Emergency and Health Services Commission. Annual Report 2011/12. EHSC Annual Report 2011/12

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1 Emergency and Health Services Commission Annual Report 2011/12 1

2 Message from the Executive Message from the EHSC President and PHSA President and CEO We are pleased that 2011/12 was a year of success that can be credited to the closer alignment of the Emergency and Health Services Commission (EHSC) and its operating entities the BC Ambulance Service (BCAS), BC Bedline, and Trauma Services BC with the Provincial Health Services Authority (PHSA) and the provincial health care system. Together, we joined our services on a strategic and operational level to enhance pre-hospital care for British Columbians. We will continue to closely align EHSC with the health sector to actively pursue opportunities for innovation and improved patient care. We can be proud of a number of initiatives that have benefitted from our partnership including improved trauma bypass protocols and new station facilities for BCAS, increased transparency and accountability to the public via the Patient Care Quality Office, and more rigorous financial reporting and evaluation tools to enable better decision making. We are advancing the paramedic profession through the Resuscitation Outcomes Consortium research to develop best practices for care. The EHSC is also making great progress in its efforts to create a system for seamless inter-facility patient transfers across British Columbia. One other highlight includes the Quality and Patient Safety team s Patient Safety Huddles, which are further developing our culture of learning. Together, we will continue to thrive and support change that further integrates EHSC into PHSA and the health sector. By tapping into PHSA s insight, resources and talent, the list of successful initiatives will continue to grow. We look forward to a bright future together as we stand committed to providing the best possible pre-hospital care to help our communities be healthy and safe. Michael MacDougall EHSC President Lynda Cranston PHSA President and CEO

3 EHSC Overview The three agencies under the Emergency and Health Services Commission (EHSC), BC Bedline, Trauma Services BC, and BC Ambulance Service, provide both pre-hospital emergency services and inter-facility patient transfer coordination and transport services. The EHSC, established in 1974, carries out its legislated mandate in accordance with the Emergency and Health Services Act. In April 2011, the EHSC successfully transitioned to the Provincial Health Services Authority (PHSA). As outlined in the Organization Chart, a number of program areas and corporate services are direct components of the EHSC, including: Medical Programs; Quality, Safety, Risk Management and Accreditation; Communications; Finance; Human Resources; and Information Management.

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5 Contents BC Bedline Trauma Services BC BC Ambulance Service A Year in Transition Burns Lake Mill Explosion Quality, Safety, Risk Management and Accreditation Program EHSC Patient Care Quality Office eambulance Facility and Station Improvements Organizational Challenges Budget BCAS Services BCAS Stations Program Overview and Highlights 5

6 BC Bedline BC Bedline (BCBL) is a 24/7 provincial service that works with hospital physicians to ensure the timely transfer of acute care patients to another hospital with a higher level of care by: facilitating physician-to-physician conference calls; coordinating calls between physicians and specialist services; facilitating air or ground ambulance transport in partnership with BCAS; arranging transfer of patients back to their community hospitals; and coordinating interprovincial and international transfers when required. In 2011, BCBL facilitated 22,800 patient transfers; call volume has risen every year and doubled since Twenty call takers, nine support staff, four supervisors and one executive director coordinate the provincewide inter-facility patient system. BCBL coordinates the transfers and works closely with the Patient Transport Coordination Centre with BC Ambulance Service to arrange transportation for the patient. EHSC is building on the success of BCBL by establishing the provincial Patient Transfer Network (PTN) to strengthen coordination and collaboration with physicians and health authorities across the province. This is a key provincial initiative that will improve care and system benefits by establishing a one-stop-shop for all patient transfer coordination in B.C. Under the PTN, transfers for high level, critical care patients will be overseen and coordinated 24 hours a day under the supervision of a critical care specialist. The network will enable physicians in the health authorities to speak directly to a physician or critical care nurse at the network who will then directly coordinate the transfer planning and transportation including air ambulance support if required. Currently, health authorities contact BCBL for most high acuity patient transfers and alternate service providers for low acuity transfers. The PTN will be the lead agency to coordinate patient transfers for all acuity levels. The PTN will reduce duplication and ensure better coordination of patient transfer planning to ensure appropriate care across regions and the province. Improving transfers of patients is another important component of increasing the quality of care for British Columbians. The PTN will begin operations in Over the past year we have worked closely with the health authorities, BC Ambulance Service and other partners to plan for the Patient Transfer Network. Our goal is better coordination of services and improved communication between health professionals to ensure patients throughout B.C. receive the appropriate care at the appropriate facility in a more timely and efficient way. Kathy Steegstra, Executive Director, BC Bedline 6

7 Trauma Services BCes Trauma Services BC (TSBC) is the newest service within EHSC. In February 2012, the BC Trauma Advisory Committee transitioned from a long-standing working group to an agency under the EHSC and PHSA. The purpose of the new agency is to increase the quality of trauma care in B.C. by integrating trauma services throughout the province. TSBS will improve trauma care by maximizing efficiencies and sharing best practices throughout the provincial health care system. Our vision is to provide a high performing, comprehensive, integrated, and inclusive trauma system for B.C. TSBC will develop a coordinated inclusive network of trauma services across the province that not only integrates with health authority services while partnering with BCBL, EHSC Medical Programs, PHSA Mobile Medical Unit as well as transportation services offered by BCAS. We are a small team with a very big responsibility to work with health authorities and trauma specialists to improve trauma care through better integration across British Columbia. Trauma is the leading cause of death in the first four decades of life, therefore improving trauma services in B.C. is an important part of the overall health care system. Catherine Jones, Executive Director, Trauma Services BC 7

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10 BC Ambulance Service For 38 years, the core business of BC Ambulance Service has been providing patients across British Columbia with the highest quality emergency medical services possible. BCAS has evolved and responded to the changing needs of healthcare since its inception in Pioneers of BCAS, Dr. Peter Ransford and Mr. Carson Smith, instilled a culture of high quality patient care and operational efficiency that is alive and thriving to this day. Under the purview of the EHSC, BCAS provides ambulance service and inter-hospital transfer services for patients requiring a higher level of care. BCAS is proud to serve as the largest provider of emergency medical services in Canada and one of the largest in North America. BCAS responds to the needs of 4.4 million British Columbians and attends calls for service across six health authorities covering almost one million square kilometres. BCAS employs 4,017 individuals 3,668 paramedic and dispatch staff, 200 support staff and 149 management staff. BCAS operates from 184 ambulance stations and three dispatch centres. In 2011/12, BCAS paramedics responded by ground to 486,138 events 394,069 prehospital (9-1-1) events, and 92,069 inter-facility patient transfers. BCAS has a fleet of 559 vehicles, including 497 ambulances and 62 support vehicles. BCAS also has a fleet of ten dedicated ambulance aircraft that transported 7,732 patients in 2011/12. In August 2011, BCAS added a dedicated air ambulance helicopter to serve the Interior, based in Kamloops. BC Ambulance Service is undergoing a period of tremendous change following our closer alignment with the health care system in British Columbia. I m proud of our organization s renewed focus on patient care and on our staff; we are continually looking at ways to better serve our communities and support our front line personnel. There were many successes in 2011/12 as well as opportunities for us to learn and improve our service. Many of our staff go above and beyond the call of duty to provide the best care possible for patients, support their colleagues, and proudly play their part in the BC Ambulance Service. Les Fisher, Chief Operating Officer, BCAS 10

11 BCAS employs 4,017 individuals 3,668 paramedics 200 support staff 149 managers BCAS operates from 184 ambulance stations 3 dispatch centres 11

12 A Year of Transition In March 2010, the Province of British Columbia announced that the Emergency and Health Services Commission (EHSC), including BCAS, would transfer to become an administrative responsibility of the Provincial Health Services Authority (PHSA). Strengthening the relationship between the health authorities and EHSC will increase innovation in pre- hospital care and enhance the role of paramedics in the health care system, particularly in rural and remote communities. In 2011/12, the majority of corporate services completed the transition. BCAS Operations Restructuring In an effort to improve pre-hospital patient care, BCAS undertook a comprehensive, six-month review of service delivery throughout the province between August 2011 and February While examining BCAS s five different organizational regions, the review found operational and administrative differences and duplication of effort and resources. In March 2012, BCAS Operations was reorganized to provide a more standard, consistent provincial approach to patient care while still respecting local needs. The new structure is aimed at eliminating duplicated efforts and focusing resources on patient care and service delivery. The new structure emphasizes similarities in service delivery rather than being structured strictly according to geographic boundaries. The purpose of the organizational changes is to focus energy and resources where it matters most: patient care. Patient Care and Service Improvement Initiatives 2011/12 was a year of considerable growth: In August 2011, BCAS added a fourth dedicated helicopter and critical care team to the air ambulance fleet. Based in Kamloops, the service transitioned from being provided on a semidedicated basis to a permanent basis following a competitive bidding process to secure the contracted aircraft. BCAS s Critical Care Transport Program was expanded through the addition of a new ground bases in Langley and Nanaimo. The new teams primarily transport patients with life-threatening conditions who require constant monitoring and support from local hospitals to major medical centers. BCAS implemented the Early Fixed-Wing Activation Program in the Northwest whereby paramedics can reserve an air ambulance airplane based on their on-scene assessment of the patient. Previously, a physician would need to access the patient in hospital and then call an air ambulance. 12

13 This new process will reduce the time it takes to get a critically ill or injured patient to a higher level of care; the program will be expanded throughout the north in 2012/13. The Primary Response Unit (PRU) concept was adopted in the Lower Mainland on a permanent basis following several trials throughout the area. PRUs are a non-transport capable response unit that is staffed by a single advanced care paramedic. PRUs enable BCAS to provide a higher level of paramedic care to more people, helping to ensure we get the right care, to the right patient at the right time. BCAS paramedics are now embedded within the Vancouver Police Department s Integrated Tactical Safety Unit (ITSU) to support patient care at large public events. To reach a patient in distress in the midst of a crowd, the ITSU works its way through the attendees, locates the patient and forms a protected, safe workspace around the paramedic and patient. The unit is based on similar teams in the UK that respond to public safety incidents following football games. BCAS s extensive fleet operations experience and robust maintenance program has been expanded to include other areas of the provincial health care system. BCAS is now managing fleet services for Northern Health and PHSA and is assisting other Canadian EMS systems in developing similar fleet management programs. BCAS s provincial service delivery model and diverse operating conditions, enables ambulances to move throughout the system so each vehicle is utilized to its fullest extent. In Greater Victoria, the location of ambulance calls has changed over time and the current stand-alone station model wasn t providing the flexibility required to best serve the region. In 2013, paramedics will be deployed from a large central station and satellite locations throughout the region; the smaller stations can be more easily relocated to respond to changing demand and provide the fastest response for patients. The EHSC Billing department has been working diligently over the past number of years to decrease the time a patient receives ambulance service to when the invoice arrives in the mail. In 2012/13, the EHSC surpassed our service targets and will have 55 per cent of our invoices distributed within in 10 days and 90 per cent billable within 30 days. 13

14 Burns Lake Mill Explosion The EHSC was put to the test on January 20, 2012, following an explosion at Babine Forest Products sawmill, just outside of Burns Lake, on a night with some of the worst weather the area had seen all winter. Paramedics quickly responded in ambulances based in Burns Lake, Southside, Fraser Lake, Vanderhoof, Smithers, and Houston. BCAS established on site command and triage and patients were swiftly transported to the local hospital. BC Bedline and air ambulance support via the Critical Care Transport Program were also drawn into the event to transport injured patients to higher levels of care at facilities throughout the province. all communities; the dispatchers in all centres and BC Bedline call takers who coordinated the response and provided support in addition to the normal workload; the critical care paramedic crews who responded by both ground and air to provide their expertise; and the managers who responded and coordinated resources. Large scale incidents require an integrated response and meticulous coordination with many other agencies. As the incident unfolded, BCAS and BC Bedline worked in partnership with Northern Health, Vancouver Coastal Health Authority and others to ensure patients got the care they needed in a timely manner. The response was truly a team effort due to the vast number of personnel involved: the paramedics across the North who responded and maintained service in 14

15 Quality, Safety, Risk Management and Accreditation Programm The EHSC Quality, Safety, Risk Management and Accreditation program (QSRMA) supports and guides the provision of the best care possible by facilitating patient-centered improvement projects, reviewing patient safety events and coordinating systems-level changes to the pre-hospital care system. The QSRMA team works closely with all programs and the EHSC Executive, ensuring patient safety is at the forefront of organizational decision-making. QSRMA focuses on building a culture of safety. In 2011, QSRMA began paramedic Patient Safety Huddles - short, frequent informal forums for staff to talk about calls to raise awareness of patient safety issues. The huddles offer a transparent and blame-free opportunity for staff to share ideas and incorporate reporting of patient safety issues into daily work. The QSRMA program awards staff with Q Pins for embracing and promoting patient safety huddles, having a positive impact on patient safety, eliminating risks to patients by reporting near misses or good catches and by advocating for patients. QSRMA collaborates with the Patient Care Quality Office which provides a clear, consistent, timely and transparent process for patients and various healthcare partners to register compliments and complaints about patient care. The Risk Management Program works with EHSC leaders to identify and assess risks, develop and monitor mitigation strategies and manage pre-hospital event-related litigation activities include working with legal counsel and the BC Coroners Service. QSRMA also leads the EHSC in the strategic goal of achieving accredited status through Accreditation Canada. 15

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18 EHSC Patient Care Quality Office As part of its closer integration with the healthcare sector, the EHSC announced that as of April 1, 2011 the PHSA Patient Care Quality Office (PCQO) would expand to include the EHSC. The EHSC PCQO operates in keeping with the legislative requirements of the Patient Care Quality Review Board Act and the related ministerial directives. The PCQO ensures care quality complaints are managed consistently, responded to in a timely fashion and accounted for transparently. All health authorities in B.C. each have PCQOs and each are represented at a provincial table whose membership includes the Ministry of Health and the leads for the Patient Care Quality Review Board Secretariat. EHSC is represented by PHSA Patient Care Quality Offices Director. Between July 1, 2011 and June 30, 2012, the EHSC PCQO processed and responded to 160 compliments, 231 complaints and 1,312 requests for information or questions. The PCQO supports service improvements through feedback from patients and helps EHSC agencies achieve its mission to provide safe, reliable and efficient care. In addition to care quality complaints, compliments and requests for information, and by leveraging the PCQO s expertise and centralized system, patient safety events are now reported through the EHSC PCQO toll-free line. Events are triaged by the patient care quality officers and sent to the most appropriate handler via the Patient Safety Learning System (PSLS). 18

19 Medical Programs m Medical Programs provides the medical input, education and oversight to guide paramedics in the provision of quality patient care. Medical Programs integrates four major functions: physician oversight, quality improvement, clinical education and research. By integrating all functions, Medical Programs strives to provide the best support possible to paramedics to enable them to provide excellent patient care. Through Medical Programs, EHSC encourages a culture of continuous learning and improvement that emphasizes a commitment to patient care and safety as well as support for paramedics. EHSC Treatment Guidelines The EHSC Treatment Guidelines (TGs) are the medical resource documents that guide paramedic treatment in the province of BC. TGs are a combination of best practice and evidenced-based medicine designed to support paramedics in making informed decisions in the field. As scope of practice increases, the TGs represent an innovative way of thinking, using a principles based approach, to guide paramedics in their decisions providing the best, most appropriate care for their patients. The TG philosophy is based on the fundamental principle that patients will be transported to hospital and treated if necessary. It also is expected that pre-hospital care occurs within a framework of medical oversight and that there is an open dialogue between the clinical leaders in our organization and paramedics. In 2011/12, the TGs underwent a complete reformatting in an effort improve navigability and usability for paramedics and several new protocols were added. The first public iteration was produced and published on Medical Programs also worked to make the TGs available as a web application for mobile devices setting the stage for to be completed. Clinical Education In 2011/12, the EHSC Clinical Education department developed and delivered a number of courses to enhance paramedic practice in British Columbia: Domestic Violence Recognition for Paramedics course, developed for Toronto EMS by Sunnybrook Hospital, was provided to BCAS paramedics. The online course focused on best approaches specifically for paramedics as they come upon a potential domestic violence situation. A new course was created to inform paramedics about changes to legislation regarding advanced care directives and patient s rights related to confidentiality and informed consent. This course uses ambulance call scenarios to discuss the policies and practices that support professional paramedic practice and comply with the recent 19

20 changes including patient privacy, rights of refusal, protecting children and vulnerable adults and patients in custody. The department also completed the first phase of the paramedic profiling project which will help support recruitment and ongoing training. The initial phase focused on identifying key attributes of successful paramedics at the PCP and ACP license levels. Better understanding of these attributes will contribute to improving paramedic selection as well as focusing paramedic education. Clinical Education also adopted a core competency education model for paramedics that address the basic, life-threatening incidents faced by paramedics in the field: trauma, pediatric emergencies, cardiopulmonary arrest and airway emergencies. These Four Pillars of maintenance of competency education are addressed through delivery of internationally-recognized certification courses. Three of the four courses, Cardio Pulmonary Resuscitation, Pediatric Emergencies for Pre-Hospital Professionals, and Airway Interventions and Management in Emergencies, were delivered previously. In 2010/11, Clinical Education completed procurement of the fourth and final course, International Trauma Life Support (ITLS) and initiated the process to become a Chapter of the ITLS, a global organization dedicated to preventing death and disability from trauma through education and emergency trauma care. ITLS is accepted internationally as the standard training course for pre-hospital trauma. These four courses represent the global standard in emergency prehospital care and provide certification upon successful completion. The EHSC courses will rotate every two years ensuring the maintenance of an accepted standard of care for these major life threatening challenges faced by paramedics in the field. Clinical Education also initiated a pilot program to explore the use of simulations in rural education programs. This program focused on small group simulations coupled with physician feedback and discussion. As a result of this program, an ongoing simulation strategy is being created. Developed by ACP paramedics for ACP paramedics, with the participation of physicians as instructors and mentors and ACP simulator operators, advanced care simulation continuing education sessions were held in the ACP centres across B.C. Resuscitation Outcomes Consortium The Resuscitation Outcomes Consortium (ROC) is a clinical trial network focusing on research in the area of pre-hospital cardiopulmonary arrest and severe traumatic injury. Other EMS agencies from across North America are working with ROC to complete clinical trials for pre-hospital cardiopulmonary arrest and severe traumatic injury. ROC is the first large-scale effort to conduct clinical trials that focus on the very early delivery of interventions by EMS teams to better optimize patient survival. The ROC office provides BCAS with the infrastructure and project support for clinical trials and other outcomeoriented research that will rapidly lead to evidencebased change to enhance clinical practice. Together, BCAS and the ROC office are conducting clinical trials that focus on the very early delivery of interventions by EMS teams to better optimize patient survival. In 2011/12, the EHSC was involved in two clinical trials. One of these trials compares the Continuous Chest Compression (CCC) to 30:2 (compression to ventilation ratio) CPR methods to determine which specific form improves patient outcomes. If CCC CPR improves survival compared to 30:2, then paramedics will be able to follow a much simpler treatment. Paramedics in all metropolitan areas are participating in this study. For trauma patients, there are no valid and reliable clinical indicators in the pre-hospital setting that help identify which injured patients require rapid surgical interventions or resuscitation. Bio Lactate in Shock Trauma (BLAST) is a simple study intended to determine if blood lactate readings taken in the pre-hospital setting predict the need for in hospital interventions. BLAST is the second clinical trial involving EHSC. Data collected through the research partnership between the ROC and EHSC has resulted in 11 20

21 publications in peer reviewed journals, including publications in the New England Journal of Medicine. EHSC investigators continue to be actively involved in publishing research in top tier medical journals. EHSC also partners with academics and graduate students throughout British Columbia. During 2011/12, seven such research partnerships were completed or ongoing. These studies involved such diverse topics as cardiovascular health risks associated with paramedic occupational exposures, workplace stress and coping, out of hospital midwifery practice, and studies of the perceptions of patient safety among paramedics. First Responder Program AED in conjunction with BCAS paramedics. In small communities, volunteer fire fighters most often provide FR services; in medium and large communities, career fire fighters most often provide FR services for the public. Participation in the FR program is voluntary. The EHSC oversees the FR Program in British Columbia and is responsible for ensuring all participants in the program have signed consent agreements and stay within the scope of practice of FRs. There are approximately 6,500 FRs in B.C. and each holds an Emergency Medical Assistant First Responder (EMA- FR) license issued by the provincial Emergency Medical Assistants Licensing Board. First Responders (FRs) are an important part of prehospital care in B.C.; they provide basic first aid such as control of potentially fatal bleeding, CPR and 21

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23 eambulance The eambulance concept began with a vision in 2010 to create a mobile communications unit by incorporating updated medical technology supported by a secure wireless network in ambulances and stations throughout the province. The eambulance system enables immediate and secure transmission of dispatch information to paramedics enroute to a call and patient care information from paramedics to health authorities while enroute to hospital. There are three essential components of the eambulance system. In-Vehicle Gateway (IVG) IVG provides secure mobile network connectivity that can be used by multiple ambulance-based systems by establishing: a secure Local Area Network (LAN) that connects devices within and around an ambulance using Ethernet or Wi-Fi, a secure Wide Area Network (WAN) connectivity to provincial networks using cellular network technology while the ambulance is in motion, Wi-Fi connectivity while the ambulance is at the station, and GPS coordinates for dissemination to local and remote devices. IVG allows BCAS to utilize communications technology that isn t dependent on any one commercial cellular carrier, uses multiple wireless and cellular technology solutions and is scalable for easy readability on mobile devices. IVG enables connections to a variety of electronic devices including in-vehicle computers, portable computer/tablet devices and medical devices such as ECG monitors. IVG is being deployed in 2012/13 to support the MobileCAD and epcr systems (below). Mobile Computer Aided Dispatch (MobileCAD) MobileCAD is a computer in the cab of BCAS ambulances that connects with the CAD system in all three BCAS dispatch centres. MobileCAD allows paramedics in the ambulance to receive pre-hospital event assignments and updates from dispatch and send back status code updates to dispatch in real time via a touch-screen computer. In addition to event information, MobileCAD also provides paramedics with maps and routing information. MobileCAD communicates with the CAD via the IVG network. Phase one of the Mobile CAD implementation was complete in 2011/12 with installation in 258 ambulances. Implementation in remaining ambulances is planned for 2012/13 and 2013/14. 23

24 Many benefits are already being realized from the implementation of MobileCAD, such as: Improved timeliness and quality of event information for both paramedics and dispatchers; Improved presentation of event-related data; Up-to-date map and routing information available and; Reduced radio traffic radio traffic in the Lower Mainland has been reduced by 65 per cent. epcr Electronic Patient Care Record (epcr) system replaces BCAS s current paper-based electronic PCRs which are completed following each call paramedics respond to and scanned into the database at the ambulance station. This is a significant step towards replacing the manual Patient Care Report documentation and beginning the electronic health record. Paramedics will use 460 hand-held devices to complete and upload the epcrs remotely. Receiving hospitals will have up-to-date care information, such as vital signs, medicines and procedures administered when a patient handover to emergency department occurs, BCAS will be able to accurately report on patient care allowing trends to be identified and finding opportunities to enhance patient care; and, Realize increased operational efficiency and security due to less typing and no manual scanning. Implementation of all in-vehicle technology requires coordination of many logistics including technology installations, training of 3,600 staff and excellent internal communication to ensure that the ambulance service operations is not negatively impacted. When the epcr system is implemented in Fall 2013, paramedics will be able to collect and input data into the epcr system in real time and upload the patient s information for staff to use in the hospitals through the provincial ehealth Viewer. Each of BCAS s 460 epcr devices will be equipped with Bluetooth and WiFi, camera, bar code reader, magnetic strip reader for gathering driver licence and care card information directly and a LifePak adapter enabling uploads of patient defibrillator data. epcr ambulance network capability and safe stowage for epcr will be installed for use in ground and air ambulances by June For epcr, the benefits are patient-care focussed; when implemented, sharing patient information between health care providers and BCAS will be secure, seamless and timely: 24

25 Facility and Station Improvements The EHSC is in the midst of a multi-year strategy to improve ambulance stations and other facilities throughout the province. In 2011/12, the EHSC spent $7.9 million on the following projects: undertaking maintenance and repair work, heating, ventilation and air conditioning upgrades and replacing of broken or worn-out furniture at 160 stations ($6.1 million); and constructing new stations in Winlaw, on Quadra, Denman and Saltspring Islands and significantly renovating the Rutland station in Kelowna ($1.8 million). In 2012/13, the EHSC Facilities Department will be focussed on: planning for new stations in Richmond, Oceanside, New Westminster and Burnaby; and sourcing district manager offices in areas throughout the province. BCAS is continuing a relatively new initiative of utilizing modular structures for the construction of new ambulance stations in a cost-effective approach to providing quality crew quarters. A modular structure, such as the one in Winlaw, is approximately one third of the cost to construct versus the cost of a purposebuilt ambulance station such as one recently built in Revelstoke. This ongoing commitment directly impacts the patients who are served by BCAS and the paramedics who provide this care on a daily basis. completing HVAC upgrades in the remaining facilities; finding and constructing new facilities or renovating existing facilities for stations in Southside/Grassy Plains, North Vancouver, Coquitlam, West Shore, Fernie, Riondel, Bowser, Victoria, Vancouver Island and Kamloops dispatch centres, Vancouver administrative office, and Saanichton provincial head office; 25

26 Organizational Challenges There are several ongoing challenges that the EHSC and BCAS are working to address: Problem STRATEGY Increasing paramedic workload, particularly in the Lower Mainland Recruitment in remote communities Strategic hiring practices, engaging community leaders and expanding paramedic roles in the community health care system Recruitment in dispatch centres Strategic hiring practices, public education about the important role of dispatchers within the pre-hospital system and engagement of social media, partnering with local governments 26

27 Budget The 2011/12 budget for EHSC was $317 million. Of this amount, the majority ($242 million) related to BCAS as follows: Lower Mainland Ground Operations: $77.9 million Other Ground Operations: $88.8 million Other major EHSC program budgets include: BC Bedline: $2.5 million Trauma Services BC: $2 million Medical Oversight and Clinical Education: $5.1 million Provincial Programs: $73.4 million Service Delivery (Dispatch): $20.3 million BCAS estimated revenue recoveries from interfacility transfers at $21.8 million 27

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30 BCAS Services Ground Ambulance BCAS responds to patients using two main types of pre-hospital emergency medical service: Basic Life Support (BLS) and Advanced Life Support (ALS). The most common ambulance service provided by BCAS is BLS; these paramedic crews are responsible for providing care for medical emergencies and traumatic injuries and are composed of Emergency Medical Responders (EMRs) and Primary Care Paramedics (PCPs). BCAS employs some EMRs on an on-call, parttime basis but the majority of paramedics working across B.C. are employed as PCPs - working in both full-time and part-time positions in rural and larger communities. When more advanced care is required, BLS paramedic crews can be supported by ALS paramedic crews. ALS ambulances are staffed by Advanced Care Paramedics (ACPs) who receive additional training which enables them to perform more advanced emergency care procedures and a higher level of patient care. Service Delivery BCAS s Service Delivery program assesses, prioritizes and coordinates ground ambulance responses from three separate but integrated dispatch centres in Kamloops, Victoria and Vancouver. Service Delivery also incorporates dispatch training, development and quality improvement areas. Together, the three centres dispatched ground ambulances to 486,000 events in 2011/12 throughout the province. When a request for service is received, Service Delivery ensures that there is a timely, efficient and appropriate response of ambulances, paramedics and other resources to emergency calls. The centres are also responsible for ensuring appropriate resources are allocated and maintaining operational readiness for all areas of B.C. On April 11, 2012 the BCAS Patient Transport Coordination Centre (PTCC) was established; prior to this the three dispatch centres operated independently when coordinating inter-facility patient transfers and air coordination was managed by a Provincial Air Ambulance Coordination Centre (PAACC) which worked independently of the other dispatch centres in managing air and critical care coordination for the province. The PTCC was created to allow a central coordination centre to handle all requests, both ground and air, for transfers. At the PTCC, each call taker s sole responsibility is coordinating inter-facility patient transfers; the staff are able to fully focus 30

31 on the complexities of coordinating inter-facility transfers within the geographical challenges of B.C. Consolidating this business area allows for focus and efficiencies in inter-facility transfers while allowing the ground ambulance dispatchers to focus on the critical pre-hospital emergency calls. The PTCC has improved coordination between BCAS and BC Bedline, improving operational efficiencies. In the future, the Patient Transfer Network will be located alongside the PTCC to further enhance the provincial inter-facility patient transfer service and provide improved support for the health care system and patients. BCAS s inter-facility patient transfer service complements a number of other patient transfer operations used by health authorities to provide nonmedical patient transfers for stable patients who do not require the skills of a paramedic during transport. Provincially, BCAS s dispatch centres manage, on average, three million telephone calls a year. 31

32 Statistics 486,000 ground events throughout the province 394,000 pre-hospital (9-1-1) events 92,000 inter-facility patient transfers 32

33 Pre-hospital events include all calls for pre-hospital care both low acuity and high acuity lights and siren emergencies and routine calls. Approximately 1/3 of BCAS s calls are high acuity lights and siren calls, 1/3 are low acuity routine calls and 1/3 are inter-facility patient transfers. Historical Provincial Event Volumes 33

34 BCAS Stations In 2011/12, BCAS operated from 184 ambulance stations plus additional facilities: Provincial headquarters in Victoria Three Dispatch Operations Centers (Victoria, Vancouver and Kamloops) Four Administrative Offices (Victoria, Vancouver, Kamloops, and Prince George) 10 local offices for District Managers (Campbell River, Castlegar, Chilliwack, Cranbrook, Dawson Creek, Kelowna, Parksville, Smithers, Kelowna airport and Vancouver airport). Station Designation BCAS ambulance stations are classified as metropolitan, urban, rural or remote. Station classification is dependent on call volumes, geography, remoteness, proximity to other ambulance stations and health authority designation of facilities that are in the area. stand-by at the station ready to respond. When they respond to a call, they are paid their full hourly wage for three hours. Sixty-five remote stations are staffed similar to volunteer fire departments where paramedics are called to respond by pager from the community. When on-call, paramedics receive a stipend to be available and their full hourly rate for four hours when responding to a call. BCAS Fleet BCAS utilizes ground ambulances, supervisory support vehicles and a fleet of Gators and bicycles to respond to events across B.C. In 2011/12, BCAS added 22 ground ambulances to the fleet as medical support units for major incident responses, Gators for special event response and training vehicles. Thirty-six metropolitan stations are staffed 24 hours per day by full-time paramedic crews. Thirty-five urban stations are also staffed 24 hours a day using a combination of full-time staff and paramedics working standby shifts. Forty-eight rural stations are staffed using a stand-by model, where paramedics are paid a reduced rate to 34

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36 Program Overview and Highlights Critical Care Transport Program BCAS utilizes Critical Care Transport (CCT) paramedics to provide highly-specialized emergency care and long-distance transport between health facilities for critically ill or injured patients. BCAS is one of only two ambulance services in Canada utilizing critical care paramedics. The CCT Program in B.C. essentially brings an intensive care unit to the patient and allows physicians and nurses to remain in their local hospitals. In this model, highly-trained paramedics with specialized equipment and knowledge of the various transport environments, provide safe, effective and efficient patient transfer services. CCT paramedics perform advanced medical interventions and work with sophisticated monitoring and ventilation equipment while enroute. The CCT program also relies on the expertise of critical care (physician) transport advisors for its functional medical oversight process. Paramedics in BCAS s CCT program work in specially-configured ambulances and utilize six dedicated airplanes, four helicopters and can call on approximately 40 pre-qualified charter aircraft across the province when required. Critical care paramedics are deployed from air bases and stations in Prince George, Richmond, Kelowna and Kamloops, Nanaimo, Langley and Vancouver; the team based in Langley was added in 2012, the Nanaimo-based team was added in Requests for fixed and rotary-wing air ambulance, neonatal, maternal and paediatric transfer services are processed through the Patient Transfer Coordination Centre based in Vancouver. BCAS has two distinct protocols in place to ensure that aircraft are deployed and available when required to respond to a patient with an acute illness or injury. Autolaunch is the simultaneous dispatch of both ground and air ambulances for specific emergency situations based on information provided from the scene by callers. This protocol helps ensure that patients with life-threatening injuries are transported to a trauma centre as quickly as possible. The Early Fixed-Wing Activation Program enables responding paramedics at the scene to determine if the patient may need to be airlifted to an acute care hospital. They will activate the critical care transport (CCT) paramedics and aircraft to begin preparing for the emergency flight right away. Previously, only a hospital physician would have been able to activate the CCT team. 36

37 Air Ambulance Call Volume and Gators also provide contracted paramedic services at major public and international events, professional sporting events, movie sets and community fairs when not otherwise needed. Emergency Management Infant Transport Team BCAS s Infant Transport Team (ITT) paramedics provide emergency medical care to B.C. paediatric, neo-natal and high-risk obstetrics patients while en-route to specialized care units in hospitals. Based at BC Children s Hospital, these specialized paramedics are required to complete a specific training program focussing on providing care to children, and the advanced skills specific to those patients. ITT paramedics liaise with specialist physicians who provide support and guidance. Special Operations In 1992, BCAS was one of the first North American Emergency Medical Services agencies to organize and deploy a Special Operations team of paramedics on bicycles for major public events where crowds can limit access and speed of response for normal ambulance vehicles. The primary objective of BCAS s Special Operations is to provide rapid response care through congested areas allowing paramedics to arrive at the patient s side faster than a traditional ambulance vehicle. BCAS s paramedic bike squads are also supplemented by two Gators purchased to support ambulance coverage during peak crowd times. Gators are specialized all terrain vehicles that are used to transport patients from on scene to the ambulance, in situations where the ambulance is unable to reach the patient due to ground conditions. The bike squad BCAS actively participates in emergency planning, mock disaster exercises and other joint training initiatives with other emergency management organizations to ensure disaster preparedness and response capabilities are identified and deployed quickly and effectively when they are needed most. To ensure paramedics are prepared to respond to and recover from major emergencies, BCAS is a strategic partner with the Province-wide Emergency Management Office (EMO). Based in Vancouver, the EMO provides provincial oversight and direction in the planning of multicasualty incidents, major emergency situations that involve multiple patients at one scene. The team also provides guidance in the areas of hazard recognition and risk assessment by identifying and documenting the hazards that pose the greatest threat at the station, regional and provincial levels and developing strategies to manage these risks. In addition, the EMO provides direction and advice regarding major incident support and hazardous substance and Chemical, Biological, Radiological, Nuclear and Explosive response. Public Outreach Vital Link and Good Samaritan Award Program Support provided by quick-thinking members of the public can often mean the difference between life and death for patients. Whether performing bystander CPR, providing critical information to dispatchers or assisting paramedics on scene, British Columbians are an important link in the health care system. To recognize the significant contributions made by citizens during medical emergencies, BCAS supports two community award programs: the Vital Link Award and the Good Samaritan Award. The Vital Link Award is presented to citizens who are involved in saving a 37

38 life through successful cardio-pulmonary resuscitation (CPR) efforts. The Good Samaritan Award is presented to individuals who have provided unselfish and humanitarian assistance during a medical emergency. It is BCAS s hope that by recognizing contributions and reinforcing the importance of bystander support, similar behaviour will be encouraged. ACT High School CPR Program Cardiovascular disease is the second leading cause of death in B.C., accounting for more than one-fifth of all deaths in the province. Since 2005, BCAS has worked in partnership with the ACT Foundation to ensure that students in B.C. are becoming well-versed in this lifesaving skill through the ACT High School CPR Program. Through this partnership, over 40,000 high school students in British Columbia receive training in CPR each year. Research shows that a cardiac arrest victim is four times more likely to survive if CPR is administered by a bystander while paramedics are enroute to the scene. With most out-of-hospital cardiac arrests occurring at home, early recognition of a cardiac emergency by a family member, early access to medical help (calling 9-1-1) and early citizen CPR are critical to saving lives. P.A.R.T.Y. Program Together with local partners, BCAS is helping to educate B.C. youth about how to stay safe through the P.A.R.T.Y. Program (Prevent Alcohol and Risk-Related Trauma in Youth). P.A.R.T.Y. is a one-day, in-hospital, injury awareness and prevention program designed to reduce death and injury due to alcohol, drug and risk-related behaviours. Open to students ages 16 and older, participants follow the path of a trauma patient from the time of injury until discharged from hospital. During these sessions, paramedics hold a mock-crash demonstration and describe in detail the process they go through when they attend a serious motor vehicle collision. The program is structured to bring them face to face with the consequences of risky behaviour. 38

39 Community Support Many paramedics throughout B.C. play prominent roles in their communities by volunteering and fundraising for many non-profit and charitable organizations, participating in blood and food drives, travelling to other countries for disaster relief support, 9/11 memorials and coaching sport teams. Partnerships Shuswap Lake BCAS responds to many calls in the summer due to the popularity of houseboats in the summer. Working with the volunteer society, Coast Guard Auxiliary, Emergency Management BC and the Columbia-Shuswap Regional District, BCAS is part of a multi-agency partnership that greatly increases public safety and emergency patient care. Heavy Urban Search and Rescue Teams BCAS is included in a Vancouver-based team that locates people entrapped following a disaster. HUSAR includes search, medical and structural assessment capacity. Integrated Tactical Safety Unit Based in Vancouver and developed along England s model of tending to patients in a soccer riot, the Vancouver Police Department officers work their way through a crowded event to form a line and create a safe workspace for BCAS paramedics to attend to patients. Patients are then rushed from the scene to a staging area that ambulances and Gators could access and then to hospital. Fees BCAS fees are heavily subsidized for persons with a valid BC Care Card and who are covered by the provincial Medical Services Plan (MSP). The ambulance service fee for MSP beneficiaries is $80. Fees are not an insured benefit under MSP or the Canada Health Act. Further information on ambulance fees in B.C. is available at 39

40 Trauma Services BC A program of the Provincial Health Services Authority 40