Pembroke – Renfrew County Chief Paramedic Mike Nolan presented a grim picture of ambulance response time, the availability of ambulances and pressures on the system serving the largest geographic county in the province at a county health committee meeting last week.
“It’s not common if you see one ambulance in Cobden, it’s the only ambulance available to cover 10,000 square kilometres,” he told the new health care committee recently.
While this is the worst-case scenario, ambulance coverage in the vast geographic area is always a challenge, he added.
“Even at best, when I have 10 ambulances staffed on base, that means I have one ambulance per thousand square kilometres of coverage,” he said.
Some areas are especially in a crisis situation because there is no local hospital. He pointed out in Eganville this is a problem. With graphs showing response times increasing, the chief said it is time to look at the system and the resources available.
“We need to talk about putting another ambulance on the road, 24 hours a day, seven days a week, especially in communities like Eganville to be able to backstop that decay of rural response time,” he said.
His comments were part of an overview of the system. With several new members of the health care committee, this provided a snapshot of the system and the challenges. There are significant pressures on the system, Chief Nolan cautioned.
“It is taking us longer to do calls, there are more calls, the calls are more complicated and when we complete a call, we are more often to get stuck in an emergency department or some other part of the health care system and no longer be available for that next call,” he said.
The overall availability of ambulances for any call has been significantly reduced in the last two years, he cautioned. In his career at the county, which is about 20 years, the situation is the worst it has ever been.
“We are routinely getting down to one, two, three or zero ambulances available at night in the county, almost on a daily basis,” he said.
As the largest geographic county in the province, there are additional pressures, he said. This is compounded by the fact the population is spread about in nodes and also decentralized areas.
Chief Nolan explained there are different challenges for people depending on location. The average response time for rural areas is higher than the urban areas, he showed. As well, average response time is increasing from nine and half minutes in 2020 to 11 minutes in 2022. Those in rural areas saw their response time in 2022 go to 13 minutes. The longer it takes for paramedics to arrive the worse outcomes for the more acute situations, he said.
“I think most people care when they call 911 how long it takes us to get there,” he noted.
There is an aging population in the county and “a lot of us have aged a lot in the last two years,” he said, resulting in more use of the health care system.
Showing how long it is taking paramedics with each case, he pointed out this has increased from an average of 61 minutes in 2017 to 88 minutes in 2022. Not only are the number of calls going up, but it is taking longer for each call to be completed, he explained.
If an ambulance goes to Ottawa to the Queensway Carleton, for example, it is not uncommon for one call to take six hours to complete, he said. This can be due to offload delay or getting a call in the city, among a few reasons.
Fortunately, local hospitals are working with alternatives to move patients outside the county with non emergency transfer options, he said.
However, there has been an increase in hospital off-load time locally which keeps paramedics at the hospital longer, Chief Nolan said. The average hospital time increased from 31 minutes in 2019 to 50 in 2022 and the average off-load time increased from 20 minutes to 31 minutes. The paramedics retain the care for the patient until the hospital takes over care.
“When you do 15,000 calls, every minute matters over the course of the year,” Chief Nolan cautioned.
A positive change in recent years has paramedics working in emergency departments to help with off-load issues in some county hospitals, he said.
In Renfrew County there is an aging population and call volumes are increasing. The paramedic service looks at response time performance and evaluates this according to the severity of the call. Community paramedic response units on the road can be used as surge capacity and are advanced care paramedics, so they can provide a response.
“They work in the daytime when the majority of calls occur,” he added.
Another pressure on the system is the ambulances are getting more expensive due to supply chain issues. At the same time the ambulances are seeing their kilometres increase rapidly due to the increase in calls and the ambulances need to be replaced earlier than anticipated.
Chief Nolan said the county system allows for 10 ambulances on days and seven on nights, which has been the holding pattern for some years. He said it will be time to discuss adding another ambulance to the system to deal with the added pressures.
However, the chief added response time is not the only indicator which needs to be looked at. The community paramedicine program, palliative care program and other initiatives have improved outcomes and reduced the utilization of 911 and emergency departments in many cases. While response time is an indicator, the quality of service also needs to be looked at, he said.
“I like to think we are a little more sophisticated in terms of how we look at our community, in terms of quality of life, in terms of patient satisfaction, in terms of what we bring when we respond to patients,” he said.
“We know response time matters, but it is not everything,” he said.
New Models of Care
Chief Nolan and the County of Renfrew Paramedicine program have long had a reputation for innovation in the province. The chief told the committee the county is working to best serve the community through innovative programs and is looking for new programs and ideas to serve needs better.
“We are leading the conversation with the province and our partners to provide paramedics the knowledge skills and ability to safely treat people in their home, keep them in their own home and no longer obligate a trip to the hospital,” he said.
This saves resources for the next available call. It also provides patients the opportunity to choose treatment in their home. This is being done in a coordinated way with Renfrew County Virtual Triage Assessment Centre (VTAC) and hospital partners, he said.
“We can get you a prescription and book you a specialist and keep you at home,” he said, as an example.
Paramedics in the home can do a consultation with the physician in hospital, he explained.
“Taking you to the hospital is not always the right answer,” he said.
Models of Care is a priority for the provincial government, so there will be more information coming on this.
Chief Nolan said other positive steps are having a staff member at the call centre and working with the dispatchers. Having a commander on site works better dealing with shift overrun and other factors. It helps paramedics and patients, he said.
“We are the second paramedic service in the province to be allowed to do this,” he said.
Another positive program is mental health support available as an accessible service. As a result, the majority of the WSIB mental health claims are legacy claims prior to the implementation of the new program, he said. The PTSD program has been a significant cost for many years.
Continued work with VTAC has helped ease the pressure on the system, he stressed. This is an alternative for patients without a family doctor, he said.
The importance of advocacy for the paramedicine program in the county continues, Chief Nolan said in conclusion.
“I’m asking for your advocacy to create sustainable funding models and policy to support these programs which do represent a model of care for the rest of Ontario and much of rural Canada,” he told the health committee.
While some programs are funded 100 percent by the province, others with 50/50 on the municipal levy. If there is an additional ambulance added to the system that will be another pressure on the levy.
“That is why we need more on the 100 provincially funded programs,” Chief Nolan said.