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:
- Try transporting selected patients to destinations other than hospital emergency departments (clinics, urgent care centers, etc.) or assessing and releasing them if they don't require immediate attention.
- Better promote Telehealth Ontario, a free provincewide 24/7 nurse advice line, and try referring low-acuity callers to it.
- The Ministry of Health and Long-Term Care should implement outreach teams to support enhanced community care of patients in long-term care homes.
- See if communications-center software can better coordinate patient distribution decisions.
The report also instructed EDs to develop prediversion surge protocols, and urged hospitals to find ways to better predict and handle patient bottlenecks.
In a move Americans may find shocking, the Ontario government actually backed the Improving Access findings with cash and resources. Simultaneously with the report's release, Smitherman announced a $96 million plan to realize its findings. The plan included allotting more than $5 million for a pair of alternative-destination demonstration projects. It was supplemented by what the provincial government called its Critical Care Strategy, a companion effort to help relieve ED pressures at the hospital level.
While limited in scope, the alternative-destination projects, now completed, displayed much promise.
"It was just a study for us, but I think it was important, because we did demonstrate that low-acuity patients don't necessarily need to go to a hospital emergency department," says Toronto EMS Chief Bruce Farr, who was part of the team behind the Improving Access report. "Urgent care centers really can fill their needs. The big problem was getting to them, because there were only two."
The Ministry of Health is also funding increased home-care personal support and nurse-led outreach teams to patients in long-term care homes. Generally, authorities in Ontario, as in many places, are embracing the concepts of public health—taking proactive care to at-risk populations in hopes of preventing emergency calls before they occur. In Toronto, a key component of this is a program called CREMS, for Community Referral by EMS.
"Our paramedics can now go into a person's home and determine that they don't have an immediate health problem, but they do have care access issues," says Farr. "It might be something like a broken piece of equipment. Instead of transporting that patient by ambulance, our paramedics can call a number and give the patient confirmation that at, say, 10 o'clock tomorrow morning, they'll hear from somebody who can fix their problem."
"People can get a consult from community care staff and visits from home-care staff," adds Gillies. "If it's something chronic, like someone going to the hospital to have their dressings changed, well, that's something home care can provide. Instead of them being a constant ambulance call every two or three days, why don't we just have community services come to their home and do that for them?"
That kind of outreach has led to a drop in repatriation calls (i.e., taking patients back to hospitals that have treated them) and on the whole has been so successful that it may be expanded.
Other measures tried in Ontario will seem more familiar to American providers. One recent effort involves dispatching medics to hospitals to watch over multiple patients awaiting handoff, thus freeing multiple crews. Another is better tracking and managing the distribution of nonurgent patients to hospitals through a central communications center, making sure ambulances are, as possible, sent to unclogged EDs.
A new project from the Ministry involves funding the hiring of emergency department nurses specifically dedicated to receiving and caring for ambulance patients. This allows the faster turnaround of delivering EMS crews that previously might have been delayed.
"We're nicknaming them the EMS Hallway Nurse, because they're going to be looking after our patients only," says Gillies. "They won't be doing triage, they won't be running to do bloodwork on other patients. They're solely looking after EMS patients. Hopefully that will take some of the stress off of our crews."
Despite some initial reservations, Ontario hospitals have largely bought in to these various initiatives, and while the EMS nurse effort is just getting started, it seems to be showing benefits already.
"We already have three hospitals up and running with EMS nurses in the emergency departments, and we have signed agreements from 13 of our 14 key hospitals that we want on board," says Farr. "They're doing their best to find nurses to fill these positions, and while it's too early to tell, statistically, how it's working, we're already seeing what appear to be major improvements in a couple of those hospitals."
THE HOSPITALS' ROLE
As in the U.S., the problem of emergency department overload and resulting diversion/offload delays, as much as it impacts ambulance operations, must primarily be addressed through solutions at the hospital level. This aspect hasn't been overlooked in Ontario. The Ministry's $90 million Critical Care Strategy is aimed at improving access to and the quality of critical care services in the province by addressing the policy, funding and operational issues that contribute to wait times. It consists of seven initiatives, including creation of critical care response teams (with intensive-care physicians and nurses and respiratory therapists available 24/7); focus on capacity management and surge planning; development of health human resources (e.g., training intensive-care doctors or physicians in community hospitals in advanced resuscitation techniques); providing system-level training; improving critical care information systems; collaborations for performance improvement; and examining ethical aspects of access.
To support the effort, hospitals are measuring and reporting key performance indicators, including ambulance offload times.
"When you start to tie pay for performance around that, you very quickly get the attention of hospitals' senior administration," notes Farr. "We have an excellent working relationship with our hospital CEOs in our community, and they very carefully watch the performance of their EDs. I don't think that happened 10 years ago."
Another strategy that must be part of any solution is the creation of more long-term care homes, which are presently too few in Ontario. Many patients who seek hospital treatment—and occupy beds for extended periods—could be more efficiently served in such facilities, authorities say. As well, there will be an even greater emphasis on home and community care. The province last year debuted its Aging at Home strategy to expand community living options for seniors with a wider range of home care and community support services. It's directing more than $700 million to the effort, giving 14 Local Health Integration Networks (LHINs) latitude to try new approaches and develop new partnerships.
Throwing money at a problem doesn't always solve it. But as American providers can attest, solving the intractable challenges of EMS without money is no picnic either. All other things being equal, it can be helpful, for patients and providers alike, to have good support from the state—especially with systemic problems like offload delays.
"My paramedics come in and work their 12-hour shifts and do an excellent job," Farr says. "And at 7 o'clock at night, I don't like to see anybody who should be sitting down to dinner with their family or going to their child's hockey game forced to stay and give care to a patient in a hospital corridor. If we can stop that, the bonus that comes along is being able to give better service to the community, and make sure ambulance availability is as good as we can have it."
Esteem Power: How Respect Benefits EMS Recruitment Down Under
First some similarities: Like EMS in America, emergency ambulance service in Australia is largely run at the state level. Demand is rising, and there are occasional, and occasionally severe, manpower shortages.
But there are some significant differences between the countries that give important context to any discussion of measures to ensure an adequate workforce. Most important, prehospital emergency care is, to put a blunt point on it, valued in Australia.
It's supported by the national government. It's supported by state governments. It's well integrated into an established continuum of public health and healthcare. And even young people seem to hold it in something close to actual esteem.
So you see we're talking apples to oranges here.
"It's really been, in recent years, an emerging profession," says Bill Lord, head of undergraduate paramedic programs at Monash University in Victoria, the nation's largest university. "Ten or 20 years ago, ambulance officers were really just technicians, and they saw themselves as part of an emergency service. Now, in most states, ambulance is clearly aligned with health. We don't see ourselves as part of the fire or rescue services."
This distinction, which almost fully omits the public safety component of the American EMS identity, may be part of the solution to manpower issues—not in and of itself (worker shortages persist across the Australian healthcare fields), but because it lets ambulance services reap the full benefit of the government's support of healthcare.
HIGHLY DESIRABLE
Take Victoria. Starting salary for new medics there is around $50,000 U.S., plus 10 weeks of paid leave per year. There's also plenty of opportunity for overtime.
"There are sometimes long hours, but the conditions are pretty good," says Lord. "There's good superannuation, and the salary's good. Some paramedics can earn $100,000 a year through overtime."
There are shortages in Victoria, but one of the contributors is a current transition in paramedic education models. Services throughout the country are moving from hire-then-train systems to hiring graduates of the nation's university paramedic programs. There are currently only 11 such university programs in Australia and New Zealand, and they're not turning out enough graduates to meet services' needs. Meanwhile, call volumes are rising, exacerbating shortages. The Victoria government has funded hundreds of new paramedic positions, but boosting the number of available university program slots to fill them depends on federal funding that's not expected to be forthcoming.
All the universities can do, then, is shift open student positions from less-popular degree programs. They can't create new positions, but they can move existing ones around to accommodate demand. And at least at Monash, demand is healthy indeed. Its bachelor's-level paramedic course was the university's fourth most popular choice among prospective students in 2007.
"Which is bizarre," says Lord, "given that we offer the full range of medicine, law, engineering and more. We had more people wanting to do the paramedic course at this university than all those other disciplines except medicine. It's a highly sought after profession."
Among Lord's students are those qualified in pharmacy, nursing, behavioral neuroscience, biomedical science and physical therapy, as well as disciplines like podiatry and myotherapy. Many have given up established healthcare careers to take paramedic courses. One passed on a place in medicine. Last time Monash opened enrollment for its program, it had 60 positions available. Around 600–700 applied.
FILLING HOLES
Even with good general interest in the profession, though, Australia's primary state-operated ambulance services, faced with low unemployment and rising demand, have had to take steps to keep their positions filled.
"What most of the jurisdictions have done includes recruiting interstate—poaching from each other, really—and introducing an overseas workforce component," says Lyn Pearson, executive director of the Council of Ambulance Authorities, an umbrella organization representing the state services. "That's gone a good ways toward resolving the issue for the moment."
Luring from your neighbor doesn't much help their staffing issues, of course, but new environments can help keep peripatetic providers stimulated, and services can benefit from the new perspectives of new blood. Moving around domestically has also become easier to do: Australian practice guidelines are largely similar state to state, and the CAA is working to develop an accreditation process for the university programs to ensure their students meet standard minimum qualifications.
"It makes a degree much more transportable," Pearson says. "Movement between the states is pretty easy now because there's not much difference in what they're looking for. It's usually just local training that needs to occur to qualify someone to work in another state."
In many places, those with healthcare backgrounds can be fast-tracked through training and into service. That includes those from overseas—a number of states are actively courting foreign providers. Leading the way is Australia's most populous state, New South Wales.
"I guess we have a big draw in that a lot of people want to migrate to Australia," says MishKaa Griffiths, who manages recruitment for the Ambulance Service of New South Wales. "It's a young country, crime levels aren't as bad as in many countries, and a lot of people want to move here with their children."
The service is, importantly, the only one in Australia that offers permanent visas to overseas-trained medics. Other states offer only temporary visas.
"Once someone comes to work for us," Griffiths notes, "they're a permanent resident of Australia and have access to things all permanent residents do, such as healthcare and so forth."
There are still some shortages, of course; providers, as part of a current dispute with state government, want 360 more staff added to the service. But even as that is worked out, pay and working conditions continue to improve. NSW ambulance officers would get an 8% work value pay raise, in addition to a 2.5% general wage increase, under a July proposal from the state health department.
Where shortages persist, other, more familiar stopgap-type measures have been employed. In some places, firefighters are utilized as first responders. Others have turned to single-paramedic response models. Elsewhere, medics have stopped doing interfacility transfers. And in many places, variations on the public health and community paramedicine themes are being pursued as a way to prevent problems before they occur.
This concept relates to the recruitment issue in two ways. First, by preventing emergency calls, it helps control call volume and reduce overtime, thus improving working conditions. Second, it provides an opportunity for nonemergency work in the community, a more-personal and less-physical alternative to riding the ambulance that may appeal to some types of providers.
"That might keep the interest of the paramedic in small communities where there's not enough emergency work to keep them busy all the time," suggests Pearson. "If they're doing that kind of thing as well, it fulfills a need that's not been able to be filled in other ways."
"It might make the job even more attractive," adds Lord, "if there's a pathway to specialize as a more autonomous, independent kind of health professional."
That kind of approach especially makes sense in rural areas, which Australia has in abundance. Most of the country's population is along its coasts; the interior can be amazingly sparse. In the Northern Territory, there are 215,000 people over an area more than twice as big as Texas.
Maintaining ambulance service in these areas can take some doing. Most services rely heavily on volunteers; in many rural and small-town locations, the spirit of volunteerism remains strong. Victoria, though, has taken the additional step of paying its vols—some now earn up to $40,000 a year from running calls on top of their full-time jobs.
There are fewer vols in New South Wales, and small towns there are typically served by paid medics on compulsory postings. They aren't always pleased to go, frankly, but have been known to come to see the virtues of such settings.
"Most of these communities are extremely tight-knit," says Griffiths. "Some of the city officers we send out there go kicking and screaming. Then when they come back a year later, they say it's the best thing they ever did, and in fact want to stay there, because the housing is cheaper, and their kids have fresher air and all those good country things. People there will do anything for you."
WORKFORCE PLANNING
The intricacies of delivering ambulance care in a place like Australia require an organized, systematic approach, and so a lot of attention has been paid in the country to developing the workforce of the future. "Services need to be able to offer employment that's attractive to people," says Lord, "and that's largely a function of the nature of the work."
The community paramedicine approach and potentially expanded scopes of care are part of this. And as younger workers enter the field, other changes are occurring too.
"The whole XY generation looks a lot more at their work/life balance issues," says Pearson, whose group has examined the changing worker base. "That means thinking much harder about issues like part-time employment. We have a very small part-time workforce in ambulance, but we're seeing more people wanting to work part-time. Services will have to prepare for that."
Bucking national trends, New South Wales is maintaining its in-house training model, which allows it to develop street-ready medics faster. But it's also working with its local university, Charles Sturt, to employ paramedic students during the second year of their three-year courses, then boosting their pay when they complete their degrees.
"We're changing that model so it'll be more encouraging for people to go to university and complete their degrees," Griffiths says, "as well as start with us earlier and reap all the benefits. We know the future is graduates, but right now it's important to have a mixture."
FLEXIBILITY
For Australian ambulance services, flexibility is a key in recruitment, whether it's in training/education, work hours and shifts, or moving between states. It's also more than a little helpful to pay providers a decent wage and give them bearable working conditions.
American systems may not have the political backing to do all these things. But they should note the wisdom behind them.
"It's a huge challenge to get people attracted to your service—I think that's a worldwide issue," says Griffiths. "I think the important thing with any job is that as long as you offer your staff something of value, they'll stay."
Choose Wisely: Protecting U.K. Medics From Violence, Abuse
Start with some numbers: Last year, the Sunday Telegraph newspaper reported in July, there were 57,205 physical assaults on health and emergency workers in the United Kingdom. That's 1,100 a week. Ambulance staff, a U.K. healthcare watchdog found in 2004, endure more violence and bullying than other employees of the country's National Health Service, with more than half of surveyed paramedics and ambulance technicians having had calls turn physical. Of particular concern is knife violence: This year's British Crime Survey documented more than 350 knife assaults a day across England and Wales. Stab-proof vests for EMS crews, first introduced in London in 2002, spread to Essex in 2006 and are now being trialed even in rural Shropshire.
Also, some of those prehospital numbers might be low.
"I think there's a large element of underreporting," says Richard Hampton, head of the National Health Service's Security Management Service, which oversees the protection of U.K. healthcare workers, including those on ambulances. "Some members of staff may believe being assaulted is part of their job, or don't think anything will be done about it. Well, it self-evidently is not part of their job, and nothing can be done about it if it's not reported."
Doing something about violence against ambulance staff and other healthcare providers is the challenge facing Hampton's office and the U.K.'s local healthcare trusts. Here's some of what they're trying.
'MAKE YOUR CHOICE'
The Security Management Service took on the job of reducing violence against NHS staff in 2003. One of its first steps was to establish standard definitions for both physical and nonphysical assaults (e.g., threats, verbal abuse), so as to better measure and track the problem. It also directed individual health bodies (ambulance services, hospitals, etc.) to name security managers to serve as local contact points on all issues of violence and provider safety.
"That role is critical," says Hampton. "These people are on the ground, and they know what's needed and appropriate for the needs of their individual health bodies."
The SMS trains and accredits these specialists, who also oversee security of things like medications and physical assets. They liaison regularly with the Service and lead local implementation of security measures, and work for prosecutions of offenders. Health bodies must also have an executive board member who champions security management.
Front-line providers also receive conflict resolution training. This starts with learning to recognize potential hazards and situations that could turn ugly and act in a manner to defuse them, and progresses on to basic techniques of self-defense: how to break away when being held, use of the ambulance as a safe haven, etc.
More recently, the Your Choice of Treatment campaign began its national pilot in Kent, where 1,870 NHS staff had been attacked in three years. It's essentially an advertising campaign with a clear and simple message: You can be treated by ambulance staff, or you can be treated by law enforcement and the justice system. Vivid visual depictions of both alternatives are prominently displayed on the sides of ambulances and throughout the community, and officials tout the ultimatum to local media.
"It's basically saying, 'Make your choice'," explains Bill Chilcott, who until July served as security manager for the South East Coast Ambulance Service (SECAmb), which serves Kent, Surrey and Sussex. "Behave well, and you'll come in the ambulance. Don't behave well, and you'll go in a prison van. We're sending the message to the public that attacks on our staff are unacceptable, and we're sending the message to staff that if it occurs, you need to report it, and we will support you in taking action."
"We will take whatever appropriate action is necessary," adds Hampton. "There are a range of sanctions that can be brought against individuals, and jail is one of them."
Getting that message across is as important internally as it is externally. It's zero tolerance for abuse of ambulance workers, but it hinges on oft-put-upon field providers reporting all their incidents, no matter how frequent, seemingly trivial or ultimately harmless. That doesn't always happen.
"I believe we have a lot of underreporting," says Chilcott. "Crews that work in busy urban areas with things like pubs and nightclubs often confront people who are aggressive in the way they speak and behave. Staff may become immune, to a certain extent, to that kind of behavior, and therefore don't report it. We're trying to create a culture where staff report assaults, and we will support them in having action taken against anyone who assaults them."
"The message we need to get over is, we need to report every single incident, however minor," says Hampton. "Sometimes, with a violent individual, it's not one incident that allows action to be taken. Sometime it takes a number of incidents. Only by reporting can we find out that these incidents have happened. It requires a cumulative approach."
DANGER ZONES
Locally, some communities have turned to "blacklisting" addresses where they fear staff may be attacked. This doesn't mean refusing to respond; it means responding with eyes wide open, and possibly law enforcement backup. Last year in Merseyside and Cheshire, there were more than 200 addresses to which police escorts had to accompany ambulance responses due to past instances of violence or aggression. In the Lothians region of Scotland, the measure is one of several thought to be contributing to a recent reduction in attacks on crews.
SECAmb has two levels of what it calls "history markers." Addresses where crews have actually been assaulted or seen weapons displayed get red markers, and future responses to those locations require police accompaniment. In places where someone's merely been aggressive—verbally abusive or threatening in manner—the marker is amber, and crews know to proceed with caution.
"We don't contact the police, and so some of our staff are reticent about attending addresses with amber marks," Chilcott notes. "They believe they're at risk and could be assaulted. So what we say is, go and make an assessment with the person who's there, and if you need the police at that stage, call them."
The idea here is not only that even bullies and jerks deserve basic medical care, but that there might also be others living at the address, and a problem person's spouse, child, parent or visitor shouldn't be penalized for their pugnacity. As well, people die and simply move away. Ergo, the law requires twice-yearly review to make sure information on marked addresses remains valid. If a red-marked address has had no further incidents after six months, it can be downgraded to amber. Similarly, amber locations can have their markers removed if there have been no more problems. This recognizes that even nice folks can behave badly if they or a loved one are in pain or medical distress.
BODY ARMOR
Body armor isn't yet sweeping the British ambulance services, but it has its supporters. The London Ambulance Service, facing an assault a day on its staff, broke this ground by outfitting its 2,200 providers in the capital in 2002. Providers in adjacent Essex, having seen the vests on their LAS counterparts at joint incidents, requested and got them two years ago. "I would much rather have seen the cost of providing the vests spent elsewhere," the chief executive of the Essex Ambulance Service, Anthony Marsh, told the Essex Chronicle, "but ultimately we need to ensure that staff feel, and are, as safe as possible."
In July, The Observer newspaper reported that the Oxfordshire-based Body Armour Company had received roughly 10,000 orders for vests from local government, primarily for front-line NHS staff, and that overall, stab- and bullet-proof vests were being procured in the "tens of thousands."
Outside of London, anyway, this all may be a bit premature. Essex hadn't actually had any staff stabbed before issuing the vests, and 30% of providers surveyed in West Midlands (Shropshire) didn't even want them.
In SECAmb's case—and from the national perspective as well, according to Hampton—the evidence isn't yet strong enough to warrant them for all providers.
"We believe we should only give this type of equipment where the threat clearly exists," Chilcott says. "We haven't had any bladed attacks on our staff reported. If we had, that would be evidence for us to give our people stab vests. Our line is that we will issue stab vests when it is necessary to issue them. And we review the threat regularly."
This, by the way, is a good illustration of why reporting incidents is considered so important by the NHS. Anyone would report being slashed or stabbed, presumably, but in evaluating the knife threat and the need for stab vests, officials also need to know about things like mere brandishings.
"You can only really put in a measure if you have the evidence to support it," Hampton says. "If someone has experienced a knife problem that's not reported, then an ill-informed decision is going to be made about the protection of staff."
PROGRESS?
Because of the varying ways assaults on providers were defined before the SMS began tracking them, it's difficult to compare today's rates of violence to those of five or 10 years ago. The first complete set of data on the subject the SMS has is from 2004–05, and it showed 1,333 reported physical assaults against ambulance personnel in England. For 2006–07, that number had dipped to 1,006, a decrease of almost 25%. "We're rather hoping that's as a result of some of the things we've done," Hampton says.
Since the Service's various efforts are still relatively new, it's hard to know for sure. Overall, crime in Britain dropped by 9% in 2007, and violent crime by 12%, so trends society-wide are positive. Still, with high-profile attacks continuing, it can't hurt to stake out an unmistakable position of zero tolerance for violence.
With that as the NHS' stance, transgressors know to expect a hard line, and providers know their service will have their back. That's good to know when it's a jungle out there.
"What I have the most difficulty with," says Hampton, "is that on 55,709 occasions in the last financial year, somebody considered it entirely appropriate to assault a member of NHS staff. Each member of the NHS staff is dedicated to providing care for somebody. And there is a distinct paradox between the intention to provide care and the total lack of respect that results in an assault. It's something we need to address.
"I'd be astonished if I saw any job description that had being assaulted as part of it."
