Emergency medical services in Canada

infobox country
common_name = Canada




capital = Ottawa [cite web|url=https://www.cia.gov/library/publications/the-world-factbook/geos/ca.html|title=All facts unless otherwise cited, are from: The CIA World Fact Book|accessdate=2008-10-06]
area_km2 = 9984670
area_sq_mi =
population_estimate = 33,212,696
population_estimate_year = July 2008
population_density_km2 = 3.32
population_density_sq_mi =
healthcare = Socialized

Emergency medical services in Canada are the responsibility of each Canadian province or territory. As such, the services, including both ambulance and paramedic services, may be provided directly by the province, may be contracted to a private provider, or may be delegated to the local government level, which may in turn create its own service delivery arrangements with municipal departments, hospitals, or private providers. The approach, and the standards, vary considerably between provinces and territories.

Organization

Land Ambulance

In Canada, responsibility for Emergency Medical Services, as a part of health care in general, has been allocated to the provincial/territorial level of government. With the exception of British Columbia, which operates its EMS services directly, the method used for service delivery will vary to some degree between jurisdictions. Typically, the provincial/territorial government will provide enabling legislation, standards, accreditation or licensing, [cite web|url=http://www.assembly.nl.ca/legislation/sr/regulations/rc960999.htm|title=Consolidated Newfoundland and Labrador Regulaton 999/96|accessdate=2008-09-24] and oversight to a variety of potential system operators, including municipalities, hospitals, or private companies. Municipalities or hospitals may also, in turn, elect to provide EMS service directly, as a branch of another municipal department, such as the fire department [cite web|url=http://www.winnipeg.ca/fps/|title=Winnipeg Fire and Paramedic Service website|accessdate=2008-09-25] or health department, [cite web|url=http://www.york.ca/Services/Emergency+Medical+Services/default+Emergency+Medical+Services.htm|title=York Region EMS website|accessdate=2008-09-25] or may contract out this responsibility to a private company. The approaches used for service delivery are governed by what is permitted under the legislation of the individual province or territory, or under the by-laws of a local municipality, when that municipality accepts responsibility for EMS service. [cite web|url=http://www.calgary.ca/DocGallery/BU/cityclerks/8118.pdf|title=City of Calgary By-law 8118|accessdate=2008-09-24] Provincial governments may also, as in the case of the provinces of New Brunswick, [cite web|url=http://www.accesswave.ca/~scan/nbambulance.htm|title=EMS and Hospitals in New Brunswick|accessdate:2008-09-25] Nova Scotia, [cite web|url=http://www.gov.ns.ca/ehs/|title=Nova Scotia Emergency Health Services website|accessdate=2008-09-25] and Prince Edward Island, [cite web|url=http://www.marscan.com/peiambulance.htm|title=EMS and Hospitals in Prince Edward Island|accessdate=2008-09-25] contract directly with a single private company, Medavie EMS [cite web|url =http://www.medavieems.com/|title =Medavie EMS website|accessdate=2008-09-25] (the same one in these three cases) to provide seamless, province-wide services.

Air Ambulance

Canadian provinces are also served by air ambulance services. These arrangements may come in a variety of forms, including direct service provision, contracts between private companies and the provincial government, or they may be 'brokerage' arrangements, in which one private company takes the lead on service provision, perhaps even operating some of their own aircraft and providing dispatch services, but subcontracting many of the operations to smaller air charter services. In some cases, the inter-facility transport of high-acuity patients may be a mix or air-based and ground-based resources. [cite web|url=http://www.ornge.ca/|title=ORNGE (Ontario) website|accessdate=2008-09-25] Canada is a vast country, and the sheer size dictates that in many cases, the traditional helicopter-based air ambulance service found in the U.S., the U.K., or Europe is impractical as the distances required exceed the flight range of the aircraft. For this reason, the use of fixed wing aircraft is commonplace. As another feature which is somewhat unique to Canada, in some jurisdictions not all air ambulance calls are emergencies; distances to tertiary care centres mean that patients with lower-acuity medical conditions will also be flown on occasion.

tandards

Vehicles

As examples of standards, individual provinces and territories will typically specify, generally through legislation and regulations, [cite web|url=http://www.qp.gov.sk.ca/documents/English/Regulations/Regulations/A18-1R1.pdf|title=Ambulance Regulations (1989), Province of Saskatchewan|accessdate=2008-09-24] the specifications and types of vehicles which may be used in EMS. These vehicles will include ambulances but may also include rapid response vehicles (sometimes called 'fly-cars'), and specialized Emergency Support Units, such as equipment vehicles and mass-casualty transport vehicles. To illustrate, each province or territory, and also the Canadian military, have their own unique ambulance specifications. Individual provinces or territories may also specify types of mandatory equipment in those vehicles, including medical equipment.

taffing and training

Individual provinces and territories will also typically specify required levels of mandatory staff training for that particular province. [cite web|url=http://www.cma.ca/multimedia/CMA/Content_images/Inside_cma/Accreditation/pdf/summary_regulations.pdf|title=Summary of Legislation and Regulations (2007)- Canadian Medical Association Conjoint Accreditation Services] At the moment British Columbia, Alberta, Nova Scotia, Ontario and Prince Edward Island are served by highly educated paramedics with advanced skill sets. Other jurisdictions have not yet reached these levels, and some jurisdictions have or are considering the introduction of critical care paramedics and/or paramedic practitioners. [>cite journal|author=Garza M|title= Canadian Paramedics Make House Calls|journal=JEMS|volume=32|year=2007|issue=9|url=http://www.jems.com/news_and_articles/articles/jems/3209/beyond_ems.html;jsessionid=1D1DD8262BCAE083C18E3691C94FD16D] On a province by province basis, the progress varies, driven primarily by public demand, acceptance by the medical community, and funding resources. A great deal of the recent advancement in standards of care and procedures have been driven by formal outcome-based research [cite journal|author= Stiell IG, Nesbitt LP, Pickett W, Munkley D, MD, Spaite DW, Banek J, Field B, Luinstra-Toohey L, Maloney J, Dreyer J, Lyver M, Campeau T, Wells G|title= The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity |journal=CMAJ|volume=178|year=2008|issue=9|doi=10.1503/cmaj.071154] and clinical trials. An excellent example of this was the groundbreaking research work on the management of S-T segment elevation myocardial infarctions (STEMI), undertaken in cooperation with the Ottawa Paramedic Service. [cite journal|author+Le May MR, So DY, Dionne R, Glover CA, Froeschl M, Wells GA, Davies RF, Sherrard HL, Maloney J, Marquis, J-F, O'Brien ER, Trickett J, Poirier P, Ryan S, Ha A, Joseph PG, and Labinaz M.|title=A Citywide Protocol for Primary PCI in ST-Segment Elevation Myocardial Infarction|journal=NEJM|volume=358|number=3|pages=231-240|url=http://content.nejm.org/cgi/content/short/358/3/231] Indeed, particularly in larger services, some paramedics undertake their own formal research projects or collaborate with other researchers in the medical community, leading to publication, as with the preceeding two references; both of which had paramedics in lead investigator roles.

Response times

Canada is such a diverse country, with 13 separate jurisdictions governing EMS operations, that no single standard for response time measurement currently exists. Urban areas, such as Toronto, will set standards according to percentiles, in this case the standard is 8 minutes and 59 seconds or less, 90 percent of the time on AMPDS triaged Delta and Echo calls. [cite web|url=http://www.health.gov.bc.ca/bcas/overview/|title=BC Ambulance Service website|accessdate=2008-09-30] There is no jurisdiction in Canada that is currently reporting successful acheivement of this response time standard, [cite web|url=http://www.canada.com/reginaleaderpost/news/story.html?id=9f5b3d38-cfb0-4776-9221-cb17f740ebfd|title=Regina Leader-Post article|accessdate=2008-09-30] and services cite a variety of reasons for this failure, but continue to aspire to the standard. [cite web|url=http://www.canada.com/ottawacitizen/news/story.html?id=9babe412-2dd3-4520-867f-7daf2253a622|title=Ottawa Citizen article|accessdate=2008-09-30] This approach to response time monitoring is accepted in most urban areas of the country, however, there are some jurisdictions which reasonably set a second standard for rural (the majority of the country) response. Such standards can vary from one jurisdiction to the next. Additionally, there are jurisdictions do not set specific response time objectives, instead simply reporting average response times for emergency calls. [cite web|url=http://www.gnb.ca/cnb/news/he/2007e0751he.htm|title=Ambulance New Brunswick website|accessdate=2008-09-30]

Towards national standards

There are currently major initiatives for improved standardization of staff training underway in Canadian EMS. The Paramedic Association of Canada has produced the National Occupational Competency Profile, [cite web|url=http://www.paramedic.ca/Content.aspx?ContentID=4&ContentTypeID=2|title=National Occupational Competency Profile|accessdate=2008-09-25] and many provinces are working toward meeting these standards. Provinces and territories are also responsible for standards with respect to the dispatching of EMS resources, and some jurisdictions are measuring performance, benchmarking, and setting standards. In addition, initiatives by the EMS Chiefs of Canada [cite web|url=http://www.emscc.ca/|title=EMS Chiefs of Canada website|accessdate=2008-09-25] organization are working towards improved interoperability and a 'best practices' approach to the overall management of EMS systems.

Funding and costs

EMS services in Canada are generally funded, at least in part, and to varying degrees, by the government of the province or territory in which they operate, through the Ministry of Health or Health Department of that level of government. Health insurance in Canada is universal, with the entire country operating in an environment of socialized medicine, and to some degree covers the cost of emergency ambulance service. The degree to which individual use of EMS is subsidized by provincial health insurance varies by province, and may be supplemented by either partial fees for service, or from the property tax revenues of local municipalities operating such services. The approach to such systems varies, as well. In some jurisdictions, funding is at the 100 percent level, [cite web|url=http://www.pchr.ca/Default.aspx?tabid=718|title=Peace Country Health Region (Alberta) website|accessdate=2008-09-25] and occurs without the patient being aware of its' existence. Other jurisdictions fund at varying levels, but may require 'up front' payment for service, which is subsequently reimbursed. [cite web|url=http://health.gov.sk.ca/adx/aspx/adxGetMedia.aspx?DocID=2141,94,88,Documents&MediaID=1367&Filename=ambulance-road-fees.pdf|title=Saskatchewan Regional Health Services - Road Ambulance Fees|accessdate=2008-09-25] This may be particularly true of out of jurisdiction services, with an individual from one province, who requires EMS service in another province, being required to pay for that service and then submit the receipt to their own provincial health insurance scheme for reimbursement. In some jurisdictions, such as Ontario, a 'deterrent fee' scheme is used to discourage the medically unnecessary use of EMS by the public. In such cases, the provincial health insurance scheme will pay the majority of the cost of EMS service (around 80%) for medically necessary EMS service (when a physician decides that the service was not medically necessary, they can cause the patient to pay the full, uninsured amount of the charge), [cite web|url=http://www.williamoslerhc.on.ca/body.cfm?id=269|title=Wm. Osler Health Centre website|accessdate=2008-09-25] with the patient receiving a bill for the additional 'deterrent fee' at some point after the emergency is over. Within Ontario, for example, such deterrent billing occurs through the receiving hospital, despite the fact that the hospital neither provides nor oversees EMS in most cases.

Private transport services

In addition to regular EMS, many jurisdictions also have non-emergency patient transport services operating. In many jurisdictions, these are companies who specialize in non-emergency patient transfers. Such companies have their own vehicles, which are similar to ambulances and carry similar patient care equipment. These services, certainly welcome and necessary, relieve the workload on public EMS through the elmination of some, or most, of the non-emergency transfer volume, [cite web|url=http://www.oha.com/client/OHA/OHA_LP4W_LND_WebStation.nsf/resources/Non-EmergencyAmbulanceTransferIssuesforOntarioHospitals/$file/Non-EmergencyAmbulanceTransferIssuesforOntariosHospitals.pdf|title=Non-Emergency Ambulance Transfer Issues for Ontario Hospitals|accessdate=2008-09-25] and some provide service to the public that is of the highest standard. In many cases, such services are small private business operations, using second-hand ambulances which have been retired from public EMS service, while others use vehicles expressly built for their purposes. [cite web|url=http://www.voyageurtransportation.ca/medical/|title=Voyageur Transportation website|accessdate=2008-09-25] There has, however, been some controversy, in some jurisdictions, with respect to the operating procedures of some (but not all) of these services. In some cases, the vehicles are often made to look as much like an EMS ambulance as possible, [cite web|url=http://www.froems.com/patient_transportation.html|title=First Response Ontario EMS website|accessdate=2008-09-25] even retaining emergency lights and sirens (which they are forbidden by law to actually use), and incorporating the word 'Paramedic' (this term is not protected in Canada), variations on 'EMS' (in some cases, 'Event Medical Services') or spelling variations of 'ambulance' (e.g. 'ambu-lans'), or using the Star of Life logo on their vehicle markings. While such services may not be breaking any current Canadian law, many Canadian paramedics believe that such services work hard to create an erroneous public impression, and that such practises actually mislead the public into the belief that they are receiving an equivalent service, when in fact they are not. These services are not generally licensed, or required to meet any recognized standard, and despite the impression that they work hard to create, the operators will quickly insist that they are not 'ambulances', because becoming actual ambulance services would subject them to licensing and standards. These services generally attempt to recruit staff who meet provincial EMS qualification standards, but are under no legal obligation to do so. Such services are not covered by provincial health insurance, operating on a fee-for-service basis, and are not considered to be a legitimate part of mainstream EMS. [cite web|url=http://www.health.gov.on.ca/english/public/program/ehs/land/service_qa.html|title=Ontario Ministry of Health website|accessdate=2008-09-25]

References

External links

* [http://www.paramedic.ca/ Paramedic Association of Canada]
* [http://www.apbc.ca/home/ Ambulance Paramedics of B.C.]
* [http://www.ontarioparamedic.ca/ Ontario Paramedic Association]
* [http://www.collegeofparamedics.sk.ca/ Saskatchewan College of Paramedics]
* [http://www.collegeofparamedics.org/ Alberta College of Paramedics]
* [http://www.paramedicsofmanitoba.ca/ Manitoba Paramedic Association]
* [http://www.paramedicduquebec.org/ Quebec Paramedic Association (in French)]
* [http://www.panb.ca Paramedic Association of New Brunswick]
* [http://www.cpns.ca/ College of Paramedics of Nova Scotia]
* [http://www.panl.ca/ Paramedic Association of Newfoundland and Labrador]