Emergency Response Department – Emergency Medical Services Deployment

Recommendation:
That the September 5, 2002, Emergency Response Department report be received for information.

Report Summary

The Emergency Response Department (ERD) has examined various Emergency Medical Services (EMS) deployment models. The Asset Management and Public Works Department (AMPW) spearheaded a value engineering analysis, and assisted ERD in its analysis by providing cost estimates of the infrastructure associated with the various options. The most cost effective model, from patient care, quality of service, operational and cost perspectives, is the Single Start Deployment Model.

Previous Council/Committee Action

Previous action by City Council and the Community Services Committee is provided in Attachment 1.

Report

  • Administration is advising City Council that it will work towards achievement of the 8:59, 90% response time target for EMS, and of the manner in which it will implement the target.
  • By this report Administration is also responding to City Council’s February 2001 direction, that Administration report back with a cost/benefit analysis and the funding required for the Emergency Response Department to implement the Single Start Station concept”.
  • The medical community, both in Edmonton and elsewhere, supports the accepted industry response time of 8:59, 90%. ERD’s Medical Director advises that resources should be directed towards the achievement of that goal in a manner that provides effective and quality emergency medicine and care.
  • Administration’s position, in partnership with the medical community, is that the Single Start Deployment Model is the most cost-effective means of achieving the response time target.
  • Based on its examination of options, and on the Community Services Committee’s and City Council’s previous decisions following from the Fitch Review, the Department has documented its understanding in a statement of Principles for Action on deployment (Attachment 2). These Principles for Action will be the framework by which the Department puts in place the deployment model appropriate to achieve the response target.
  • This information is brought forward for City Council’s consideration in advance of the annual budget consideration process, so that the rationale and implications may be considered on an information basis before a budget is considered and approved.
  • The issue of funding for the EMS deployment model will be before City Council for its consideration during the review and approval processes for the 2003 and subsequent budgets.

Budget / Financial Implications

  • The financial implications of implementing the Single Start Deployment Model (i.e. cost avoidance) are detailed in Attachment 2.
  • As noted, the corporation’s current Long Range Financial Plan – the ERD component - is based on implementation of this Deployment Model. ERD’s budget submissions (operating and capital), and AMPW’s budget submissions in support of ERD, will support implementation of this Deployment Model.
  • The capital budget funding requirement is, in the budget submissions, scheduled to commence in 2004.
  • If Administration’s position and understanding as stated in Attachment 2 are approved, then ERD and the corporation must take other steps (operational, supported by budget) necessary to achieve a different deployment model.

Background Information Attached

  1. Emergency Medical Services Deployment – Previous City Council and Community Services Committee Actions
  2. Emergency Response Department - Emergency Medical Services: Deployment to Achieve A Plan for Renewal

Others Approving this Report

Bill Burn, General Manager Asset Management and Public Works Department

(Page 1 of 2)

Attachment 1

Emergency Medical Services Deployment – Previous City Council and Community Services Committee Actions.

November 27, 2001

City Council received for information the advice:

The Administration requires more time to fully and adequately provide the (single start station) information for City Council consideration.

February 13, 2001

City Council agreed:

  1. That implementation of the Single Start Station for the City’s Emergency Medical Services (EMS) be endorsed, as recommended in the 2000 KPMG – Fitch and Associates Report on Emergency Medical Services in the City of Edmonton, and consistent with the strategic direction for EMS.
  2. That the Administration bring forward for City Council’s consideration, through the Community Services Committee, its proposal for implementing the Single Start Station concept, including the required funding and cost benefit analysis.

November 30, December 1/4/14/15, 2000

City Council agreed:

That Project No. 01755171, Expansion of Station #42 Emergency Medical Services, be delayed and that the Administration report back to the June 18, 2001 Community Services Committee meeting for consideration in the 2002 Capital Budget (P. 103, Vol.1).

April 10, 2000

The Community Services Committee agreed:

That the Community Services Committee endorse the recommendations of the Administration as detailed in Attachment 4 of the March 27, 2000 Emergency Response Department report (“Fitch Review – Part 1: Recommendations Accepted or Rejected by ERD”).

NOTE:

The Administration’s recommendations as detailed in Attachment 4 of the March 27, 2000, Emergency Response Department, report endorsed by the Committee on April 10, 2000, included the following (quoting verbatim from that report to the Committee):

Respecting Fitch recommendation (2):

(2) The Chief of EMS establish response time requirements for the City of Edmonton to place a transport capable ALS ambulance on the scene of all emergent requests within 8:59 minutes with 90% reliability.

DEPARTMENT POSITION:ACCEPT

JUSTIFICATION: Best practice among North American services places a transport capable ALS ambulance at emergent calls within 8:59 with 90% reliability.

and

Respecting Fitch recommendation (5):

(5) The Chief of EMS implement a single shift start and stop location and rotate units to deployment stations during their shift.

DEPARTMENT POSITION:ACCEPT

JUSTIFICATION: The single start and stop station will increase utilization of resources, improve internal communications and organizational culture, and will allow for cost savings.

Attachment 1 - Page 1 of 12

Attachment 2

Emergency Response Department - Emergency Medical Services:

Deployment to Achieve A Plan for Renewal.

Emergency Medical Services Deployment:

Principles for Action

  1. The service level target for emergency medical services provided by the City of Edmonton is:

A transport capable ALS ambulance on the scene of all emergent requests within 8:59 minutes, with 90% reliability.

  1. The Emergency Response Department, assisted by Administration, will prepare operational plans and budgets for the emergency medical services deployment model which will most effectively and efficiently move the City towards achieving the 8:59, 90% service level target.
  1. The Issue
  • The City’s Emergency Medical Services (EMS) is facing major externally-imposed issues and challenges not within the City’s ability to influence. These can be summed up as follows:
  • demand growth related to demographic change – rapid population growth, part of which is the changing age characteristics – aging - of the population;
  • health care is changing; any one hospital does not necessarily provide the same services as any other hospital; the symptoms presented by a person being served will determine where the patient must go, rather than considerations of the hospital’s proximity to the person being served, or the hospital’s proximity to the ambulance unit; and
  • the City’s EMS serves all hospitals (destination) in the Capital Health Authority region, including active treatment hospitals in St. Albert and Leduc.
  • In 1999 the City commissioned a major review of its emergency medical service (KPMG, and Fitch & Associates). The overall objective in commissioning the review (the Fitch Review), and the objective of the recommendations resulting, was:
  • to enable the City to provide a high-quality emergency medical service in Edmonton, and
  • to ensure that during a period of continuous and rapid growth, service to the public is maintained.
  • The Fitch Report was submitted to the City in early 2000. The Community Services Committee directed Administration to review the recommendations, report back to the Committee respecting its position on the recommendations, and prepare implementation recommendations for the Committee’s and City Council’s consideration. Administration accepted the majority of the Fitch recommendations and reported this to the Community Services Committee, which endorsed Administration’s position. A Plan for Renewal, for the whole of the Emergency Response Department (ERD), was the implementation plan, an “integrated” ERD plan incorporating the Fire Rescue service as well as EMS, and making substantive organizational recommendations for the whole of ERD.
  • The Fitch Report emphasized that, to achieve the desired objectives for the City’s emergency medical services, the recommended actions should be considered and implemented as a comprehensive package. Their implementation could/should not be piecemeal, or on a pick-and-choose basis. They were interdependent. The successful achievement of the objectives for the service:
  • to enable the City to provide a high-quality emergency medical service in Edmonton, and
  • to ensure that during a period of continuous and rapid growth, service to the public is maintained,

was dependent upon the recommendations being implemented as an integrated, comprehensive package.

  • Since City Council’s 2000 implementation decisions respecting A Plan for Renewal, and through subsequent budget approvals and organizational decisions and actions, the majority of the endorsed Fitch Report recommendations have been implemented.
  • One of the important actions was the change of the emergency medical service from a combined Basic Life Support – Advanced Life Support (BLS – ALS) service to an “all ALS” service. Two of the Fitch Report recommendations were aimed towards issues of deployment:
  • establishment of the 8:59, 90% response time service target, and
  • implementation of a single shift start and stop location.

These recommendations were among those supported by Administration, and for which the Community Services Committee endorsed Administration’s position in 2000. City Council subsequently, in 2001, endorsed implementation of a single start station.

  • These recommendations remain the two major implementation actions which the City has not yet been able to implement. Understood in the approvals and endorsements given in 2000 and 2001 was the recognition that their achievement would require resource allocation and action over a period of time. Implementation can occur only with approval of Administration’s budget submissions for the required operational and capital elements. In the intervening time since early 2000 – through two subsequent annual budgets - ERD and AMPW have not achieved the required budgets.
  • As noted in the September 23, 2002, ERD presentation to City Council on Department Services, in 2001, the last complete year of measurement, EMS had an Advanced Life Support unit on the scene within 9 minutes, 82% of the time.
  • Achievement of the response time service target is principally dependent on deployment of resources. The Fitch Report recommendation for the deployment of resources was therefore critical to the achievement of the response time service target. The Report recommended implementation of a single shift start and stop location. The recommendation was in essence not about building a station (i.e. a Single Start Station), but about implementing a model for deploying emergency medical services resources – the Single Start Deployment Model – in order to achieve the response time service target.
  • The Single Start Deployment Model is only one of a number of deployment options for achieving a targeted response time. However, the Fitch Report considered Single Start to be the most effective deployment model – not only in financial terms, but also in terms of other desired operational characteristics of EMS. The Single Start Deployment Model was accepted as such into A Plan for Renewal.
  • Because of the need for longer-term planning to achieve the 8:59, 90% response time service target, ERD is now in the position where it is critical that decisions be taken and commitments made. The Department therefore affirms that it will operate according to the two Principles for Action for deployment stated above, upon which it intends to proceed towards realizing the objectives of the City’s commissioning the Fitch review, and of implementing those objectives through A Plan for Renewal. The Department takes this position for the following reasons:
  • on April 10, 2000, the Community Services Committee endorsed Administration’s positions respecting establishing the 8:59, 90% response time target and implementing the single shift start and stop location;
  • on February 13, 2001, City Council endorsed implementation of the Single Start Station;
  • the Department must achieve the deployment model which is the most effective model to achieve the response time target; and
  • the Department and Administration require a clearly-stated and unequivocal commitment for planning and budgeting.
  1. The First Principle: The 8:59, 90% Response Target

The service level target for emergency medical services provided by the City of Edmonton is:

A transport capable ALS ambulance on the scene of all emergent requests within 8:59 minutes, with 90% reliability.

  • The more fundamental of the two Principles for Action is the commitment to the 8:59, 90% response time service target. The response time target is central to all EMS planning and operational decisions, and budget submissions. As stated in the Fitch Report:

Fundamental elements necessary for success in every modern EMS system include:

  • Clinical sophistication.
  • Operational efficiency.
  • Leadership effectiveness.
  • Financial support and accountability.

Each of these elements must be present and well balanced for the system to be sustainable. They are tightly interrelated and must be considered as a system of care (emphasis added). Communities that fail to recognize the universal truth about these elements and the systemic nature of EMS may achieve acceptable performance for a time, but ultimately these services struggle to maintain that performance, or fail entirely.

Key measures of clinical sophistication include level of service and response time. The system in Edmonton fails to deliver the correct level of service (paramedics) to patients within industry standard response times.[1]

and:

… typical requirements for Delta response times are to place a transport capable ALS unit on the scene within 8:59 (eight minutes and 59 seconds) with a minimum of 90% reliability.[2]

  • A definitive 1993 article reporting the results of research in the Seattle area clearly concluded that the shorter the time interval between cardiac arrest and pre-hospital interventions (i.e. emergency medical service), the higher is the probability of survival. It concludes that knowledge of this can …guide an EMS system to improvements that should increase the survival rate.[3]
  • The 8:59, 90% response time service target, for a transport capable Advanced Life Support on the scene of all emergent requests, is grounded in sound, evidence-based clinical research. Evidence-based research clearly demonstrates that the earlier the response by advanced cardiac life support (ACLS), supported by a first responder program also in place, the better the chance of survival from cardiac arrest.
  • The same principles of timeliness of care and transport translate into better outcomes in all critically ill and traumatized patients – not just in relation to cardiac arrest. It is commonly understood that the longer the brain is without enough oxygen and nutrients, the more irreversible damage is done. The timeliness of care by a paramedic is imperative.
  • The medical community in Edmonton is a major stakeholder in the City’s emergency medical services. This group receives the patients that pre-hospital EMS workers manage and transport to their facilities. This relationship ensures optimization of the care for the sick and injured. The feedback on response time, from the hospital system, comes from various sources. Individual physicians who receive patients EMS transports to the hospitals provide immediate feedback. System-wide feedback comes from the City’s Emergency Medical Services Advisory Committee (EMSAC). Many of the individual members of EMSAC made submissions to the KPMG and Fitch & Associates consultant team.
  • The recommendations of the Fitch Reportwere approved by EMSAC.
  • The medical evidence supporting the response time target is documented throughout medical literature. A Canadian observational study in Ontario (the Ontario Pre-hospital Advanced Life Support, or OPALS) collected data on the Ontario pre-hospital environment over the last eight years, as Ontario adopted Advanced Life Support. One of the conclusions from the Phase I study was that survival of patients from cardiac arrest can be enhanced by minimizing emergency medical services response times. Multiple studies have shown that survival from cardiac arrest is directly proportional to the time of response. This not only includes time until a first responder initiates cardio-pulmonary resuscitation (CPR) and defibrillation, but also the addition of advanced cardiac life support (ACLS) administered by paramedics or physicians. Survival to hospital discharge from out-of-hospital sudden cardiac arrest depends on time elapsed until CPR, defibrillation and/or advanced care are provided. Phase II of OPALS demonstrated that even with a first responder program in place (i.e. a fire fighter defibrillation program, similar to that provided by the Edmonton response system), the earlier the response the better the chance of survival from cardiac arrest. These conclusions are echoed repeatedly in individual papers and analyses cumulating the results of several studies.
  • In February 2002, the Journal of Emergency Medical Services reported on a 200-city survey of United States emergency medical services systems. In this comprehensive survey on operational issues in the United States, the response time goals closely resembled the 8:59, 90% target. The response time performance standards for arrival of a transportable ambulance ranged from 6:40 minutes to 9:11 minutes. The variability was often due to the fact the time interval measurement is different in various systems. All in all, the response time of 8:59, 90% falls within the North American standard.
  • The OPALS (Ontario) experience indicates that, notwithstanding the 8:59, 90% target, a defibrillator should be at the bedside in less than the targeted 8:59 minutes, and should be followed up rapidly with advanced care and transport capability to optimize patient care.
  • The Chain of Survival full medical response service provided by ERD in Edmonton includes the first medical response (FMR) from the Fire Rescue Service, dispatched in parallel with ambulance dispatch. The defibrillator response is provided by the Fire Rescue FMR, and the follow-up advanced care, etc. is provided by EMS. The Chain of Survival is, in ERD’s judgement, more effectively and efficiently provided by the fact that both first medical response and advanced cardiac life support are delivered by one governance institution – the City of Edmonton – where the Fire Rescue Service is also located.
  • Without this initial non-EMS FMR response provided in Edmonton’s case, the response time by EMS operating alone would need to be substantially less than 8:59.
  • Other Canadian cities have also adopted the 8:59, 90% benchmark as their standard response time. The city of Ottawa adopted the goal after Fitch & Associates reviewed their EMS system in January 2001. Ottawa adopted the recommended principles and made the budgetary changes to allow the EMS system to achieve the new target response time.
  • The City’s Medical Director states: … resources should be directed to the achievement of the accepted industry standard response time of 8:59 minutes 90% of the time. The medical evidence, industry experts and our medical community are supportive of this goal.[4]
  1. The Second Principle: Deployment to Achieve the 8:59, 90% Service Level Target

The Emergency Response Department, assisted by the Administration, will prepare operational plans and budgets for the emergency medical services deployment model which will most effectively and efficiently move the City towards achieving the 8:59, 90% service level target.