Land Ambulance Services

31 Pages·2013·0.5 MB·English

Chapter 3
Ministry of Health and Long-Term Care
Section
3.04 Land Ambulance
Services
830 ambulances and an additional 300 emergency
Background
response vehicles (which have a paramedic but can-
not transport patients).
The Ministry of Health and Long-Term Care
RESPONSIBILITIES
(Ministry) oversees ambulance services based on
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The provision of land ambulance services in requirements set out in the Act. The Ministry’s 3.
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Ontario is governed by the Ambulance Act (Act). responsibilities include setting patient-care and o
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Under the Act, the Minister of Health and Long- ambulance equipment standards, monitoring and e
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Term Care must ensure “the existence throughout ensuring compliance with those standards, and, M
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Ontario of a balanced and integrated system of through service reviews, certifying ambulance •
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ambulance services and communication services service providers to operate in Ontario. The Min- r
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used in dispatching ambulances.” The Act further istry’s land ambulance functions employ about 560 a
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states that every municipality will “be responsible full-time equivalent staff, most of whom work at
for ensuring the proper provision of land ambu- Ministry-run dispatch centres.
lance services in the municipality in accordance
with the needs of persons in the municipality.”
DISPATCH CENTRES AND BASE
Accordingly, 42 municipalities and eight other
HOSPITALS
designated delivery agents, primarily in remote
areas (collectively referred to in this report as Twenty-two dispatch centres are responsible for
municipalities) are responsible for providing land dispatching Ontario’s land ambulances. Of these,
ambulance services in Ontario. Most municipalities 11 are run by the Ministry, six by hospitals, four by
provide the services directly, although about 15% municipalities and one by a private operator. Seven
have chosen to contract with a third-party provider. base hospitals (each of which comprises a group
Two types of paramedics generally provide land of doctors working out of an established hospital)
ambulance services—primary care paramedics provide medical oversight to paramedics—includ-
(who perform basic and some advanced life sup- ing any required advice on pre-hospital patient
port procedures) and advanced care paramedics care, as well as continuing education. Since 2008,
(who perform basic and all advanced life support the number of calls requesting an ambulance, the
procedures). In total, municipalities have about number of ambulances dispatched and the number
121
122 2013 Annual Report of the Office of the Auditor General of Ontario
of patients transported have been gradually increas- load nurse program, in which hospital nurses take
ing, as shown in Figure 1. In 2012, about 1.3 million responsibility for ambulance patients in order to
ambulances were dispatched and about 970,000 reduce ambulance delays at busy hospitals.
patients were transported in Ontario, an increase of There is a glossary of terms at the end of this
about 15% for both since 2008. report.
FUNDING
Audit Objective and Scope
Over the last few years, the Ministry has funded
about 50% of each municipality’s prior-year costs
for municipal land ambulance services, plus an Our audit objective was to assess whether the Min-
increase for inflation. The Ministry funds 100% istry has procedures in place to ensure that munici-
of the cost of land ambulance services for the 10 pal land ambulance services are meeting Ontarians’
First Nations ambulance services and for certain transportation health-care needs in a cost-effective
other (primarily remote) areas. The Ministry also manner and are in compliance with ministry and
funds 100% of the Ministry-approved costs of legislative requirements. Senior management at the
ambulance dispatch centres and base hospitals. Ministry reviewed and agreed to our objective and
For the 2011/12 fiscal year, total land ambulance associated audit criteria.
costs were an estimated $1.1 billion, which includes Our audit work was primarily conducted at the
4 $627 million of ministry funding (as shown in Ministry’s Emergency Health Services Branch. We
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n Figure 2) and $477 million of municipal funding. also visited three municipal ambulance services—
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ti Ministry funding includes $12 million for the off- Toronto Emergency Medical Services (run by the
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M S City of Toronto), the Superior North Emergency
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V Figure 1: Number of Calls Received, Ambulances Medical Service (run by the City of Thunder Bay),
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3 Dispatched to Patients,1, 2 and Patients Transported,
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t 2008–2012 Figure 2: Estimated Ministry and Municipal
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h Source of data: Ministry of Health and Long-Term Care Expenditures on Land Ambulance Services, 2011/12
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1,400,000 ($ million)
Source of data: Ministry of Health and Long-Term Care
1,200,000
Dispatch [Ministry-funded] ($103)
1,000,000
Ministry administration
800,000 [Ministry-funded] ($21)
600,000
Number of calls received Base hospitals
400,000 Number of ambulances [Ministry-funded]
dispatched to patients ($15)
200,000 Number of patients transported
Other
[Ministry-funded]
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2008 2009 2010 2011 2012 ($15)
1. Although not included in the number of ambulances dispatched to patients,
dispatch workload also involves dispatching emergency response vehicles
Municipal land
(which occurred 116,000 times in 2012) and repositioning ambulances—
ambulance services
for example, to be closer to the next anticipated call (which happened
620,000 times in 2012). [municipally funded]
($477)
2. While an ambulance is generally dispatched for each call received, in
some cases (such as when there is a highway traffic accident), many more
calls are received than ambulances dispatched. In other cases (such as Municipal land ambulance services
when the closest ambulance is dispatched, as well as when the closest
[Ministry-funded, including
ambulance with an advanced care paramedic is dispatched), more
offload nurse program] ($473)
ambulances are dispatched than calls received.
Land Ambulance Services 123
and Essex-Windsor Emergency Medical Services services and thereby increasing the grant from
(run by the County of Essex)—to examine certain $241 million to $401 million to meet that com-
accounting records relating to ministry grants paid mitment. Since 2008/09, annual increases have
to municipalities, as well as to obtain their perspec- averaged 6%. Overall, while the cost to fund land
tive on the delivery of land ambulance services ambulance services almost doubled, the number
in Ontario. In addition, we visited two dispatch of patients transported in that same time frame
centres—one operated by the Ministry and one increased by only 18%. The Ministry does not know
operated by a municipality—and a base hospital whether the additional funding has resulted in
to obtain further information on their policies and better value for money in terms of service levels
practices regarding land ambulance services. We and patient outcomes. Ministry data indicated
also spoke with representatives from the Ontario that since 2005 there has been some improvement
Association of Paramedic Chiefs (a not-for-profit in ambulance response times, but in the 2012
organization consisting of senior management from calendar year still only about 60% of the 50 munici-
46 municipalities and nine contracted ambulance palities responded to 90% of their emergency calls
service providers that provides advice to the Min- within 15 minutes, as shown in Figure 5. Further-
istry regarding emergency medical services) and more, there is no patient-centred measure of the
from the Ontario Hospital Association to obtain time from receipt of an ambulance call to the time
their perspectives on land ambulance services, an ambulance arrives at a patient’s location.
as well as with representatives from the Ontario The Ministry’s funding formula provides more
Stroke Network and the Cardiac Care Network of funding to land ambulance services that spend 4
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Ontario to learn more about ambulance transporta- more, regardless of the level of service they actually n
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tion of stroke and cardiac patients, respectively. provide. The Ministry indicated that varying service ti
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In conducting our audit, we reviewed relevant levels were expected and that it had not compared M S
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documents and administrative policies and the funding provided to each municipality with the V
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procedures; analyzed information; interviewed ambulance services provided. Further, the Ministry 3
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appropriate staff from the Ministry, municipal land had not determined the reasons for variations in t
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ambulance services, base hospitals, and dispatch funding, which could result from differences in the h
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centres; and reviewed relevant research from distances ambulances travel for patients (urban
Ontario and other jurisdictions. In addition, we versus rural), efficiency of ambulance operations,
asked the Ministry to run a number of computer or municipal priorities and tax-based funding.
reports to assist in our analysis of dispatch proto- Data from the Ontario Municipal Benchmark-
cols. We also engaged two independent consult- ing Initiative representing some municipalities
ants, each of whom has expert knowledge of land indicated that the 2012 total cost per hour of land
ambulance services, to advise us. ambulance services among 13 reporting municipal-
ities ranged from a low of $156 to a high of $247,
with significant cost variations even among urban
Summary municipalities.
The Ministry has not tracked or reviewed any
patient outcome information, such as the survival
Ministry funding to municipalities almost doubled rates for people with cardiac arrest or stroke who
between the 2004/05 and 2011/12 fiscal years, were transported to hospital, either overall or by
with the largest increases between 2004/05 and ambulance service. This type of information could
2008/09 reflecting the government’s commitment be used to improve ambulance services. There have
to provide 50% of the cost of land ambulance been some improvements to parts of the quality
124 2013 Annual Report of the Office of the Auditor General of Ontario
assurance processes since our audit in 2005, such when the ambulance is dispatched to pick
as more timely service review follow-ups. However, up a patient. Instead, they will report on
more work is needed to ensure that dispatch staff how quickly patients are reached based on
are consistently evaluated and that their workloads paramedics’ assessment of each patient when
remain reasonable in order to prevent errors in the the ambulance arrives at the scene. The
dispatch process. Ministry had not analyzed the inherent dif-
In addition, we noted the following other areas ficulties in using this retrospective approach
where action is required. to measure ambulance response times. We
found no other jurisdiction that used a similar
approach. Other jurisdictions generally meas-
Ambulance Service Response Times
ure response time based on a call’s assessed
• Although the Ministry has recently set more
urgency at the time of dispatch.
meaningful response-time measures for the
most time-sensitive patients (such as those
who are choking or experiencing cardiac Dispatch
arrest), it has not set standard response-time • In 2012, 20 of the 22 dispatch centres tracked
targets for other urgent patients, such as their time to dispatch emergency calls. None
stroke patients or most heart attack patients. of them dispatched 90% of emergency calls
Each municipality sets its own response-time within two minutes, as required by ministry
targets for transporting these patients, and policy. However, all dispatched 90% of these
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3. the targets vary significantly based on fac- calls within three and a half minutes. Even
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e amount of tax-based funding available to responsibility and half of the dispatch centres
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municipalities. are Ministry-run, starting in 2013, each dis-
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• • The Ministry needs to ensure that response patch centre can choose what percentage of
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a consistent and comparable manner, factoring two minutes. We noted that the chosen per-
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in geographic differences, so that users can centages ranged from a low of 70% to a high
meaningfully compare their municipality’s of 90%, which may affect response times for
performance with others. In 2006, the Stand- urgent patients.
ing Committee on Public Accounts (PAC) • Dispatch protocols are generally designed to
recommended that response-time targets be over-prioritize calls when there is uncertainty
similar for similar communities. Although about a patient’s condition. Only about
recommended by the Ministry’s Response 25% of patients actually require an urgent
Time Standard Working Group in 2006, defin- response, but about two-thirds of calls are pri-
itions to distinguish target response times for oritized at the most urgent code, requiring the
different geographic areas have not yet been fastest response. The municipalities we spoke
developed. with indicated that over-prioritizing this many
• The Ministry expects to start publicly calls can leave few or no ambulances available
reporting municipal land ambulance response to respond to new calls that are truly urgent,
times in 2014. Under the Ministry’s new thereby causing delays. The two dispatch
approach for measuring ambulance response centres that use a different type of dispatch
times, municipalities will no longer report system experienced less over-prioritization.
times based on the call’s assessed urgency
Land Ambulance Services 125
• The Ministry has not assessed whether the • Ministry policy requires that all patients be
current number of dispatch centres is optimal transported by an ambulance responding to
for performance. Centralized dispatch may a call unless the patient signs a form refusing
help to contain costs and ensure that the clos- transport. The Ministry has not assessed using
est ambulance responds to a call. emergency department diversion strategies
• Only one dispatch centre is able to provide to reduce ambulance wait times at emergency
callers with the locations of publicly access- departments and free them up to respond
ible automated external defibrillators (AEDs), to new calls more quickly. Strategies similar
which can significantly improve survival to those used successfully in other jurisdic-
rates for cardiac arrest patients if available tions include referring low-risk patients to
within minutes. The other dispatch centres Telehealth Ontario to obtain a nurse’s advice
are not able to tell callers whether there is an or having paramedics treat low-risk patients
AED nearby. It may therefore take the caller at the scene without transporting them.
additional time to locate an AED and could Notwithstanding this, we noted that in 2012
increase the risk to the patient. over 25% (or about 350,000) of ambulances
• Non-ambulance emergency response vehicles, dispatched did not transport a patient. The
which cannot transport patients and which Ministry has not assessed the underlying
require that an ambulance also be dispatched, reasons to determine, for example, how many
account for about 25% of the municipal of these situations arose from patient refusals,
ambulance fleet, yet such vehicles responded calls cancelled before arrival of an ambulance 4
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to only 10% of calls. These vehicles are about or paramedics having successfully treated n
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50% Ministry-funded, and the municipalities patients at the scene. ti
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we visited indicated that they were often used M S
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for administrative purposes rather than being V
Patient Transfer at Hospital •
deployed for ambulance calls. A portion of 3
• The Ministry started funding an offload nurse r
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provincial funding could potentially be better t
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program in 2008 as a temporary measure to a
directed to serving callers. h
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reduce the time ambulances spend waiting
at hospitals for patients to be accepted. It
Patient Transport to Hospital has not evaluated this program’s ongoing
• The Ministry has no provincial protocol to effectiveness or analyzed whether there are
enable consistent identification of certain more cost-effective ways to reduce offload
heart attack patients (called “STEMI” patients, delays. Between the 2008/09 and 2012/13
which stands for ST-segment elevation fiscal years, ministry funding for this program
myocardial infarction—a type of heart attack totalled $40 million. We found that since this
resulting from a blocked artery). Outcomes program was implemented, ambulance wait-
for STEMI patients can be greatly improved ing time has actually increased at 20% of the
if they are transported in time to specialized hospitals funded.
care centres. A June 2013 survey conducted • Ministry data indicated that offload wait times
by the Cardiac Care Network of Ontario indi- of more than 30 minutes occurred for about
cated that not all ambulances had both the 80% of the ambulances transporting the most
appropriate ECG equipment and paramedics urgent patients, but the Ministry generally did
trained to read the test results to identify not know whether this was due to the hospital
STEMI patients and thereby help ensure not accepting the patient or other reasons,
timely treatment with better outcomes. such as time spent cleaning and restocking the
126 2013 Annual Report of the Office of the Auditor General of Ontario
ambulance. Hospitals in only one municipal- response time (that is, the time from call receipt
ity in the province inform that municipality’s until a dispatcher advises an ambulance service to
dispatch centre when a patient is accepted. send an ambulance) and the ambulance response
Therefore this is the only municipality able to time (that is, the time from when the dispatcher
determine the time it takes hospitals to accept notifies the ambulance service until the ambulance
a patient once an ambulance arrives. arrives at the patient’s location). This approach
• Paramedics orally brief emergency depart- enables the Ministry, which has legislative control
ment staff about the patient. Patient records over dispatch, to monitor dispatch response times,
generally cannot be electronically shared and the municipalities, which control ambulance
because the electronic patient-care records service provision, to monitor ambulance response
introduced by most municipal land ambulance times.
services over the last few years are not com- Most 911 requests for land ambulances are
patible with hospital systems. In some cases, transferred to the local dispatch centre nearest
patient-care records are not received by emer- the caller. Twenty of the 22 dispatch centres pri-
gency departments until days later and some oritize calls using a dispatch protocol, which was
test results are not received at all, which could developed by the Ministry with input from phys-
affect time-sensitive treatment decisions. icians, called the Dispatch Priority Card Index II
(DPCI II), as described in Figure 3 column A. The
other two dispatch centres prioritize calls with
Quality Assurance Over Patient Care
4 the internationally used Medical Priority Dispatch
3.0 • The Ministry has assigned responsibility for
n System (MPDS) codes, as described in Figure 3 col-
o oversight of the vast majority of paramedic
ti umn B. DPCI II Code 4, as well as MPDS Codes Echo
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e patient-care activities (referred to as “basic life
M S and Delta, are all considered emergencies, and
support activities” and including management
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• of chest pain, childbirth and hip fractures)
3 lights and sirens. Upon arrival at the patient’s loca-
r to municipal land ambulance services. Base-
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h requires care using the same scale used in emer-
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reviewing paramedics’ performance of more
gency departments: the Canadian Triage and Acuity
complex or risky medical procedures, told us
Scale (CTAS), as described in Figure 3 column C.
that municipal land ambulance services may
Until December 2012, ministry policy required
not have the expertise to provide proper med-
both dispatch and ambulance response times
ical oversight of basic life support activities
to be tracked for all emergency calls. In 2012,
performed by paramedics.
almost 710,000 (60%) of ambulances dispatched
to patients were for calls classified as emergen-
cies (that is, DPCI Code 4 or MPDS Codes Echo
Detailed Audit Observations
or Delta). Changes to a regulation under the
Ambulance Act that took effect in January 2013
require tracking of specific dispatch and ambulance
RESPONSE PRIORITIZATION AND TIME
response-time measures for only those patients
Many jurisdictions measure overall ambulance whose conditions are classified as CTAS 1 by the
response time—that is, from when a dispatch cen- paramedics who arrive on the scene. The Ministry
tre receives a call to when the ambulance arrives indicated that this new requirement was based on
at the patient’s location. In Ontario, two separate recommendations made in 2006 by the Response
response-time measures are used: the dispatch Time Standard Working Group, which consisted of
Land Ambulance Services 127
nadian Triage and Acuity Scale (CTAS) by paramedics when ambulance reaches nt’s location Description Resuscitation Examples: cardiac* and/or respiratory arrest; major trauma (severe injury or burns); unconsciousness Emergent Examples: chest pain with cardiac features; stroke; serious infections Urgent Examples: moderate trauma (fractures, dislocations); moderate asthma Less urgent Examples: constipation with mild pain; chronic back pain; earache Non-urgent Examples: minor trauma (sprains, minor lacerations); request for medication or dressing change; sore throat y a blocked artery.
ent C. Ca Used patie CTAS Level 1 2 3 4 5 sed b
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s When an Ambulance Is Needed, from Most to Least UrMedical Services, and Canadian Association of Emergency Physicians B. Medical Priority Dispatch System (MPDS) Used by 2 of Ontario’s 22 dispatch centres to prioritize calls received CodeDescription EchoLife-threatening calls, usually identified early in call; excludes calls with scene safety concerns, such as gunshot to chest Examples: cardiac arrest*; choking; severe asthma DeltaOther life-threatening calls Examples: major trauma (severe injury); unconsciousness; gunshot to chest CharlieCalls involving, for example, chest pain with cardiac features or stroke, as well as conditions benefiting from assessment by advanced-care paramedic, such as a person requiring intravenous glucose; irregular heart rhythms requiring an ECG test BravoCalls involving, for example, moderate trauma (fractures, dislocations) or calls where patient condition is unknown (e.g., caller is unable to answer questions) AlphaLess-serious calls from the community Examples: constipation with mild pain; chronic back pain; minor trauma (minor lacerations, sprain) Alpha 1, Calls primarily from long-term-care homes; patient 2, and 3condition less serious OmegaNo ambulance transportation required; caller connected with appropriate assistance (e.g., Telehealth) k, part of the heart muscle is damaged due to lack of oxygen ca Chapter 3 • VFM Section 3.04
Figure 3: Three Ways of Prioritizing Patient ConditionSource of data: Ministry of Health and Long-Term Care, Toronto Emergency A. Dispatch Priority Card Index (DPCI) II Used by 20 of Ontario’s 22 dispatch centres to prioritize calls received CodeDescription 4Urgent/Emergency: life- or limb- threatening; person requires immediate attention Examples: cardiac arrest*; stroke; major or moderate trauma (severe injuries or fractures); major and moderate asthma 3Prompt: all other calls 2Scheduled: transfers between health-care facilities (e.g., for diagnostic tests or treatment); delay not detrimental to patient safety 1Deferrable: unscheduled inter-facility transfer or low-risk lift assists (e.g., person has fallen and is unable to get up, but has no injuries); delay not detrimental to patient safety * In cardiac arrest, the heart stops beating. In a heart attac
128 2013 Annual Report of the Office of the Auditor General of Ontario
ministry, municipal and physician representatives patient, to be experiencing either sudden cardiac
and reported to the Land Ambulance Committee, arrest or any other CTAS 1 condition. That is,
which was co-chaired by the Ministry and the after the paramedic reaches the patient, he or she
Association of Municipalities of Ontario (AMO). assesses whether or not the call should have been
Ministry policy still requires those dispatch centres dispatched within two minutes. As a result, the
that use DPCI II to track their response times for all determination of which calls were required to be
emergency calls. dispatched within the two-minute standard occurs
Studies have indicated that a one- or two- only after the paramedic reaches the patient, rather
minute delay in the arrival of emergency medical than at the time of dispatch.
personnel can significantly affect the survival of Even though dispatch is legislatively a ministry
CTAS 1 patients. In 2012, fewer than 12,000 calls, responsibility, and half of Ontario’s 22 dispatch
or less than 1% of total calls, involved CTAS 1 centres are Ministry-run, each dispatch centre can
patients. Therefore, under the new regulation, choose its own target for the percentage of calls to
tracking of specific response times is required only be dispatched within two minutes. These targets
for this relatively small number of ambulance do not require ministry approval. For the 2013 cal-
calls. Figure 4 shows both the pre- and post-2013 endar year, we noted that the targeted compliance
response-time standards. rate ranged from a low at two dispatch centres of
70% of emergency calls dispatched within two min-
utes to a high at seven dispatch centres of 90%.
Measuring Dispatch Response Times
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on In 2012, 20 of the 22 dispatch centres tracked the Measuring Municipal Ambulance Service
ti time it took them to respond to emergency calls.
ec Response Times
M S None of them dispatched 90% of emergency calls
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3 However, all dispatched 90% of these calls within measured separately from dispatch response
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t three and a half minutes. times. Ministry data indicated that since 2005,
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h As required by changes to a regulation under the there has been some improvement in ambulance
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Ambulance Act, each dispatch centre was to estab- response times, but in the 2012 calendar year,
lish by October 2012 a target for the percentage still only about 60% of the 50 municipalities
of calls to be dispatched within two minutes when responded to 90% of their emergency calls within
those calls involve a patient who is determined by 15 minutes, as shown in Figure 5.
the paramedic, when the ambulance reaches the
Figure 4: Response-time Standards, Pre- and Post-January 2013
Source of data: Ministry of Health and Long-Term Care and Ambulance Act
Dispatch Ambulance Service
Pre-2013 90% of Code 4 calls within 2 minutes, 90% of Code 4 calls within the actual time it took to respond to
per ministry policy 90% of Code 4 calls in 1996
Commencing Dispatch centres measure whether Municipality measures the percentage of cardiac arrest patients
January 2013 90% of Code 4 calls are dispatched reached with an automated external defibrillator within 6 minutes
within 2 minutes, per ministry policy. and the percentage of CTAS 1 patients reached by paramedics
within 8 minutes, per legislation.
Dispatch centres measure percentage Each municipality determines its own response-time standard for
of CTAS 1 calls to be dispatched in CTAS 2 to CTAS 5 calls, and also sets a target for the percentage of
2 minutes, per legislation. calls that it aims to reach within this time standard, per legislation.
Land Ambulance Services 129
the scene within eight minutes of the ambu-
Figure 5: Percentage of Municipalities Responding to
lance service being notified by the dispatcher.
90% of Code 4 Calls* within 15 Minutes, 2005–2012
• For patients at other CTAS levels (as determined
Source of data: Ministry of Health and Long-Term Care
by the paramedic when the ambulance reaches
60
the patient)—how often an ambulance
50 reaches the patient, after being notified by the
dispatcher, within a time established by the
40
municipality. For these patients, the munici-
pality sets both the response-time targets to be
30
met and the target rate of compliance, which
20 can reflect, among other things, differences
in geographic distances and funding available
10
to municipalities through taxes. As shown in
0 Figure 6, this approach has resulted in a wide
2005 2006 2007 2008 2009 2010 2011 2012
variety of response-time targets and target
* Includes calls from MPDS dispatch centres, based on Ministry’s
determination of which MPDS calls are equivalent to DPCI II Code 4. compliance rates for the same CTAS code: one
municipality may aim to have an ambulance
In our Annual Reports for 2000 and 2005,
reach 60% of CTAS 2 patients within 10
we recommended that the Ministry, together
minutes, whereas another might aim to reach
with municipalities, review the response-time
90% within 10 minutes. 4
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requirement then in use for reasonableness and 3.
Municipalities submit their chosen targets in n
consistency. As well, in 2006, the Standing Commit- o
their annual response-time performance plans to ti
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tee on Public Accounts (PAC) recommended that e
the Ministry, but may change the plans at any time M S
the Ministry report to PAC on how it would update
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by notifying the Ministry. The targets do not require V
response-time targets. •
Ministry approval, including those for CTAS 2 3
Until January 2013, the legislated standards r
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patients who require an emergency response. t
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required land ambulance services to respond to a
The Ministry allows municipalities to use their h
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90% of emergency calls within the actual times
own definition of urban versus rural areas in their
it took to respond to 90% of Code 4 calls in 1996.
response-time performance plans. Although many
The legislation was subsequently changed based
Ontario municipalities include rural and urban
on recommendations the Response Time Standard
areas, only three such municipalities have provided
Working Group made in 2006.
separate targeted compliance rates for these areas.
Legislation that came into effect as of January
Our review of the municipally established targeted
2013 requires each municipality to establish a tar-
compliance rates for cardiac arrest and CTAS 1
get rate of compliance for the following response-
patients indicated that they varied significantly, as
time measures:
shown in Figure 7. The lower targets were gener-
• For all patients with sudden cardiac arrest—
ally set by municipalities in rural areas, due to the
how often any individual equipped with a
longer anticipated time to reach a patient.
defibrillator reaches the scene within six min-
As with dispatch, the determination of which
utes of the ambulance service being notified
calls are required to be responded to within the
by the dispatcher.
established time frames occurs when the paramedic
• For all CTAS 1 patients (as determined by the
reaches the patient, rather than at the time the
paramedic when the ambulance reaches the
ambulance service is notified.
patient)—how often an ambulance reaches
130 2013 Annual Report of the Office of the Auditor General of Ontario
Figure 6: Municipalities’ Chosen Response-time Compliance Rate Targets for CTAS 2 to CTAS 5 Patients, 2013
Source of data: Ministry of Health and Long-Term Care
Chosen Compliance Rate
Chosen Ambulance # of Municipalities (% of time chosen response-time
Response-time Choosing Targets target will be met)
Target* (minutes) in this Range Lowest Highest
CTAS 2 8–15 43 50 90
16–30 7 50 90
>30 0 — —
CTAS 3 8–15 41 50 90
16–30 9 50 90
>30 0 — —
CTAS 4 8–15 20 50 90
16–30 29 55 100
>30 1 50 50
CTAS 5 8–15 18 50 95
16–30 29 55 100
>30 3 50 75
4 * Chart includes the urban response-time target for the three municipalities that set both urban and rural targets.
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e ambulance response times based on urgency of areas.
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the call at the time of dispatch, an approach that The 2006 report from the Response Time
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• enables the ambulance’s response to be adjusted Standard Working Group recommended three geo-
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r based on the information available at that time. graphic levels for reporting response times: urban,
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a We could find no other jurisdictions that evaluate rural/light suburban, and remote. In 2006, PAC
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the timeliness of ambulance response based on the also recommended that response times be similar
assessment made by the paramedics after reaching for similar communities considering, for example,
the patient. The Ministry has not evaluated the local factors such as urban population densities and
practical difficulties inherent in this retrospective road infrastructure. As well, both a 2010 Ministry-
approach. Subsequent to our fieldwork, the Min- commissioned report and a 2011 report released by
istry indicated that it has begun discussions with the Ontario Association of Paramedic Chiefs recom-
the municipalities on how best to track and report mended that municipalities establish definitions for
response times using the retrospective approach. urban, rural, and remote service areas. However,
as of May 2013, no such standardized definitions
for measuring response times had been adopted by
Differentiating Rural and Urban Response
municipalities or the Ministry.
Times
Generally, rural areas will have longer ambulance
Transporting Patients to Specialized Care
response times than urban areas, because longer dis-
tances must typically be travelled to reach patients. Adopting Transportation Protocols
We noted that in Nova Scotia, response times are To obtain the best outcomes, patients with certain
measured using a nine-minute response-time conditions, such as stroke and a certain type of
standard for urban areas, a 15-minute standard for