Message from the executive 05 bcehs overview 07 BC patient transfer network 07 Trauma services bc 08. program overview and highlights 18

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3 Contents Message from the executive 05 bcehs overview 07 BC patient transfer network 07 Trauma services bc 08 BC Ambulance Service 11 program overview and highlights 18 medical programs 21 quality, safety, Risk management and accreditation program 23 bcehs patient care quality office 23 information management/ information technology 24 human resources 25 communications 26 organizational challenges 28 budget 29 public outreach 31 fees 32

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5 Message from the Executive This fiscal year has been one of change, challenge and accomplishment. One of the biggest changes has been passage of the legislation enabling BC Emergency Health Services to become officially aligned with the Provincial Health Services Authority (PHSA). Together, we will focus our energies on improving patient care. In fact, we have already started on a number of changes in that regard: Creation of the Patient Transfer Network: This coordinated approach improves the inter-facility transfer process to ensure patients throughout the province receive the appropriate care at the appropriate facility in a timely, efficient way by working collaboratively across all health authorities. Introduction of Emergency Physician Online Support: This real-time clinical support provides BCAS ground paramedics with 24/7 rapid access to consultation with an emergency physician. Paramedics will select the appropriate pre-programmed toll-free number on their cell phone to connect with a either a Primary Response Physician (PRP) during events or an Emergency Transfer Physician (ETP) during inter-facility transfers. Pursuit of excellence: Accreditation is a key marker of excellence in today s world. We have started Accreditation Canada s Q-Mentum process, which is designed to help emergency medical service agencies increase performance, accountability and efficiency, increase clinical quality and decrease risk. The accreditation process provides a template for organizations to improve their overall performance. The coming fiscal year is full of promise for the dedicated employees of BCEHS and the patients we serve. We will work to maintain the momentum we have developed as we continue our alignment with PHSA and the health sector. Carl Roy Interim President, BC Emergency Health Services 5

6 The three agencies under the BC Emergency Health Services (BCEHS) - the BC Patient Transfer Network, Trauma Services BC and BC Ambulance Service - provide both pre-hospital emergency medical services and inter-facility patient transfer coordination and transport services.

7 BCEHS Overview The three agencies under the BC Emergency Health Services (BCEHS) the BC Patient Transfer Network, Trauma Services BC and BC Ambulance Service provide both pre-hospital emergency medical services and inter-facility patient transfer coordination and transport services. BCEHS, previously the Emergency and Health Services Commission, was established in 1974 and carries out its legislated mandate in accordance with the Emergency Health Services Act. On March 14, 2012, the provincial government passed the Emergency and Health Services Amendment Act, officially aligning the newly-named BCEHS with the health sector and the Provincial Health Services Authority. As outlined in the BCEHS organization chart, a number of program areas and corporate services are direct components of the BCEHS, including: Medical Programs; Quality, Safety, Risk Management and Accreditation; Communications; Finance; Human Resources; and Information Management. BC Ambulance Service, the BC Patient Transfer Network and Trauma Services BC are the organization s operating entities. BC Patient Transfer Network On April 1, 2013, BC Bedline transitioned to become the BC Patient Transfer Network (BCPTN) - a 24/7 provincial service that works with hospital physicians to ensure the timely transfer of acute care patients between health care facility by: Facilitating physician-to-physician conference calls; Coordinating calls between physicians and specialist services; Facilitating air or ground ambulance transport in partnership with BC Ambulance Service; Arranging transfer of patients back to their community hospitals; and Coordinating interprovincial and international transfers when required. The BCPTN expands on the previous services offered by BC Bedline by increasing the clinical oversight involved in patient transfer planning. BCPTN features registered nurses that provide medical advice when coordinating high acuity/ complex patient transfers as well as access to emergency transfer physicians and other specialists when needed. A new triage process ensures patient transfer coordinators connect sending and receiving physicians as quickly as possible while linking in other appropriate resources as required. The BCPTN is being phased in and the goal is that it will eventually serve every health authority-operated facilities in the coordination of all inter-facility transfers within BC, the repatriation of BC residents, and movements of BC patients out-of-province where required. BCPTN will manage and report on transfers of all acuities involving costs to the provincial healthcare system, namely BC Ambulance Service or contracted Alternate Service Provider transport companies, plus the repatriation of patients thus moved. In 2012/13, BC Bedline/BCPTN received 25,355 transfer requests, and 24,488 of these cases resulted in patient transfers to another facility. Once the BCPTN is fully implemented it will feature: BCEHS Emergency Transfer Physicians - these independent physicians will act as the ultimate owners of all transfer plans. For the most complex transfer requests, they will work with sending and receiving physicians to enable patient handover and establish the patient s clinical care requirements during transport. They will act as an escalation route for any patient transfer. 7

8 Clinical Transfer Nurses these registered nurses will manage the patient transfers, reducing patient risks by providing clinical oversight to the transfer planning process. They will also act as the escalation route for low acuity transfers. A single telephone number for all transfer requests - a centralized triage process will ensure all requests are recorded, tracked and allocated to the correct level of clinical oversight. Structured transfer planning process - a standard approach to determining patient needs and developing the appropriate transfer plan will result in a faster planning process. Clear ownership of the transfer plan, coupled with a new mechanism for setting transfer priority, will eliminate confusion. Clear communication of plans to facilities will support care planning. Integrated repatriation planning - developing repatriation plans early will assist with setting expectations about transfer timelines. Regular monitoring of patient status and communication of repatriation plans will assist facilities in planning for patient return. Patient flow coordination - facilities will provide daily updates on bed occupancy vs. acuity of patient to help identify patient flow priorities and enable updates to repatriation plans to be clearly communicated. This will be a structured data collection and communication process and the collated provincial picture will inform transfer planning processes. Trauma Services BC During 2012/13, our first full year of service, Trauma Services BC (TSBC) put the services, personnel and strategic direction in place to begin realizing our vision for a high-performing, standardized, comprehensive, integrated and inclusive trauma/injury system for BC. TSBC leaders and council members include: BC Patient Transfer Network; BC Emergency Health Services Medical Programs; Provincial Health Services Authority Mobile Medical Unit; and other ad hoc members to support key initiatives. administrative and medical directors of trauma from each of the health authorities; BC Ambulance Service representatives from both air and ground services; 8

9 TSBC has focused on key changes to trauma care both nationally and provincially, specifically: Improving data collection - The inclusion of more sources of data in the BC Trauma Registry will better quantify the breadth of traumatic injury in BC which will provide a more accurate picture of the burden on injury on provincial health care services. Pilot a process to establish a provincial plan of standardized care (clinical practice guidelines) and transport destinations for specialized trauma patients. The newly-formed Provincial Burns Working Group are working to identify benchmark burn care protocols and to create a provincial burn program. Trauma destination protocols define which hospitals are best equipped to handle certain levels of trauma patient injuries sustained. Research indicates that some types of traumas have better outcomes when taken directly to Level I or Level II Trauma centres rather than after referral from a lower level facility. These destination decisions will align with policies of the BC Provincial Transfer Network and BC Ambulance Service to ensure the patient is transported to the facility that can provide the most appropriate care as soon as possible. TSBC is also working to improve clinical support for rural health care facilities for critical trauma patients. BC Telemedicine is an innovative solution whereby the excellence of care brought by expertise provided at designated trauma centers centres can be supported via video feed, supporting the practitioners at rural hospitals. In addition, a new partnership between the Trauma Association of Canada and Accreditation Canada has been formed, aimed at creating a trauma distinction program within the accreditation process. This work will significantly impact TSBC by developing provincial data collection metrics and standards that will form the basis of a truly provincial trauma care standard and system design. Trauma care in BC has matured from a set of disparate site-based protocols for severe injury, to regionalized efforts at coordination to a new provincial trauma coordinating office and leadership over this past year. Despite the progress over the past 25 years of trauma care in BC, there is still more to be accomplished in the areas of injury prevention, rehabilitation, burn care, and overall integration. TSBC will continue to have a leadership role in improving trauma care for patients across B.C. 9

10 Responses to ground and air ambulance events are coordinated through dispatch centres in VANCOUVER, VICTORIA & KAMLOOPS BCAS covers the 944,700 square kilometres of the province of British Columbia with a ground fleet of 562 vehicles ambulances & 62 support vehicles. In 2012/13, BCAS employs 4,396 staff - 3,808 paramedics and dispatchers and 588 clinical management and support personnel. In 2012/13, BCAS responded to an average of 56 events per hour throughout the province. 413,123 pre-hospital (911) events: through dispatchers, dispatch staff and paramedics, expert patient care is delivered from the time a call for help is placed to 911 to treatment at the scene and trasport to hospital; 90,920 inter-facility transfers: BCAS ensures that patients are closely monitored while enroute to a medical facility that is equipped to meet their needs; and, 6,700 air ambulance calls In 2012/13, BCAS resonded to more than 504,000 events throughout the province. An ambulance is dispatched to an emergency call nearly every minute, of every hour, in British Columbia. BCAS s ground ambulance fleet travels more than 20,200,00 kilometers every year - equivalent to more than 500x around the world.

11 BC Ambulance Service For 39 years, BC Ambulance Service (BCAS) has been providing patients throughout BC with safe, high quality, emergency medical and interfacility transfer services. 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. Patient Care and Service Improvement Initiatives A number of operational enhancements were undertaken in 2012/13: The BCAS Patient Transport Coordination Centre goes live, operating out of the Vancouver Dispatch Operations Centre. The PTCC coordinates all inter-facility transfers, both ground and air, for patients throughout British Columbia. Centralizing all transfer dispatch services enables the other three ambulance communication centres to focus exclusively on calls and co-locates the transfer planning at BCPTN with ambulance dispatch operations. BCAS Dispatch Operations Centres began the Race to ACE, a process to become an Accredited Centre of Excellence (ACE) by the International Academy of Emergency Dispatch (IAED). Only 80 emergency dispatch centres in the world have achieved this level of accreditation. The aim is for BCAS Dispatch Operations to be accredited by the end of 2013/14. BCAS expanded the Early Fixed-Wing Activation Program throughout the north following a successful pilot in the Terrace area in 2011/12. The program enables paramedics to 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. This new process reduces the time it takes to get a critically ill or injured patient to a higher level of care. BCAS joins the Heart and Stroke Foundation BC & Yukon and the provincial government in implementing the Public Access to Defibrillators (PAD) program. This initiative will provide 450 AEDs to public places across the province over three years. Paramedics throughout B.C. have volunteered to train venue staff and provide ongoing support to the facility and staff with regards to maintaining and utilizing the AED. BCAS s extensive fleet operations experience and robust maintenance program continues to expand and include other areas of the provincial health care system. Within the last two years, BCAS has undertaken fleet maintenance for the Northern Health Authority (April 2011) and the Provincial Health Authority (June 2012) in order to ensure consistent, robust and thorough fleet maintenance throughout the province. In October 2013, BCAS will also begin fleet maintenance for the Justice Institute of British Columbia. BCAS established the Assessment and Investigations Unit (AIU) to track and trend all operational concerns and complaints within BCAS, provide logistical support to area managers in the completion of investigations of those complaints and conduct investigations at the request of the BCAS Senior Operations Team. With its provincial scope, the AIU steers the process of a uniform, standardized response to all operational complaints and offers managers a timely analysis of complaint trends to better inform decision making for mitigation. 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 2012/13, BCEHS renovated an existing station to become a central reporting station. In 2013/14, paramedics will be deployed from this one large 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 11

12 for patients. The BCEHS 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, BCEHS surpassed our service targets and will have 40 per cent of our invoices distributed within in 20 days, and 90 per cent billable within 45 days. Major Event Response Late at night on April 23, 2012, the BCAS Dispatch Operations Centre in Kamloops received a report of an explosion and fire with multiple patients at the Lakeland Mill in Prince George. BCAS immediately began a coordinated emergency medical response. BCAS responded with three ambulances from Prince George, up-staffed two additional local ambulances, dispatched two ambulances from both Vanderhoof and Quesnel as well as assigned the units and the Medical Support Unit. The BCAS Technical Advisor was engaged from the start of the incident, providing direction on hazards and decontamination, first by phone and then by attending the scene. Two duty BCAS aircraft and one up-staffed aircraft responded. Behind the scenes, BCAS managers were coordinating activities and resources with Northern Health Authority and BC Bedline, now the BC Patient Transfer Network. BCAS decontaminated and transported 16 patients from the scene. The integrated, seamless response to this incident demonstrated the significant contribution that the provincial ambulance system makes to patients in need and the entire healthcare system. 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, part-time basis but the majority of paramedics working across B.C. are employed as PCPs - working in both full-time and parttime positions in rural and urban 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 504,000 events in 2012/13 throughout the province, a four per cent increase compared to 2011/12. 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 BC. On April 11, 2012, the BCAS Patient Transport Coordination Centre (PTCC) came into being; prior to this the three dispatch centres operated independently when coordinating inter-facility patient transfers. Air coordination was managed by a Provincial Air Ambulance Coordination Centre which worked independent 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 interfacility patient transfers; the staff are able to fully focus on the complexities of coordinating interfacility transfers within the geographical chal- 12

13 lenges of BC. Consolidating this business area allows for focus and efficiencies for inter-facility transfers while allowing the ground ambulance dispatchers to focus on the pre-hospital emergency medical calls. In September 2012, the Patient Transfer Network moved into the same facility and is located directly beside the PTCC, further enhancing provincial inter-facility patient transfer system for health authorities and patients. BCAS s interfacility patient transfer service complements a number of other patient transfer operations used by health authorities to provide non-medical 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 individual telephone calls a year. statistics Historical provincial event volumes 133, , ,852 91,855 92, , , ,069 90, , / / / / /2013 Patient Transfers Pre-Hospital Events Pre-hospital events include all calls for pre-hospital call - both low acuity and high acuity - lights and siren emergencies and routine calls 13

14 BCAS Stations In 2012/13, BCAS operated from 184 ambulance stations plus additional facilities: Provincial Headquarters in Victoria Three Dispatch Operations Centers (Victoria, Vancouver and Kamloops) Three Administrative Offices (Vancouver, Kamloops, and Prince George) 12 local offices for District Managers (Campbell River, Castlegar, Chilliwack, Cranbrook, Nelson, Clinton, 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. 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 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. 14

15 Facility and station improvements BCEHS is continuing with a multi-year strategy to improve ambulance stations and other facilities throughout the province. In 2012/13, BCEHS spent $17 million on the following projects: undertaking maintenance and repair work, heating, ventilation and air conditioning upgrades and replacing of broken or worn-out furniture at 181 locations ($ 5.9 million); completing new facilities or significant renovations at a number of locations such as Victoria (Douglas Street), Fernie, Grassy Plains, Riondel, and Langford ($7.8 million); and renovating and providing new furniture to improve functionality in the Victoria, Vancouver, Kamloops Dispatch centers and in Vancouver for the new Patient Transfer Network site, Scheduling and Clinical Education ($3.3 million). In 2013/14, the BCEHS Facilities Department will be focussed on: construction or renovation of facilities in North Vancouver, Bowser, Oceanside, Surrey, Richmond, Mackenzie, Burnaby and Saanichton provincial head office; and continuing to source district manager offices in areas throughout the province, to support a closer working relationship with paramedics. BCEHS 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. Modular crew quarters are now in place in Winlaw and Grassy Plains and on Saltspring Island, Quadra Island, Riondel and Denman Island. This ongoing commitment directly impacts the patients who are served by BCAS and the paramedics who provide this care on a daily basis. 15

16 BCAS Ground Fleet The BC Ambulance Service (BCAS) ambulance fleet is designed and equipped to support paramedics with providing patient care on the scene of an emergency and during transport to hospital in a multitude of diverse terrains and conditions throughout the province. In relation to the fleet, BCAS uses: 500 ambulances (including 16 4x4), 62 support vehicles, 46 bikes, and 2 gators. BCAS ambulances are currently manufactured by Crestline Coach Limited and Demers ambulances, based out of Saskatoon and Montreal respectively. Most ambulances are based on Ford or Chevrolet platforms. The newest model of Demers Ambulances was designed by a committee of BCAS paramedics over the last two years. Modifications include: a swivel chair in the back to replace bench seating; the addition of light switches and oxygen access by the rear doors; easier-to-use steps for elderly and mobility-challenged patients; the installation of a back-up camera which allows the driver to see what is happening in the back of the ambulance; and heated spinal boards and clamshells that use latent energy in newly-installed solar heat ducts. Green initiatives The 2013 Demers Ambulances use Eco-Smart technology which reduces idling by up to 40 per cent by monitoring the battery condition and interior temperature and shutting down or restarting the engine as needed to maintain electrical power or interior temperature. There are currently five sprinter van ambulances in the Lower Mainland and on Vancouver Island with the Mercedes Benz Sprinter 2500 chassis. This chassis has a 3.0 L V6 BlueTEC Diesel engine, one of the cleanest diesel engines available. These ambulances are used throughout Europe and are ideal in urban areas that require short distance driving. Sprinter ambulances provide greater fuel efficiency and reduced nitrogen oxides and particulate emissions. Fleet renewal After being in service for four or five years, BCAS ambulances are refurbished and reallocated to stations with lower call volume in order to increase their useful lifespan. Generally BCAS ambulances are decommissioned after reaching a mileage of 300,000 kilometres and 7.5 years of service. BCAS has one of the most efficient and detailed fleet replacement plans in North America: Decommissioned ambulances are used as support vehicles, medical support units or training vehicles. In 2011, BCAS began remounting older ambulance boxes on new chassis from the manufacturer. Remounted ambulances cost 50 per cent less than new ambulances. Annually, new or refurbished ambulances are brought into service. 16

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18 program overview and highlights Critical Care transport team 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 BC 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 911 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. Air Ambulance audit In March 2012, the Office of the Auditor General (OAG) of British Columbia released an audit report related to the air ambulance service of BCAS s Critical Care Transport (CCT) Program. The OAG concluded that the BCAS is unable to demonstrate that it is providing timely, quality and safe patient care through the air ambulance service. The audit report recommended that BCAS takes steps to ensure it is providing patients with the best air ambulance services possible with the resources it has available by: actively managing the performance of its air ambulance services to achieve desired service standards for the quality, timeliness and safety of patient care; reviewing whether the distribution of staff and aircraft across the province is optimal for responding to demand for air ambulance services; and regularly identifying and reviewing a sample of air ambulance dispatch decisions to ensure that resources are allocated with due consideration for patient needs and available resources. BCAS began work to establish service standards, robust performance measures and reporting for the critical care and aviation areas of the CCT Program. This work will address the OAG s concerns and enable BCAS to demonstrate the efficiency and effectiveness of the air ambulance service. 18

19 8,356 8,209 7,732 7,756 8, / / / / /2013 *includes ground and air critical care transports infant transport team BCAS s Infant Transport Team (ITT) paramedics provide emergency medical care to BC 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 deployed 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 unavailable to reach the patient due to ground conditions. The bike squad 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 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 multi-casualty 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. 19

20 BCEHS Medical Programs provides the medical input, education and overshight to guide paramedics in the provision of quality patient care.

21 MEDICAL PROGRAMS BCEHS 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. Medical Oversight Emergency physician online (real time) support BCEHS launched the Emergency Physician Online Support (EPOS) project in 2013 to provide reliable, consistent direct medical oversight for paramedics responding to 911 calls. EPOS is comprised of 45 emergency medicine specialists who provide immediate telephone support for paramedics during pre-hospital responses. This physician cohort also provides clinical guidance in the planning of transfers for complex patients requiring referral to tertiary care. With EPOS, paramedics have one number to call for 24/7 physician support regardless of when or where clinical support is required. EPOS uses innovative telecommunications technology to route the call from a paramedic, who could be anywhere in the province, to the physician on-call. In order to support the project, a comprehensive change management program was undertaken to provide physician orientation to BC Ambulance Service policies and procedures, paramedic scope of practice and BCEHS treatment guidelines. Paramedics were also trained to improve their communication skills when presenting patient information to the physician. PROFESSIONAL PRACTICE BCEHS Medical Programs also made the following enhancements to paramedic practice and emergency medical services in 2012/13: Equipped and trained primary care paramedics to perform 12-lead electrocardiograms on patients suspected of experiencing a type of severe heart attack. BCAS worked with health authorities to established bypass protocols which enable paramedics to transport the patient to a hospital that can provide definitive care rather than the closest facility (if they are different). Worked with the BCEHS Quality, Safety, Risk Management and Accreditation and BC Ambulance Service Operations teams to revise the ambulance Resource Allocation Plan (RAP). The RAP prescribes the qualification, number and urgency of ambulances responding to almost 900 different call types. Pursuing accreditation from the Canadian Medical Association for the BCEHS Critical Care Paramedic training program. research 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. BCEHS and other EMS agencies from across North America are partners in the ROC and undertake 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 coordinates with BCEHS to ensure the requirements of the research protocols are being met while collating enrollment data specific to the ROC studies. Together, BCEHS and the ROC office are conducting clinical trials that will rapidly lead to evidence-based change to enhance clinical practice and better optimize patient outcomes. In 2012/13, BCEHS is participating in three clinical trials: Comparing outcomes associated with CPR provided with continuous chest compressions versus a 30:2 compression to ventilation ratio. Paramedics in a number of metropolitan and urban 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 are an early predictor of shock and the need for aggressive in-hospital interventions. BLAST is the second clinical trial involving BCEHS. ROC is comparing the efficacy of two different antiarrhythmic drugs or no drug at all. The 21

22 Amiodarone Lidocaine Placebo (ALPS) study is looking at victims of sudden cardiac arrest who demonstrate a shockable rhythm that will not convert with defibrillation. Patients are receiving one of two different antiarrhythmic drugs or a placebo followed by further attempts at defibrillation to determine the most effective therapy in these situations. Data collected through the research partnership between the ROC and BCEHS has resulted in 11 publications in peer reviewed journals, including publications in the New England Journal of Medicine. BCEHS investigators continue to be actively involved in publishing research in top tier medical journals. Beyond the ROC partnership, BCEHS is also conducting a trial looking at Primary Care Paramedic acquisition of 12 lead electrocardiograms to detect acute myocardial infarction and whether performance in the overall medical management of these patients can be improved by providing transport to a designated facility and early access to primary percutaneous coronary intervention. BCEHS also partners with academics and graduate students throughout British Columbia. During 2012/13, seven 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. CLINICAL EDUCATION The BCEHS Clinical Education Division (CED) provides educational oversight through program design and development, delivery and evaluation. CED aims to improve patient care through learning and education. and coordinates trauma training world-wide. Emergency Physician Online Support CED created an online orientation course for the new BCEHS physician support network for ground paramedics during and inter-facility transfer calls. Paramedics on calls and calltakers arranging inter-facility transfers now have 24/7 access via telephone to an emergency physician to assist with the patient s care. College of BC Midwives A new course was developed and delivered that will improve paramedic s awareness of midwives educational level, medications within their scope of practice, and responsibility when midwife is on the scene. FIRST RESPONDER PROGRAM First Responders (FRs) are an important part of prehospital care in BC; they provide basic first aid such as control of potentially fatal bleeding, CPR and 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. BCEHS 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 BC and each holds an Emergency Medical Assistant First Responder (EMA-FR) license issued by the provincial Emergency Medical Assistants Licensing Board. In 2012/13, CED was focussed on the following: Dealing with Death and Dying Course Developed a new course for paramedics to enhance their skills in providing comfort for the next of kin of the deceased patient and increase confidence in delivering death notification while managing the call and scene. The team won the BC Patient Safety & Quality Council 2012 Coping with End of Life Award. International Trauma Life Support (ITLS) BC Emergency Health Services became an approved ITLS Chapter and adopted ITLS as the trauma education standard for paramedics. ITLS is a non-profit organization dedicated to excellence in trauma education and response 22

23 BCEHS has a management services agreement with the Provincial Health Services Authority (PHSA) to support effective and efficient corporate services and patient care quality and safety services. The following BCEHS program areas provide services for the three operating entities and report directly to PHSA. QUALITY, SAFETY, RISK MANAGEMENT AND ACCREDITATION PROGRAM The BCEHS 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 QS- RMA team works closely with all programs and the BCEHS executive to ensure patient safety is at the forefront of organizational decision-making. QSRMA focuses on building a culture of safety. Accreditation Canada Primer survey, a readiness assessment for the broader QMentum process, includes an organizational self-assessment and Patient Safety Culture survey, both designed to provide a baseline for focused ongoing improvement based on evidence-driven best practice. With the continued support of staff, front-line paramedics, call-takers and all levels of organizational leadership, BC- EHS anticipate a successful Primer process in June of In 2012/13, QSRMA launched an adverse event reporting system to enable staff to report concerns regarding patient safety events through to the Patient Care Quality Office (PCQO). The PCQO logs the issue in the provincially-supported Patient Safety and Learning System for (PSLS) for management, tracking and learning. Last year, QSRMA also coordinated BCEHS preparation for a Primer accreditation process through Accreditation Canada. BCEHS previously participated in a national pilot program as part of the development of Accreditation Canada s Emergency Medical Standards. Work undertaken in the lead-up to the QSRMA collaborates with the PCQO 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 BCEHS 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. The Risk Management Program also supports patients and their access to health care information through the Patient Records Office. BCEHS PATIENT CARE QUALITY OFFICE Since April 1, 2011, the Provincial Health Services Authority Patient Care Quality Office (PCQO) expanded to include the BCEHS. The 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. Between July 1, 2012-June 30, 2013, the BCEHS PCQO processed and responded to 173 compliments, 126 complaints and 856 requests for information or questions (from government, the public, internal/external stakeholders). The PCQO supports service improvements through feedback from patients and helps BCEHS 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 BCEHS 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). Since July 1, 2012, the PCQO has received and triaged 253 events. All health authorities in BC each have PCQOs and each are represented by their leads at a provincial table whose membership includes the Ministry of Health and the lead for the Patient Care Quality Review Board Secretariat. BCEHS is represented by PHSA Patient Care Quality Offices Director. 23

24 INFORMATION MANAGEMENT/ INFORMATION TECHNOLOGY 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 British Columbia. 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 ambulancebased 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 was deployed in 445 ambulances 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 and patient transfer 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 two of the MobileCAD implementation was started in 2012/13 with installation in 351 ambulances completed by yearend. Implementation in the remaining units in the fleet will continue in 2013/14. 24

25 epcr The 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. Paramedics will use 430 hand-held devices to complete and upload the epcrs remotely. When the epcr system is implemented in Spring 2014, 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 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. 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: Receiving hospitals will have up-to-date care information, such as vital signs, medicines and procedures administered when a patient arrives in the emergency department, 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. The implementation of epcr has been delayed several due to challenges with the IT infrastructure. The goal is to have the first epcr pilot in four BCAS stations in Winter 2013/14. The province-wide roll out will take three months to complete and includes coordination of many logistics such as technology installations, training of 3,600 staff and excellent internal communication support to ensure that the ambulance service is not impacted. human resources In order to support BCEHS transition to the health sector, the Human Resources Division is working closely with PHSA to ensure that the right people, are in the right jobs, at the right time, doing the right thing. Human Resources has undertaken a comprehensive leadership development program to further develop the skills of the organization s front-line and corporate leaders in order to deliver or directly support the best possible patient care. Leaders 25

26 across the organization were provided with two courses, one to define personal leadership style through self-assessment, and another aimed at creating a coaching culture. The courses have been well-received from staff and this work will continue in 2013/14. In 2013/14, Human Resources focussed efforts in the following areas: Employee engagement the staff recognition programs were more closely aligned with those in the health sector as the long service awards and Employee Awards of Excellence were merged into the same event. Four separate recognition events were held around the province in the late fall. Additionally, BCEHS will be included in the health sector s employee engagement survey for the first time in 2013/14 providing a baseline of information to support planning. Recruitment and Retention BCEHS, along with many other health care providers and employers, continues to be challenged to hire staff in rural and remote areas. Human Resources has partnered with BCAS Operations to develop targeted recruitment campaigns in communities with persistent staffing shortages. BCEHS and BCAS will continue to work with communities, industry, first responder groups and the health sector to fill vacancies in rural and remote areas. Health and Wellness - BCEHS is taking advantage of the opportunities afforded by being part of the health care system to use existing information infrastructure to track employee absences, disability management and workplace health. As part of a comprehensive cccupational safety and health strategy, Human Resources is leading the development of a multi-faceted paramedic safety initiative that includes programs related to musculo-skeletal injuries, violence in the workplace, exposures to communicable diseases, and slips/trips/falls. communications The BCEHS Communications department provides a wide range of professional public relations and corporate communications services. The objective of the department is to enhance awareness of BCEHS role, operations and services provided within the context of the health care system and support internal staff and change management communications province-wide. In 2012/13, BCEHS Communications undertook a number of initiatives aimed at refining the internal communications infrastructure and processes including: Undertaking the second organization-wide communications survey to better understand what mediums are preferred and utilized by staff to receive information; Updating communications tools and distribution based on staff feedback; and Refreshing the employee intranet to improve the navigation. Sustaining a robust public safety education program comprises a large segment of BCEHS Communications resources. The department supports the Vital Link and Good Samaritan, Public Access to Defibrillation, and ACT Foundation-BCAS High School CPR programs; issues public service announcements and provides and responds to request from news media for corporate and operational information; and leads a safety campaign to reduce the instances of children falling from doors and windows. 26

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28 organizational challenges There are several ongoing challenges that BCEHS and BCAS are working to address: PROBLEM Increasing paramedic workload, particularly in the Lower Mainland Recruitment in remote communities Staff morale/engagement STRATEGY BCAS added two additional ambulances based in Surrey, changed shift start and end times to ensure coverage during peak hours and reduce overtime, and completed the work to update the Resource Allocation Plan Strategic hiring practices, engaging community leaders and working with health authorities to expand paramedic roles in the community health care system Emphasize importance of in-person communication with leaders, commitment to including front-line staff in the development of new initiatives, leadership training 28

29 budget The 2012/13 budget for BCEHS was $307 million. Of this amount, the majority, $241 million, related to BCAS as follows: Lower Mainland Ground Operations $81.5 Other Ground and Corporate Operations $84.4 Provincial Programs (includes Fleet and Air Programs) $73.9 Service Delivery (Dispatch) $23.1 BCAS estimated revenue recoveries from inter-facility transfers $21.8 Total $241 BC Patient Transfer Network $2.6 Trauma Services BC $2.0 Medical Oversight and Clinical Education $7.3 Corporate Services $56.1 Information Management / Information Technology Ambulance and Corporate Facilities Other (Finance, Human Resources, Communication, Quality Office) 29

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31 Public outreach In 2012/13, the Heart and Stroke Foundation B.C. & Yukon, the Province of British Columbia and BCEHS launched the BC Public Access to Defibrillation (PAD) Program which makes Automated External Defibrillators (AEDs) available in public places where large amounts of people gather. BCAS paramedics provide on-site orientation, on-going program oversight and stewardship. The PAD AED registry is linked to BCAS dispatch, where emergency medical dispatchers are able to access the location information of the AEDs and direct callers to access and use them. The program will instill 450 AEDs in recreation centres, arenas, parks and other public places over the next three years. BCAS paramedics and dispatchers are also involved in a number of other initiatives that support the health and safety of the public: 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 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 foundation - bcas 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 life-saving skill through the ACT Foundation-BCAS 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 911) and early citizen CPR are critical to saving lives. window and door safety With the support of industry and health sector, BCEHS created a decal to remind parents to lock doors and windows in order to keep children safe during the warmer months. The decals are supplied to paramedics attending community events across the province and distributed to daycares and public health units throughout Fraser Health. BCAS also partnered with BC Children s Hospital to raise awareness of this serious issue and distribute the decals. 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. 31

32 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. community support Many paramedics throughout BC 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 BC is available at 32

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