Report on Emergency Medical Services Review – Part 1

Recommendation:
  1. That Attachment 2 (“Fitch Review – Part 1: Answers to Questions from Members of Council”) be received for information.
  2. That Attachment 3 (“Fitch Review – Part 1: April 2000 Overview”) be received for information.
  3. That the Community Services Committee endorse the recommendations of the Administration as detailed in Attachment 4 (“Fitch Review – Part 1: Recommendations Accepted or Rejected by ERD”).
  4. That Attachment 5 (“Fitch Review – Part 1: Recommendations Conditionally Approved by ERD, but Requiring Further Study”) be received for information, and the Administration be directed to report back to the Community Services Committee at its meeting on May 15, 2000 addressing the outstanding issues.
  5. That the Administration be directed to prepare an overall implementation plan for the Committee’s consideration at its meeting on May 15, 2000.

Report Summary

  • At its meeting on February 28, 2000 the Community Services Committee heard from the consultants engaged in 1999 to review the City’s emergency medical services. This report provides the Administration’s response to the Committee’s direction for a subsequent report responding to Councillors’ questions and the Department’s response to the Fitch Review, and providing other relevant information.

Previous Council/Committee Action

Previous Committee action is detailed in Attachment 1.

Report

  • At its meeting on February 28, 2000 the Community Services Committee heard from the consultants engaged in 1999 to review the City’s emergency medical services.
  • Attachments 2 through 6 to this report provide the Administration’s response to the Committee’s direction for a subsequent report responding to Councillors’ questions and providing an implementation plan (including a financial strategy). The attachments consist of:
  • answers to the questions from members of Council (Attachment 2);
  • a general overview of the response to the Fitch Review (Attachment 3);
  • an itemized response to the 17 of 32 recommendations of the Fitch Review – Part 1 for which the Administration has a specific position which it requests the Committee endorse (Attachment 4); and
  • a discussion of the 15 Fitch Review – Part 1 recommendations which need further consideration by the Administration (Attachment 5).
  • The Department has not prepared the requested financial strategy, because there is a need for direction per receommendations 3. and 4. above. Without this direction there is no clear understanding of the course of action for which a strategy should be prepared. The financial strategy will now be presented at the May 15, 2000 Committee meeting.
  • The Department’s position on the emergency medical service to be provided by the City is as follows:
  • all ALS service (encapsulated by Fitch recommendation 1);
  • single start station (encapsulated by Fitch recommendation 5);
  • modified shift schedule to match peak demand (encapsulated by Fitch recommendation 4); and
  • details related to the foregoing.

That is reflected in its responses to Fitch – Part 1 recommendations, as detailed in Attachment 4, and in its recommendation that the Committee endorse the Department’s position. With respect to modified shift schedules, this will require a change in the collective agreement.

  • The Department has not yet come to a conclusion respecting the transfer function. Alternatives are: a separate service, an integrated service, or a tiered service.
  • This report does not present the complete implementation plan contemplated on February 28. It is an interim stage in the work to having such a plan. This report presents preliminary concepts for development into an “implementation plan”. Preparing the details of that plan will require substantial further analysis and work by the Administration.
  • It is apparent at this point that implementation of the endorsed recommendations of the Fitch Review will result in significant operational changes, with significant financial implications. Therefore the Administration requests the Community Services Committee, at this point consider and endorse the general direction, i.e. provide its advice on and support of the direction (specifically as presented in Attachments 3. and 4.) before the Administration proceeds further.
  • It is intended that final approval will be requested when the implementation plan (including financial strategy) is brought to the Committee on May 15, 2000. The Committee will be requested to recommend to City Council those parts of the implementation which require Council’s consideration and approval.

Budget / Financial Implications

  • The consultants’ review of the City’s emergency medical services indicated that the cost of implementation of their recommendations was in the order of $4.9 million.
  • The actual financial implications depend on the implementation plan.
  • No funding has been allocated in the 2000 Budget for this item.

Legal Implications

  • Assuming the City continues to provide transfer services for the Capital Health Authority (CHA), a contract between the City and the CHA will be required.
  • The collective agreement will need amendment respecting modified shift schedules.

Justification of Recommendation

  1. The procedure agreed by the Committee provided for members of City Council to submit their written questions through the Office of the City Clerk. Attachment 2 provides information in response to those questions.
  2. Information is provided as to the emergency medical services review process taking place within the Department. This is the process by which the Committee’s February 7 and 28, 2000 directions are being addressed.
  3. The review process has resulted in the Department taking a position of “approve” or “reject” on the majority of the 32 recommendations of Fitch - Part 1. The Committee is requested to endorse these, so that the process can move forward with more certainty to develop an implementation plan.
  4. For the Committee’s information, some of the Fitch – Part 1 recommendations are generally noted as “approve” by the Department, but require further analysis before the Committee will be asked to endorse them.
  5. With the Committee’s support of the Department’s current response to the majority of the Fitch – Part 1 recommendations (recognizing that the response to some recommendations is yet to come) and of the preliminary financial strategy, the Administration can then prepare an overall implementation plan for the Committee’s and Council’s subsequent consideration.

Background Information Attached

  1. Previous Council/Committee Action
  2. “Fitch Review – Part 1: Answers to Questions from Members of Council”
  3. “Fitch Review – Part 1: April 2000 Overview”
  4. “Fitch Review – Part 1 Recommendations Accepted or Rejected by ERD”
  5. “Fitch Review – Part 1: Recommendations Conditionally Approved by ERD, but Requiring Further Study”

Background Information Previously Distributed

  1. KPMG - Fitch & Associates: Review of City of Edmonton Emergency Medical Services – Part 1; February 2000

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Attachment 1

Report on Emergency Medical Services Review – Part 1:

Previous Council/Committee Action

  • At its meeting on February 28, 2000, the Community Services Committee agreed:
  1. “That the February 7, 2000 Emergency Response Department report, including Attachment 1, be received for information.
  2. That Attachment 1 of the February 7, 2000 Emergency Response Department report be referred to the Emergency Medical Services Advisory Committee (EMSAC) and the Capital Health Authority (CHA) for their consideration, and that they each be invited to make a written submission for consideration at the Special Community Services Committee meeting on April 10, 2000.”
  • At its meeting on February 7, 2000 the Community Services Committee

agreed:

“That the following procedures be adopted by the Community Services Committee to deal with the Administration’s report on the consultants’ review of emergency medical services, and on the subsequent implementation of changes in emergency medical services:

  1. that the report be dealt with at the Monday, February 28, 2000 regular Community Services Committee, at 1:30 p.m. time specific, in Council Chamber;
  2. that the following procedures be used for both the public and in-private portion of the February 28 meeting:

a)the consultants will make a presentation on the consultants’ review of emergency medical services;

b)Councillors will have one five minute round of questions of the consultants;

c)Councillors will have the opportunity to submit written questions to the Administration through the Office of the City Clerk by Noon on Monday, March 6, 2000;

d)the report be received for information and referred back to the Administration for the preparation of a subsequent report, or reports, and recommendation(s) as follows:

(i) responding to Councillors’ questions;

(ii) providing comments and observations on the consultants’ review;

(iii) outlining the Emergency Response Department’s proposed implementation plan resulting from the review, including a financial strategy;

(iv) responding to such other direction as the Committee may give, including any invitation to agencies and organizations for input; and

  1. that a Special Community Services Committee meeting be scheduled for 9:30

a.m. on Monday, April 10, 2000 in Council Chamber to consider the report directed in 2. above and to hear from the Emergency Medical Services Advisory Committee (EMSAC), the Capital Health Authority (CHA) and such other agencies and organizations as the Committee may direct.”

  • At its meeting on June 16, 1999 the Executive Committee agreed:

“That the Emergency Response Department be given approval to hire KPMG Consulting and Fitch & Associates to jointly undertake a review of the Emergency Medical Services Branch.”

Attachment 1 - Page 1 of 2

Attachment 2

Fitch Report – Part 1:

Answers to Questions from Members of Council

Coun. A. BOLSTAD

1)Hospital Transfer Contract

A.Are there operational changes we could make to ensure we at least break even with this contract?

The EMS.COM2000 team has created an implementation plan that includes development of a business case outlining the different models for providing transfer service. These models will be costed and reviewed with CHA. The goal is to arrive at a contract that covers the Department’s costs for providing the service, while ensuring the CHA’s needs are met.

B.If it doesn’t look like we can break even, shouldn’t we make plans to abandon the service when the contract runs out?

Not delivering transfer service is an option that may be considered, if the City and the CHA are unable to arrive at a satisfactory contract for service. Currently, the CHA has expressed interest in negotiating a new contract that would reflect the Department’s costs for providing the service. Providing a contracted transfer service allows the administration to have control over response to transfer requests.

Coun. T. CAVANAGH

1)Should we be in the Transfer business?

There are many factors involved in answering this question. For example, the Department needs to determine, through negotiations with the CHA, if the City can recapture its costs for providing this service. Having a contractual agreement offers the City control over response to transfer requests. A decision must be made as to the level of Transfer Service in which the City of Edmonton wants to be involved.

2)What is the cost to have all ALS workers in the system?

Each ambulance currently requires a total of eight persons to run 24 hours/day, 365 days a year. In addition, two more staff cover absences such as vacation, sick, training, etc., for a total of 10 staff per ambulance. To move toward an all ALS system, each ambulance would require a minimum six Paramedics, and four staff who may be EMTs.

This gives the minimum number required to move towards an all ALS system (a 60/40 ratio of Paramedics to EMTs). The Branch is currently at a 56/44 ratio. If the Branch were able to move to the 60/40 ratio today it would need to adjust staff to 87 paramedics and 57 EMTs. This ratio is the minimum required; however, it is not viewed as a sustainable number. Best practice sites suggest a 70/30 ratio, which equates to 101 Paramedics and 43 EMTs using today's staffing. A mid-range hourly wage is $22.22 for a Paramedic and $18.68 for an EMT, plus 17% benefits. The total cost would vary with the number of ambulances required for the deployment model used.

Summary of additional costs to going all ALS:

  • There are no vehicle upgrade costs to moving to all ALS within the currentdeployment model. However, there is an estimated $225,000 vehicle upgrade cost to implement the Fitch deployment model.
  • Staffing Costs: An upgrade of 10 EMT positions to Paramedic positions would be needed. The costs would be the difference between the EMT pay rate and the Paramedic pay rate for 10 employees or approximately $79,687.57 annually.
  • Other areas that require change would incur an internal cost of doing normal business.

3)Was this report done after the opening of the NE Health Centre? If not, what effect does it have?

This report was completed prior to the opening of the NorthEast Health Centre. The Centre has no effect on station deployment; however, it will have some impact on the transfer volumes.

Coun. B. MASON

1)Is there any kind of Quality Assurance measuring toolin place for EMS road staff? If not, would it not be of benefit to institute some type of Quality Assurance measuring tool in respect of EMS road staff in order to provide an overall perspective with respect to the quality of services delivered?

The Branch currently tracks various performance indicators through its Quality Assurance program. This program is under review and will be impacted by the results of the Fitch recommendations.

2)The Fitch report is based on workflow data over a 13-month period ending August.1999. The Fitch report makes recommendations for a change in the work flow procedure. Were similar changes to the workflow procedures not recommended by the earlier reports? Morck and Nowak? Were these earlier recommendations not implemented in October 1999?

Morck and Nowak identified several areas for improvement related to work flow, but they did not make recommendations on dealing with these issues. Subsequent to the Morck and Nowak report, an ERCC Review Committee identified and confirmed the issues and made recommendations to improve work flow. For example Morck and Nowak identified a bottleneck in the single dispatch position for handing all fire and emergency medical reports. The subsequent recommendation was to split this into separate entities. That recommendation has been implemented, together with several others, prior to the end of October 1999. The Fitch Report identifies other work flow improvements.

3)Please describe the present deployment plan? How was the plan developed? Has the present deployment plan been encountering any technological difficulties? What is the view of the department as to how well it is working?

The current deployment plan is determined using a computer-based program which combines the elements of a response-based system and geographic considerations. There have been some difficulties with the System Status Management, and the Department has budgeted for the upgrade of the Computer-Aided Dispatch system this year.

Coun. M. PHAIR

1)If future directions were to achieve ambulances on the road at all times, why would so many ambulance stations be needed?

The Ambulance Services Act states that a primary response ambulance, when not involved in a call, must be housed in an enclosed facility, maintaining an ambient temperature of 10 degrees Celsius. There are several outside cabinets on ambulances that are not heated. In the winter, equipment stored in these cabinets could be damaged or rendered unusable due to freezing. Strategically-located stations would enhance the coverage patterns for ambulance service.

2)If recommendation #7 (“The City Manager codify an EMS service bylaw…. For the dollars invested.”) were to be implemented, would this not be essentially a Library/Police Commisssion system and a return to the former Ambulance Authority structure?

Recommendation #7 does not contemplate a board, authority or commission separate from the direction of City Council. The bylaw would establish service levels, funding and related issues. EMS would still exist within the corporate structure, albeit governed by that bylaw. City Council would control the bylaw. (Note: The Department does not support this recommendation at this time.)

Coun. R. NOCE

1)What is the status of the Ground Ambulance Services Task Force (have any of the recommendations been implemented?)

The Provincial government created the task force in October 1995, and worked through April 1996. Its report was released in 1997. Much of the report was directed at upgrading rural EMS services, from First Responder to Basic Life Support. The report stated that the Province should fund all ambulance services to a BLS level, although no action has been taken by the Province as yet.

2)What are the economic advantages of using a two tier system (i.e., ALS and BLS)

The benefits of a two tiered system are reported to be saving money and utilizing resources more efficiently by sending paramedics to critically ill patients and EMTs to less critically ill patients. Experience in sophisticated EMS systems does not support this concept. A two-tiered system often causes multiple unit responses to the same incident. This results in duplication of resources and reduced coverage of the city while two units are occupied with a single call. ERD’s experience is consistent with what other EMS services have experienced – economic advantages are minimal if any, while the two-tiered system causes other concerns.

3)Has City Council ever adopted the 7-minute response time requirement? If yes, when? If no, why not. Please provide a brief history to the 7-minute response time requirement.

From 1991 to 1993 the seven-minute response time was adopted through the approval of the long term Housing Strategy by the Edmonton Ambulance Authority (EAA), and by EMSAC. The Department can find no documentation that City Council has itself specifically approved a seven-minute response time.

4)Why is the City of Edmonton not able to achieve the 8:59:59 response time requirement standard 90% of the time?

There are not sufficient resources nor numbers of ambulances. Recent statistics show the first arriving transport capable unit arrives City wide, 80% of the time in less than 8:59 minutes. To cover 90 % of the time the City requires more units.

5)How often did multiple units respond to a single incident in 1999, 1998, 1997?

1997199819992000ytd Feb

13,51716,70214,8302,486totals

36.1%41.3%42.2%41.6%percent of events

6)What steps have been taken with Capital Health to improve drop times at local hospitals?

A timing study is planned and will be conducted in the near future. The intent of the study is to examine how EMS time is being spent in the hospital. Once this information is available, action will be taken to reduce these times. Recent performance indicators show an improving trend toward reduced drop times, from less than 0:50:01 in September, 1999, to less than 0:44:09 in February, 2000, 90 percent of the time.