Long-awaited report on N.S. ambulance system released

Nova Scotia paramedics and their ambulances are spending too much time in non-productive, non-emergency activities, according to a comprehensive review of the provincial ambulance system that was finally released Monday.

"Resources (dollars and ambulances) that could be dedicated to emergency responses are unnecessarily deployed to the [patient transfer] system to meet the contract demands," says the report from U.S.-based Fitch and Associates.

"This is inefficient and ineffective." The findings go on to say that the system does not take full advantage of "the medical sophistication that paramedics can provide."

"Although some marginal programs are present, the system relies largely on two outcomes when a patient contact occurs — either the patient is transported to the hospital or the patient must refuse transport."

Report completed in 2019

Fitch was contracted in October 2018 to produce the report for $145,000, with an original delivery date of December 2018. The firm was tasked with producing recommendations for "the most efficient, effective and sustainable EMS system in Nova Scotia for the next 10 to 15 years."

• Read the Fitch report

Watch the province's briefing on the Fitch report recommendations:

After several extensions, Health Department officials received the report in October 2019, but would not make it public until a new contract was finalized with service provider Emergency Medical Care Inc. Those talks started this past December, more than a year after the report was delivered. The new five-year deal, announced Monday, is worth approximately $165 million per year. The government has two subsequent options for two-year extensions.

Of the 68 recommendations from Fitch, 64 are built into the new contract.

For now, the government is not acting on a recommendation to move to a civilian model for the EHS communications centre. It's also passing on two proposed changes related to scope of practice for staff on the air ambulance service known as LifeFlight and a suggested change related to workers compensation.

Increasing existing fees for ambulance service or creating any new ones for a transfer system is not something being considered at this time, said Health Minister Zach Churchill.

The review by Fitch was ordered in the face of repeated stories of paramedics spending long hours at hospitals waiting for space to become available so they could release patients, as opposed to being able to drop them off quickly and get back on the road to take calls.

It's been one of the most difficult puzzles for officials in the health system to solve. According to Fitch, it will take the entire health system working together in a co-ordinated way to improve things.

Churchill issued a directive on Monday for Nova Scotia Health to begin tackling the offload issue, saying it will include monthly reporting to his department.

The issue is complicated by the fact it's often tied to availability of in-patient beds, something often affected by people ready to be discharged but who do not have a place to go, such as to long-term care.

Potential to become a national leader

One of the people who worked on the report, Fitch senior partner Guillermo Fuentes, said the changes won't be easy, but will be transformational if they can be accomplished.

"It really changes the system design in Nova Scotia to be, in our opinion, future leaders for the country," he told reporters.

"It's going to become what the country of Canada is going to aspire to be from [the perspective] of an EMS design."

Churchill said he and his department officials are committed to getting the work done. Given the amount of time lost to paramedics waiting to offload patients or attending to other matters, the minister said he believes transformation is possible using the existing workforce.

"We do have confidence that in improving these system challenges will open up more time for our paramedics to focus on what they signed up for: responding to emergencies and saving people's lives."

Paramedics have continued to draw attention to times when there has been limited coverage in certain parts of the province because ambulances are parked outside emergency departments.

The situation has proved inconvenient at best, with transfer appointments delayed or missed, and tragic and deadly at worst, when ambulances have not been there in a patient's time of need.

Mike Nickerson, business agent for the union representing paramedics, said he is hopeful the report will lead to change. Nickseron said he hopes the government includes the union in the process as recommendations are acted upon, but for now he's pleased to know their concerns have been heard.

"This report just validates what we've been saying all along and what government knew," he said.

Recommendations

The report released Monday says there are major savings to be gained by addressing these issues of lost productivity, but the estimate of how much is redacted.

The report calls for paramedics to work to their full scope of practice, for the community paramedic program to be expanded and for alternative ways to transfer patients. The province launched a one-year pilot program focused on non-acute patient transfers earlier this year.

Dr. Andrew Travers, the provincial medical director of EHS, said giving paramedics the ability to treat a patient and then have them follow up with a family doctor or telehealth, as opposed to being brought to the hospital if that isn't necessary, should also help improve the flow of the system.

"It doesn't mean we're always having to transport a patient from Point A to Point B."

The province should "amend policies or adopt legislation, as needed, to allow patients to be treated in-home or transported to alternative treatment destinations, and/or with other transport modes," according to the report.

The document says patient outcomes must trump response times and that a new system, using dedicated doctors and nurses, needs to be created to help improve the amount of time it takes for paramedics to turn their patients over to hospital staff.

In working toward that goal, EMC's contract is intended to provide the "right resource to the right patient at the right time for the right reason," according to the province.

Efforts to do that include:

• Stationing a nurse at the communications command centre to help with low-acuity 911 calls.
• Adding a second LifeFlight air ambulance team for adult patients.
• The phased introduction of a non-clinical patient transport service.
• Expanding the community paramedics program.

Opposition weighs in

NDP Leader Gary Burrill said he's glad the report is finally available. He said it speaks to system-wide challenges that exist, which serve to make paramedics' jobs more difficult.

"[It's] a system-wide problem that is indicating a health-care system that is overtaxed, under resourced and inadequately financed."

Tory MLA Colton LeBlanc, a former paramedic, said he hopes the report leads to positive changes for his former colleagues, in particular the call for them to work to their full scope of practice.

"It's essentially bringing emergency care into homes or along the side of our highways," he told reporters, before expanding on the idea.

"They have a wealth of knowledge. They have at their disposal, as an advanced care paramedic, greater than 30 drugs that they provide and can administer; similar drugs that they provide in the emergency room context."