the simulation model in order to quantify the performance and workload implications. 3.2 Project Timetable, Activities and Consultation Figure 2 opposite shows how the generic approach described above was translated into a 20-week review timetable for undertaking the Metro Ambulance analysis and modelling work The review was overseen by a BCEHS Steering Committee, and a Working Group was also established to discuss the analysis and modelling results as these emerged during the review process The main data collection and analysis activities were undertaken in the earlier phases of the review, supported by internal BCEHS stakeholder consultation. This analysis, including the demand projection work, enabled simulation and optimization models to be established midway through the review period. The models were then used to examine a range of options, the results of which were set out in a series of Progress Reports to allow informed feedback from BCEHS representatives In parallel with the analysis of Metro Ambulance data, analysis was also undertaken of First Responder activity across Metro Vancouver, and a series of meetings, supported by separate Progress Reports, took place with Municipality and Fire Service representatives. 3.3 Data and Analysis The calendar year 2014 was chosen as an appropriate sample period to represent the current service profile. A detailed call-by-call sample of workload, timings and unit activity was specified and supplied as an extract from the CAD BCEHS also supplied month-by-month reported levels of demand and response performance for the agreed sample period. This enabled ORH to validate its own analysis of the CAD workload for that period The establishment levels of staff by type/skill level (funded, actual and vacancies) were provided by BCEHS, together with representative planned and actual deployed levels Operational data were then subject to a detailed analysis to draw out the current relationship between demand, performance and resources. This provided a quantitative description of the current operational profile, drawing out factors relevant to the terms of reference. In particular the current relationship between resource utilization and response performance was exemplified, and the current matching between resource deployments and the daily/hourly demand profile assessed.

30 Figure 3: Modelling Scenarios Service Data Base Position Model Runs Service Advice Identify Efficiencies Simulation Demand Projections Current Demand Simulation Service Constraints New Locations Optimization Options for Targets Resources by Location and Type Requirements to meet targets with current demand Phasing Simulation Optimization Requirements to meet targets to agreed future date Simulation Comprehensive Deployment Plan to Agreed Future Date

31 The analysis distinguished between the different types of response in terms of vehicles (ambulance, single response, etc) and skill type. It examined the catchment areas of each station, taking account of the different mobilization times for types of vehicle and time of day A station database was also compiled listing all facilities currently available to Metro Ambulance. Some of the key items on this list were the size, tenure and capacity of current response locations. 3.4 Modelling and Appraisal Model Set-up and Validation ORH s ambulance simulation was populated using parameters derived from the data analysis work. Analysis of the CAD data provided information about such factors as demand, call locations and job cycle times. Service data were also used to determine resource numbers, types, deployment locations, and dispatch times for model input ORH also developed a detailed travel time model of the Metro operational area using commercially available software calibrated against information on journey times from CAD data. To achieve this, the area was noded with key points in relation to the road network and incident distribution Travel times between nodes are a key model input and were assigned initially based on road classifications that differentiate achievable speeds in average traffic conditions. A careful calibration process was then undertaken that gave ambulance vehicle travel times reflecting lights-and-sirens and normal speeds, different speeds for different periods of the day, and distinguishing speeds by vehicle type The model was validated, by day and hour, by comparing model outputs, such as response performance (for the main dispatch codes), vehicle workload and hospital workload, to actual parameter values measured in the sample period data. Once validated, the model could then be used with confidence to explore the effects of changes in such factors as demand, deployment numbers and deployment locations. Modelling Scenarios Figure 3 illustrates the modelling steps taken and agreed with the Steering Committee for the review The model was validated to reflect the 2014 service profile, and initially this validated model was used to assess the impact of a range of operational measures aimed at improving the efficiency and effectiveness of provision Some further modelling was then undertaken using the 2015 base position (as there were a few deployment changes in moving from 2014 to 2015) An iterative series of simulation and optimization modelling runs were then undertaken, focusing first on the 2020 year, and then back to These modelling runs were geared to the shadow targets agreed with BCEHS and incorporated agreed efficiency measures.

32 Figure 4: Demand Profile Summaries Reported Incidents /Day Mainland Island Emergency Transfers Emergency Transfers Emergency Transfers DELTA /ECHO BRAVO /CHARLIE ALPHA /OMEGA OTHER RED YELLOW GREEN BLUE Emergency FRVAL SNDTC SDRB VANNS GRVIC Transfers FRVAL SNDTC SDRB VANNS GRVIC

33 8 4 CURRENT SERVICE 4.1 Demand The CAD sample for 2014 was analysed and a validation check made on the demand level measured for pre-hospital events. As Appendix A1a shows, there is close agreement between ORH s and the Service s measurement of demand levels by month and by main determinant, in both the Mainland and Island Metro districts An assigned incident is one in which a least one vehicle has been assigned; a responded incident is one in which at least one vehicle has arrived on scene. Appendix A1 focuses on responded incidents Appendix A1b summarizes demand in terms of responded incidents, separating emergency incidents (pre-hospital events) from transfers. The following can be noted: The categorization system for transfers moved completely from AMPDS to the 4-colour system from April 2014 onwards. On the Mainland, transfers account for 14% of demand, whereas for the Island this is just 7%. Overall monthly demand levels are fairly stable across Metro as a whole. Less than 0.5% of demand met by Metro resources originates in the Rural areas The average daily demand by district is summarized in Appendices A1c - A1ci for emergency demand and A1c-ii for transfers Appendix A1d illustrates the geographical distribution of Delta/Echo emergency demand by category over Incidents have been located on the nodes assigned across the area. The geographical pattern of other emergency categories is similar to that shown here for Delta/Echo Appendix A1e tabulates the distribution of transfer demand by origin hospital by category Red/Yellow/Green/Blue for the nine-month period April to December The overall hourly profile across Metro for emergency and transfer incidents that receive a response is shown at Appendix A1f. The demand rate ranges from 16 per hour in the early morning hours (between and 06.00) to about 50 per hour in the middle of the day (between and 15.00) A summary of the salient factors of the demand profile is given opposite in Figure 4.

34 Figure 5: Resourcing Summary Metro Operations Sites Stations 37 Cross Cover Points 36 Annexes 6 Total 79 Establishments Ambulances 121 Regular FT Staff 599 Irregular FT Staff 173 PT Staff 381 Deployed Hours per Week ALS Units 2,520 BLS Units 11,521 Tranfer Units 560 Total Units 14,601 Average Utilization ALS Units 30.5% BLS Units 52.1%

35 9 4.2 Resources There were 37 ambulance stations across Metro in 2014, together with one proposed station site at Waltham Burnaby. These are illustrated in Appendix A2a. In addition to station sites, there are 36 cross cover points (that are not stations) and 6 annex sites see Appendix A2b Appendix A2c shows that the following weekly deployment hours are planned: ALS units 2,520 vehicle hours; BLS units 11,521 vehicle hours; and Transfer units 560 vehicle hours A comparison between the hourly demand and resource deployment profiles is shown at Appendices A2d to A2d-i for weekdays, and A2d-ii for weekends (the weekend is defined here as Friday to Sunday 17.59) The vehicle mobilization geographical profile for emergency incidents is illustrated in Appendix A2e. In overall terms, vehicles are mobilized in the following proportions by location type: station 40%; cross cover point/standby 3%; annex 4%; hospital 4%; other (typically on the road) 49% Staff and vehicle establishments by station are summarized in Appendix A2f The average ALS unit utilization rate is 30.5% and for BLS units it is 52.1%. Utilized time here is measured from Time Mobile to Time Clear in response to incidents. It excludes time spent undertaking standby movements. The utilization rate takes this time as a percentage of time on shift A summary of the overall resourcing position is given in Figure 5 opposite. 4.3 Response Standards A validation check was made on ORH s calculation of response times (Call Answer to Arrive on Scene) to emergency incidents by comparing average achievement levels with BCEHS-produced statistics. This was done by month for Mainland and Island, and for grouping incidents into three categories Alpha/Omega, Bravo/Charlie and Delta/Echo. The results are shown in Appendix A3a. As can be seen, there is good agreement, although with ORH s measurements in general giving slightly higher values. The overall agreement for each paired category is within 10 seconds, but with Mainland Alpha/Omega differing by 17 seconds.

36 Figure 6: Performance Profile Summary ORH Calculation Emergency Incidents: Average Response Time (mins:secs) Alpha/Omega Bravo/Charlie Delta/Echo Metro Mainland 23:03 16:34 10:41 Metro Island 13:36 11:11 08:34 Metro Overall 21:28 15:48 10:24 Delta/Echo Incidents: Fraser Valley South Delta/Richmond/Burnaby Surrey/North Delta/Tricities Vancouver/North Shore Greater Victoria Overall Percentile Performance 9 minutes 15 minutes 41.1% 79.2% 45.8% 85.9% 41.1% 83.7% 67.1% 91.7% 66.2% 93.5% 51.3% 86.4% Transfer Performance (Metro-wide) Percentage arriving at destination hospital more than 30 minutes after 'appointment time' Red Transfers 12% Yellow Transfers 34%

37 BCEHS produces regular reports on Delta/Echo emergency response times. A breakdown of 9-minute and 15-minute percentile response performance for these calls is given at Appendix A3b. Metro-wide, the 9-minute response percentage for 2014 was 51.3%, and the 15-minute percentile 86.4%. Achievement levels are higher on the Island (13% of incidents) than on the Mainland. Delta/Echo response performance varies by district (A3c), with Vancouver/North Shore and Greater Victoria returning far better percentile achievements than the other three districts Appendix A3d sets out the response performance by the three paired AMPDS determinant categories, showing the cumulative distributions as well as a range of percentile points. Bravo/Charlie response performance is similar to all emergency response performance, with Delta/Echo better and Alpha/Omega worse Appendix A3e repeats the A3d profile for each of the five districts. Response performance is best in Greater Victoria and Vancouver/ North Shore Appendix A3f shows the hourly emergency response performance achievement by paired AMPDS category. It is notable that response performance does not vary significantly by hour of the day, though there is some evidence of a dip in response performance at shift change times (early morning and early evening) Appendix A3g illustrates the geographical profile of Delta/Echo incidents that received a response outside of the 9-minute threshold in Metro Mainland (A3g-i) and in Metro Island (A3g-ii) Transfer performance is analysed at Appendix A3h. Appendix A3h-i calculates the difference between time arrive at scene and time of actual pickup. In general, performance improves from Blue through to Red. The difference between time arrive at hospital and pickup time is shown at A3h-ii for Red and Yellow transfers; for Red transfers the 50 th percentile is between 10 and 20 minutes early, and for Yellow up to 10 minutes after the appointment time A summary of the response performance profile is given opposite in Figure First Responders Introduction It was agreed that ORH should undertake an analysis of First Responder (FR) activity across the same 2014 sample period as for Metro Ambulance. Seventeen Fire Services participated and returned activity data amounting to 90,486 records (see Figure 7 overleaf) across the varying time fields, as shown in Figure 8. A total of 88,690 of these records were linked to a BCEHS event number, giving an average of 243 FR responses per day A detailed report discussing the analysis of these data has been provided separately, so only a broad summary of the findings is given here.

38 Figure 7: Participating Fire Services - Records Received (2014) Fire Service Number of Records Number of Fire Halls City of Vancouver 35, Surrey 20, Richmond 6,067 7 Burnaby 5,644 7 Coquitlam 4,088 4 Delta 3,999 7 New Westminster 3,453 3 District of North Vancouver 2,383 7 Township of Langley 2,084 7 Port Coquitlam 1,986 2 Langley City 1,747 1 Maple Ridge 1,697 3 White Rock Port Moody City of Pitt Meadows Sechelt 24 1 Scotch Creek/Lee Creek 1 1 Total 90, Figure 8: Participating Fire Services - Time Fields Supplied Field Name City of Vancouver Coquitlam Langley Misc. Municipalities Port Moody Sechelt Burnaby New Westminster Richmond IncidentBeginTime P P P P P P P P DispatchTime P P P P P P P OnRouteTime P P P P P P P OnSceneTime P P P P P P P ReturnToServiceTime P P P P P P P Incident Date P P Commit Time P P First On Scene Time P P Incident End P P Dispatched First Unit Enroute Time First Unit Arrival Time Incident Close Time P P P P Delta Misc.Municipalities include City of Pitt Meadows, District of North Vancouver, Langley City, Maple Ridge, Port Coquitlam, Surrey and White Rock

39 11 First Responder Profile The average time occupied per day on FR activity was measured from the time of call contact to the time the unit left the scene. Across all the participating Fire Services this totaled 85 hours per day on average. This ranges from 0.16 hours for the City of Pitt Meadows Fire Service to hours for the City of Vancouver Fire Service FRs mobilize very quickly from the time notified by BCEHS an average of just 18 seconds across all incident types The overall average FR response time from time notified is 5:33 (minutes:seconds) with little variation between categories, although the responses to Delta/Echo incidents are almost always faster than for Bravo/Charlie (the exceptions are for Burnaby, North Vancouver and Richmond). There is significant variation between Fire Services in these average response times, although for the most acute Delta/Echo calls, the range is about 1.5 minutes between 4:14 and 5:48 if Langley and Pitt Meadows are excluded at 7:33 and 8:25 respectively FRs respond to scene from time notified within 9 minutes on 93.4% of occasions. FR and BCEHS Profile It takes an average of 2:30 (minutes:seconds) from BCEHS receiving a call to notifying the Fire Service (2:12 if times greater than 10 minutes are excluded) The FR arrives on scene before the BCAS ambulance on the vast majority of occasions 75.5% overall and by category: 72% for Delta/Echo (FRs respond to 83% of these incidents); 80% for Bravo/Charlie (FRs respond to 43%); and 87% for Alpha/Omega (FRs respond to only between 1% and 2%) The average time period ( backup ) for the BCAS unit to arrive after the FR on these occasions also varies by incident acuity: 4:37 for Delta/Echo; 9:23 for Bravo/Charlie; and 13:23 for Alpha/Omega The 9-minute FR response percentiles from BCAS Call Answer are: 80.3% for Delta/Echo; 72.8% for Bravo/Charlie; and 74.2% for Alpha/Omega In modelling options for Metro Ambulance Operations, there is naturally interest in how the FR waiting times can be reduced. If their response continues to be quick, this waiting time could only be reduced if BCEHS response times improve. If BCEHS were to notify FRs more quickly, this would tend to increase the FR waiting time.

40 Figure 9: Resource Use - Key Statistics Response Order ALS alone 2.5% BLS alone 81.0% ALS then BLS 5.6% BLS then ALS 8.2% Other 2.7% Multiple Attendance Rates Delta/Echo 1.44 Bravo/Charlie 1.11 Alpha/Omega 1.02 Overall 1.17 Conveyance Rates Delta/Echo 83.1% Bravo/Charlie 79.5% Alpha/Omega 81.8% Overall 80.5% RAP: Percentage of Incidents with Specified Response Hot Response 41.7% Cold Response 52.1% Appropriate for FR Response 28.7% HLA Response Required 20.6%

41 12 5 SERVICE APPRAISAL 5.1 Resource Use Vehicle workload summaries are presented at B1. Ninety-five percent of responses are made by BLS (82.2%) and ALS (12.9%) units see B1a-i. Transfer units are not used for emergency response and undertake 30% of transfers; BLS units do 66% of transfers (B1a-ii and B1a-iii) Multiple attendance ratios have been calculated by category of call see B1b. For emergency incidents the overall ratio is 1.17 (1.44 for Delta/Echo incidents), and for transfers 1.04 (1.05 for Delta/Echo and Red). The frequency of vehicle combination responses by category of emergency incident is shown at Appendix B1c. ALS units respond to 43% of Delta/Echo incidents, most often following a first response by a BLS unit (23%) Non-conveyance rates are summarized in Appendix B1d-i; for emergency incidents, 16.9% of Delta/Echo are not conveyed, 20.5% of Bravo/Charlie and 18.2% of Alpha/Omega. The overall non-conveyance rate for emergency incidents is 19.5%, and for transfers 4.2%. Some 8% of incidents are cancelled before a unit reaches the scene (see B1d-ii) Appendix B1e then breaks down the average time for all the different components of a response for the first vehicle on scene (B1e-i) and then separately for BLS (B1e-ii) and ALS (B1e-iii) An analysis of average time at scene is given in Appendix B1f. ALS units spend longer on the scene of an emergency incident than BLS units (18.5 minutes compared to 17 minutes) see B1f-i. Time at scene for transfers is longer than for emergency incidents (B1f-ii) Appendix B1g-i lists the receiving hospitals in Metro in order of volume. The average time at hospital is also shown in the last column. Appendices B1g-ii and B1g-iii tabulate the number and proportion of offload delays by hospital Appendix B1h examines some aspects of the Resource Allocation Plan (RAP). Just over half of emergency incidents require a cold response with 42% hot (see B1h-i), and 29% of emergency incidents assigned as being appropriate for a First Responder response (B1h-ii). One-fifth of incidents require higher skills ( HLA ) Appendix B1h-iii shows that 20.6% of responded emergency incidents require an HLA response and, of these, 24.6% receive a first response from an ALS unit. Also, 73.2% of emergency incidents require a BLS response and, of these, 95.4% receive a BLS unit as a first response The hourly utilization profile is shown by vehicle type in Appendix B1i: B1i-i BLS units 52.1% utilized; and B1i-ii ALS units 30.5% utilized. Utilization is calculated as the time occupied from Time Mobile to Time Arrive on Scene for responses (excluding standby moves), divided by total shift time A summary of some key resource use indicators is given in Figure 9 opposite.

42

43 Improving Efficiency Introduction The description of resource use above, together with the analysis of the current service profile in Section 4, suggests areas where operational efficiency can be improved. This assessment was also supported by benchmarking analysis of key service factors (not shown in detail in this report) to inform discussion with the BCEHS Steering Committee on potential efficiencies Candidates for potential efficiencies can then be taken forward in the modelling This sub-section considers the following aspects of operational provision in turn: assignment and chute times; time at scene and non-conveyance rates; time at hospital and offload delays; resource utilization and tiering; and resource/demand matching and shifts. Assignment and Chute Times The Assignment Time (or Activation Time) is the Time from Call Answer to Vehicle Assign; the Chute Time (or Mobilization Time) is the time from Vehicle Assign to Vehicle Mobile. Times currently achieved are shown in Appendix B1e as part of the overall call cycle time This review does not cover the control and dispatch function, but the activation time is a critical consideration in an operational review where the response time clock starts at Call Answer. ORH UK benchmarking for Ambulance Red calls (similar to D/E here) gives average activation times (from Call Answer) of between 01:15 and 02:00 (minutes:seconds). The average for D/E in Metro is 2:41. An improvement to these long activation times in Metro would improve the efficiency and effectiveness of cover Long activation times are likely to be due to a combination of pressures on operational resource availability and processing issues within Control. It is not possible without a quantitative understanding of the call handling and dispatch processes within Control to determine to what extent each of these is contributing to the long allocation times. However, there is evidence that even during the quietest hours of the night, when operational unit utilization is low, Control processing times are longer than they should be. There is therefore definitely potential for a systematic review of Control being able to identify both efficiency and effectiveness improvements. Such a review in the near future would be timely given the projected increase in demand (see Section 6) and the associated need to ensure that there is sufficient capacity in Control in future years.

44 Figure 10: Proposed Improvements in Activation and Mobilization Times Proposed Targets for Delta/Echo (*) CA-VA VA-VM CA-VM Year Mins:secs Seconds Mins:secs Seconds Mins:secs Seconds : : : : : : : : : : : : : : : : : : : : : Proposed Improvements (by mid-year) in seconds for Delta/Echo (*) CA-VA VA-VM CA-VM Year Year Cumulative Year Cumulative Year Cumulative CA-VA: Call Answer to Vehicle Assign = 'Activation Time' VA-VM: Vehicle Assign to Vehicle Mobile = 'Mobilization Time' (*) Commensurate improvements in all incident categories would be expected Current times are shown in the emboldened 2014 line

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