Global Perspectives

     There's a lot of variety in the way emergency medical services are delivered in the U.S., and when you look around the developed world, there's even more. But on balance, there's more that unites us than divides us, and that's especially true of our problems.

     The litany of challenges faced by ambulance providers in other countries, even where the government is far more involved in the delivery of prehospital care than it is here, will sound familiar to American EMSers. In this article we examine three prominent issues faced in foreign locales—hospital offload delays in the Canadian province of Ontario; paramedic recruitment and ensuring a sufficient workforce in Australia; and violence and abuse against medics in the United Kingdom—and what authorities are doing about them.

     These phenomena are complex, of course, and there are no simple cures anywhere. What's more, some of the solutions employed elsewhere may not be applicable to the U.S. environment. Others, though, may be beneficial if they can be adapted and implemented here. As you peruse the following pages, consider what American EMS systems might take from the perspectives and experiences of their counterparts across the globe—is there something there for you?

Left Hanging: Combating ED Offload Delays in Ontario
     For many American EMS systems, ambulance diversion and offload delays are intertwined problems. Reduce the first, and you often increase the second. That phenomenon has also plagued our neighbors to the north. In Canada's most populated province, Ontario, diversion (bypass, in local parlance) is now mostly controlled—but long waits to hand off patients have become a recurring nightmare.

     Ontario officials confronted the bypass issue following the high-profile death of Toronto teen Joshua Fluelling in January 2000. Fluelling had an asthma attack at a time when an influenza epidemic was clogging hospital emergency departments and stretching EMS resources thin. No ALS paramedics were available, and the hospital just minutes from Fluelling's house was on critical-care bypass, meaning it could not accept any more critical patients. The BLS crew transporting him was instead directed to another, more-distant hospital. Fluelling died in transit.

     A year later, the provincial health minister announced that hospitals could no longer turn away critically ill patients. Ambulance services would begin using hospitals' Canadian Triage and Acuity Scale (CTAS) to identify patients' priority, and level 1 CTAS patients, the most urgent, would always go to the closest appropriate hospital. Lower-acuity patients could still be redirected if a hospital was overwhelmed, and ambulance services would strive to distribute the patient load equally.

     And that's basically when the offload delays exploded.

     "We don't very often have bypass anymore—with CTAS, that kind of went the way of the wind," says Glen Gillies, a medic in Toronto and spokesman for the Ontario Paramedic Association, which advocates for providers in the province. "However, now we have the offload problem. We can take all these CTAS 2s and 3s and 4s into these hospitals, but speaking the hospitals' language doesn't mean we get beds any faster."

SCHWARTZ REPORT
     By 2005, Ontario's offload problem was such that Health Minister George Smitherman created the Hospital Emergency Department and Ambulance Effectiveness Working Group to examine the issue and conceive ways to reduce it. The group's resulting report, Improving Access to Emergency Services: A System Commitment, also known as the Schwartz Report, was released in January 2006. It contained recommendations across four areas: prehospital, the ED, post-ED and oversight/accountability. The prehospital/EMS section featured four suggestions: