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What International Models Can Teach Us About High-Performance EMS

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This is the third in a yearlong series of articles developed by the Academy of International Mobile Healthcare Integration (AIMHI) to help educate EMS agencies on the hallmarks and attributes of high-performance/high-value EMS system design and operations. 

The Academy of International Mobile Healthcare Integration is honored to have several international members from whom we learn a lot about how EMS systems in other countries are built and operated. In this article we share how EMS systems in Canada and the United Kingdom are structured, the aspects of high performance and high value that are components of these systems, and what system leaders in these countries feel should be replicated in U.S. EMS systems.

Kevin Smith, Chief, Niagara Emergency Medical Services, Ontario, Canada 

How does your system operate?

EMS delivery in Canada is integrated within the provincial health systems. In Ontario paramedic services operate as part of the Emergency Health Services Branch of the Ministry of Health and Long Term Care.  

The system is financed through tax dollars; there is no private billing for emergency health services, including ambulance service. The tax-base funding is shared at the provincial and municipal levels, each contributing half the funding for the system, with overall control of the budget at the municipal level.

Generally municipalities in Ontario are responsible for the provision of land ambulance services, while the province maintains communications (dispatch) operations. The local provider develops its ambulance deployment plan and delivers it to the provincial communications center for implementation. The exceptions to this model are the municipalities of Toronto and Ottawa, which handle their own ground operations and communications due to their size and population, and Niagara.

Since a five-year pilot project that ended in 2010 demonstrated improved system performance through the implementation of technologies, processes and an integrated system design, Niagara EMS operates its own independent communications system in a performance agreement with the province. Today the Niagara dispatch center is used as a test-bed for innovations to be considered provincially and maintains accreditation as an IAED Center of Excellence.  

Air ambulance is provided through a provincial system (Ornge), and tiered response is coordinated in collaboration with the Niagara Regional Police Service and 12 local fire services. The fire departments are a mix of full-time and volunteer complements. Tier criteria is developed in consultation with a medical director using evidence-based response data. Customized response plans are then created based on response determinants, the location of the call (which municipality), ETA of paramedics and level of available local fire resources.

What attributes of high-performance EMS are part of your system?

Sole provider: Niagara EMS provides all emergency ambulance services in the municipality. There are some private nonemergency patient transfer agencies for low-acuity scheduled medical transports.

External accountability: Niagara EMS is required to report clinical outcomes and operational performance at both the municipal and provincial levels.

Control center operations: Niagara EMS operates a single control center for all emergency medical dispatch functions.

Revenue maximization: As mentioned previously, the Ontario system is publicly funded, and therefore a high level of accountability exists to all taxpayers. Costs are measured, benchmarked and publicly reported as a component of overall system performance. 

Flexible production strategy and dynamic resource management: Balanced deployment is used to serve the mix of Niagara’s urban and rural geographies. Fluid deployment is used throughout the region with the use of a flexible production strategy employing a system status management approach to move resources around the region to maximize operational performance based on both temporal (volume) and geospatial (geographic) modeling.

What metrics do you track to demonstrate value?

All EMS services in Ontario have a legislated requirement to report aggregate response times as their primary performance metric. One of the interesting aspects of the provincial response-time performance reporting is that the province took a bold step five years ago and based response time targets on the Canadian Triage and Acuity Scale (CTAS). The CTAS score is a tool that enables EMS and hospital staff to have a common method of prioritizing patient care requirements. The system is based on five levels, with CTAS 1 being the most acute and CTAS 5 the least severe. The CTAS score used to measure EMS response time is based on the paramedic’s initial assessment of the patient upon arrival and not on the priority with which the call was dispatched. This model allows for the measurement of call triage and response priorities against the actual patient presentation prior to paramedic interventions. Response-time plans are then set by the municipal agency for each of the five CTAS levels (as well as for SCA), and annual performance is measured against these targets. Response-time plans and historical performance for all services in Ontario can be found at www.health.gov.on.ca/english/public/Program/ehs/land/responsetime.html.

One of the distinctly different tools used in Niagara (and Toronto) compared to the rest of the province is AMPDS. Conventional Ontario systems use a two-level response system for emergency calls, whereas AMPDS offers a five-priority system: priorities 15 (echoalpha). This allows for enhanced resource management in that using this system, Niagara is able to reduce the number of “hot” responses to approximately 45% of all emergency responses. Most provincial systems run closer to 70% or possibly greater of responses being hot.

Niagara is also a participant with the Municipal Benchmarking Network Canada (MBNC), which publishes various EMS performance metrics such as:

  • Percent of ambulance time lost to hospital turnaround;
  • EMS total cost per weighted vehicle in-service hour;
  • 90th-percentile call-processing time.

These annual measures are reported publicly at http://mbncanada.ca/practice/emergency-medical-services-ems/.

In Niagara there is a push to deemphasize categorized response-time measures and focus primarily on clinical outcomes as evidenced through measurable EMS interventions and definitive care. This will allow a further revision of response plans to better meet the actual needs of patients in a time when severely limited emergency resources are a reality for most of us.

What attributes of your system do you feel should be replicated in the U.S.?

The economic model: The Ontario funding model allows EMS leaders to focus on the clinical care and system performance ends of the operation and not become distracted with the investment of significant resources to maximize revenue collections. The tax-based funding process also facilitates the promotion of a mobile integrated healthcare model of system design due to its valuable impact on the greater health/social care system.

Performance reporting: A transparent, consistent set of public reporting metrics to promote benchmarking with other systems to share best practices and encourage performance improvement without the threat of competitors using this information to advance their business to the detriment of others.

Paramedic credentialing: In Canada the training and credentialing programs recognize the value paramedics bring to the healthcare system. Paramedics undergo up to three years of training and are truly considered healthcare professionals. This results in compensation that matches the status of this role in our communities, which helps with career development through recruitment and retention.

What trends will have the biggest impact on your system over the next 5–10 years?

Show the evidence: Niagara is redeveloping its system to improve on the goals of providing a reliable, quality and cost-efficient service. While opportunities are currently being explored for low-acuity patients through various programs associated with MIH concepts and design, we are also looking to refine deployment and response plans to meet the clinical needs of the patient as demonstrated through measurable patient outcomes. This is achieved by isolating those patients that truly benefit from a response time where variations of seconds make a change in outcomes versus those where measurable minutes do not. This will assist the future sustainability of the system and mitigate to some degree the continual injection of millions of dollars in increased resources to keep pace with escalating demand. The goal is to ensure those who clinically need the fastest response get it and balance this with meeting the needs of all others in a variety of response options.

Healthcare reform: The government of Ontario has introduced "Patients First: Action Plan for Health Care," which has four priority areas:

  • Improve access: Provide faster access to the right care;
  • Connect services: Better coordination and integrated care closer to home;
  • Inform: Provide support through education and information;
  • Protect: Protect universal public healthcare systems, offering evidence-based value and quality.

This initiative is intended for the broader healthcare services and not specifically EMS. In fact, EMS is not explicitly identified as a systems component in making this achievable. However, this is changing as the province is learning through sponsored projects to further enhance the concept of MIH and work with partners in health and social services. An EMS aim of reducing ED visits, referring patients to alternative care pathways and working with primary care to ensure proper access to appropriate care aligns with the aim of the Patients First plan.

Larry Crewson, Director, Nova Scotia Emergency Health System

How does your system operate?

The Nova Scotia Emergency Health System is a provincial system, similar to what Kevin described, with one notable exception: All aspects of EHS are run as one unit under the EHS director of the NS Department of Health and Wellness. In our province EHS contracts for ground and air ambulance providers. There is one contracted provider for ground ambulance and the Medical Communications Centre (MCC) and separate contractors for air operations. All requests go through the 9-1-1 center, and medical calls are linked to the MCC and assigned to the contractor based on response determinants. Online physicians are available to the communications center 24/7 who help determine response levels. Adult, pediatric, neonatal and obstetric specialists are available by phone to assist with determining whether a ground or air unit is necessary and the most appropriate crew configuration for some interfacility transports.

Our system carries accreditations through the International Academies of Emergency Dispatch, Commission on Accreditation of Medical Transport Services and Commission on Accreditation of Ambulance Services.

What attributes of high-performance EMS are part of your system?

Sole provider: EHS owns all the assets and contracts for their operation. It is in many regards the classic public utility model system, plus an air-medical component. The air component is important due to the vast rural areas and remote locations including numerous islands.

External accountability: EHS is a public entity, and we are required to publicly report the operational and clinical performance of the contractor.

Control center operations: There is a single control center, and it is the only center for all ground and air ambulance operations.

Revenue maximization: As mentioned previously, our system is publicly funded, and the funding is made available based on the transparent reporting of our performance.

Flexible production strategy and dynamic resource management: Only one part of the province is staffed on a fixed strategy due to geography; for the majority the contractor uses a flexible production strategy. We use a system status plan (SSP) management approach to move resources around the region to maximize operational performance based on both temporal and geospatial modeling.

What metrics do you track to demonstrate value?

We track response times for ground and air operations, as well as clinical measures for improvement processes. EHS maintains a robust platform in partnership with Dalhousie University for the derivation of evidence-based prehospital protocols that are utilized as examples of best practices for other provinces.

What attributes of your system do you feel should be replicated in the U.S.?

Community paramedics: We have islands in our service area that are only accessible by ferry, and many of these islands have limited after-hours care centers. Our paramedics staff clinics at their stations where people with medical issues can come for assessment and some primary care treatments.

Palliative care: Across the province there are wait lists for skilled nursing facilities. Patients are looking for options to stay at home. To help with this, we provide specialty training for the medics to assist with patients registered with our Palliative Care Project to allow them to stay at home and more effectively navigate them through the healthcare system if they need additional care.

Falls program: We provide specialized training and resources for our medics to identify patients at increased risk for falls who warrant additional assessment. Once criteria are met and verbal consent obtained, the medics forward the patient care record to the Falls Prevention Program personnel in the health system for in-home follow-up to educate patients on how to reduce the risk of falls.

What trends will have the biggest impact on your system over the next 5–10 years?

Performance measures: The province is considering a move toward deemphasizing response times as a major measure for performance and looking for more patient-centered and clinical outcomes.

Call volume growth: Call volume growth needs to be continually addressed. We routinely see 4%–7% increases in call volume, likely attributable to an aging population. Being able to mitigate this rising volume and balance the impact of on the rest of the provincial healthcare system is becoming a major focus for the EHS.

Rob Lawrence, National Health Service Ambulance Service Trusts, United Kingdom

How does the U.K. EMS system operate?

The ambulance service trusts in the U.K. are part of the National Health Service. The model was created in 1948, just after World War II, and was based on military service evacuation models. In 1972 cardiologist Dr. Douglas Chamberlain created the paramedic practice for out-of-hospital care. Chamberlain was one of the authors of the Utstein template for reporting sudden cardiac arrest survival.

There are currently 11 trusts reflecting the regional political structure of the U.K. Regional “commissioning groups” establish the oversight and performance guidelines for the trust, giving local control to leaders for performance.

Calls to 9-9-9 (the equivalent to 9-1-1) are taken by NHS call centers in each regional ambulance trust. Each regional area handles the deployment and dispatch of ambulances throughout the service area. These systems use Medical Priority Dispatch algorithms and local National Health Service pathways to help triage severity and level of response. The systems are evaluated using national performance requirements reported to commissioning bodies.

In 2006 the certification of paramedics changed from a technician model to three-year university-based degree programs. Additionally the system uses emergency care practitioners (ECPs) who have enhanced credentials to deliver primary and acute care in single-paramedic vehicles for patients who can likely be treated and referred at the scene without the need for transport to an emergency department.

Dialing 9-9-9 in the U.K. does not necessarily mean an ambulance will be dispatched. The call taker will decide what is appropriate using both EMD and nurse triage protocols. This way ambulances are only sent on calls that will likely require transport to a hospital. The NHS also operates the 1-1-1 system, which is staffed by a team of fully trained advisers supported by experienced nurses and paramedics. They ask a series of questions to assess symptoms and direct callers to the best medical care. NHS 1-1-1 is available 24 hours a day, 365 days a year. Calls are free.

The master principle of the NHS is that care is free at the point of delivery. As a result ambulance trusts are nationally funded through national versus local taxation (VAT is a different thing). The government then allocates money to PCPs and employs commissioning groups to decide allocations and performance of the ambulance trusts in accordance with national performance and outcome goals.

What attributes of high-performance EMS are part of the U.K. system?

Sole provider: Each ambulance service trust is the only ambulance 9-9-9 (emergency) service authorized in the service area. This allows the systems to be very clinically proficient, operationally effective and fiscally efficient. There are some private providers for nonemergency work, but the ability of these providers to operate in the service area is decided by the commissioner and often as a result of a competitive bid process.

External accountability: The trusts are required to report the NHS ambulance quality indicators to the commissioner. These indicators include things like response times, AMAs, abandoned calls and compliance with clinical bundles for conditions like STEMI, stroke, asthma, hypoglycemia and cardiac arrest. A portion of the trust's funding is based on compliance with these measures.

Control center operations: The trusts operate their own call centers in partnership with the NHS, answering 9-9-9 and 1-1-1 calls and dispatching ambulances and ECPs.

Revenue maximization: The system is publicly funded, and the funding is made available based on the transparent reporting of operational and clinical performance.

Flexible production strategy and dynamic resource management: Many of the trusts do this for urban areas. In some rural areas they use static production and resource management strategies.

What metrics does the U.K. track to demonstrate value to the patients, payers and regulators?

The trusts are required to report their performance on national quality indicators such as clinical bundles and key operational performance measures. The Ambulance Quality Indicators data set is made available through a public website.1

What attributes of the U.K. system do you feel should be replicated in the U.S.?

Comparable performance metrics: Having a formal set of national performance measures that are publicly reported and usable to compare the operational and clinical performance of one ambulance provider to another.

The economic model:  The way the ambulance trusts are funded helps ensure a base level of service and eliminates collection issues. The model also incentivizes patient-centric decisions regarding patient destinations and outcomes.

Ambulance design: The European standard (CEN) for ambulance design focuses on functionality, ease of use for the crew and crashworthiness.2 For example, every vehicle has an integrated tail lift (ramp and winch) and uses common high-visibility color and design to minimize crashes.

What trends will have the biggest impact on the U.K. system over the next 5–10 years?

Brexit: It is likely that Brexit will lead to a period of austerity in the U.K., and ambulance trusts will have to do more with less.

Paramedic shortage: The seamless cross-boundary recruiting of paramedics throughout the E.U. and even Australia had been used to mitigate paramedic shortages in the U.K. That will likely change with Brexit, particularly if Eurozone medical staff lose the right to work in the U.K. The flow of Australian paramedics could also slow down or dry up as more jobs are now opening up with the large ambulance services there.

References

1. NHS England. Ambulance Quality Indicators Data 2015-16,  www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators/ambulance-quality-indicators-data-2015-16/.

2. Busch J. Simplicity in Form and Function. EMS World, www.emsworld.com/article/10886873/simplicity-in-form-and-function.

Kevin Smith started his career as a paramedic in Niagara after graduating from Niagara College in 1992 and going on to receive his Advanced Care Paramedic designation from Toronto's Michener Institute in 1998. Since receiving his Bachelor of Applied Business in Emergency Services degree in 2010, he has worked through various levels of the profession to his current position as chief of Niagara Emergency Medical Services.

Prior to commencing his work in Emergency Health Services, Larry Crewson was a multitour military helicopter pilot flying off ships in Canada and on exchange with the U.S. Navy. He went on to become a master air planner and director of operations to include homeland defense missions and support to natural disasters. He transferred those planning skills to critical care patient transfers in Ontario, Canada, before commencing his current role as EHS director for the province of Nova Scotia.

Rob Lawrence is chief operating officer of the Richmond (VA) Ambulance Authority. Before coming to the USA in 2008 to work as COO for RAA, he held the same position with the English county of Suffolk as part of the East of England Ambulance Service. He is a graduate of the Royal Military Academy Sandhurst and served in the Royal Army Medical Corps. After a 22-year military career in many prehospital and evacuation leadership roles, Rob joined the National Health Service, initially as the Commissioner of Ambulance Services in the East of England. He later served with the East Anglian Ambulance Service as director of operations. He is also a member of the EMS World editorial advisory board.

                                                                                                      

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