Overview

In 2013, the province will move to modernize the regulation of land ambulance response times. This means moving from the requirement that municipal land ambulance service operators meet provincially-established land ambulance response times, to a framework under which each upper tier municipality and designated delivery agent will have the freedom, flexibility and responsibility to establish, maintain, enforce, evaluate and update, and report to the ministry on, an annual response time performance plan and the response time performance that was achieved under each annual plan.

Current System

Prior to the transition of responsibility for land ambulance services to the municipal sector in 2001, the government requested that the Ministry of Health and Long-Term Care develop mechanisms by which the performance of post-transition land ambulance services could be measured. This request led to consultations with stakeholders and the subsequent development and implementation of a number of performance-based standards by the ministry.

One of these was the land ambulance response time standard, which requires that land ambulance operators – in 90% of “Code 4” (life-threatening) responses – meet the response times that had been achieved by the ambulance sector in 1996.

Response time for that purpose is defined as the elapsed time from the notification of the ambulance crew by the ambulance dispatcher of a patient requiring emergency care, to the arrival of the ambulance crew at the scene (“Time 2” to “Time 4” in the illustration below). The present response time measurement does not include the time required to process an emergency call by the ambulance communication service.

Although the response time standard is but one of over 100 standards that all Ontario land ambulance operators must comply with in order to attain and maintain land ambulance certification, response time has been adopted by the media and the public as a very visible means to gauge the efficiency and effectiveness of municipal land ambulance emergency response.

The Chronology of an Emergency Ambulance Call

An Opportunity for Change

Municipal Sector
The response times that each upper tier municipality and delivery agent is required to meet under the existing standard are now more than a decade old, and all stakeholders agree these times are no longer relevant to the operation of a modern EMS system.

The existing response time standard is based on a best-effort philosophy: each upper tier municipality and delivery agent is required to respond to all Code 4 calls within a prescribed timeframe based upon ambulance service performance in 1996.

The land ambulance system has matured significantly since 2001 when municipalities assumed land ambulance service delivery responsibility. However, instead of encouraging emergency ambulance services to recognize and respond to patients having the most severe emergency medical needs, ambulance service operators have been overly focused with trying to meet a ministry-established response time standards. These current standards mandate the same performance to all emergency calls, even in cases where there no identified medical benefit to a patient from receiving rapid ambulance response has been proven.

The new response time approach will provide for emergency ambulance response that is focused on making a difference to the health outcome of patients who are the most in need of receiving rapid pre-hospital care.

To remain relevant, ambulance response time performance must regularly adapt to changes in the demographic footprint of a municipality or community, as well as to the needs of each community and the evolving Ontario health care system. They must also recognize evidence-based medical information that identifies when providing rapid pre-hospital and ambulance response will have a likely positive impact on patient outcome.

Ambulance Dispatch
Land ambulance response time is currently defined as the elapsed time from the notification of the ambulance crew by the dispatcher to the arrival of the crew at the scene. The current response time definition applied to municipal land ambulance response does not include or recognize the time that is required to process a 9-1-1 call by ambulance communication call-takers and dispatchers.

Up to the first two minutes of all calls for emergency ambulance response is utilized by the ambulance communication service call taker to elicit caller location and patient symptom information, provide preliminary medical care advice to ensure patient safety, and to identify available ambulance resources and appropriate deployment plans and ultimately dispatch an ambulance to the call. And although not forming part of the current response time standard, this two minutes is part of the perceived response time of the ambulance as viewed from the patient’s perspective.

Ambulance dispatch reaction/notification time (dispatch response time)

Ministry/Municipal Consultations

The Municipal Amendment Act and the government’s memorandums of understanding with the Association of Municipalities of Ontario and the City of Toronto involves the municipal sector in decisions affecting them through a process of ongoing consultation related to matters of mutual interest.

Building on the existing partnership between the ministry (responsible under legislation to establish, maintain and operate land ambulance communication services, alone or in co-operation with others, and to fund such services) and the municipal sector (responsible under legislation for ensuring the proper provision of land ambulance services in the municipality in accordance with the needs of persons in the municipality, and to fund such services), a joint Land Ambulance Committee was established by the Ministry of Health and Long-Term Care to provide advice on issues related to improving provincial land ambulance services under the current fiscal framework

Recognizing that the current response time standard can and does not consider today’s patient demographics, modernizing of the health care system and changes to areas of growth, this committee undertook a review of current response time practices.

The Ministry of Health and Long-Term Care has implemented the new land ambulance and ambulance communication centre response time framework founded upon principles that have been advanced by the Land Ambulance Committee.

The New Provincial Land Ambulance Response Time Framework

Responsibilities of the Municipal Sector

Beginning in October 2012, every upper tier municipality and delivery agent will:

• Develop an annual response time performance plan;
• Ensure that this plan is continually maintained, enforced and where necessary, updated;
• Provide each plan and each update to the ministry;
• Report to ministry on the response time performance achieved under the previous year’s plan.

The response time performance plans developed by the municipal sector:

• Will include response time commitments for CTAS 1,2,3,4, and 5 patients. CTAS (Canadian Triage Acuity Scale) is an international medical triage standard utilized by hospitals, ambulance communication services and paramedics to identify how urgently a patient requires medical care;
• Will recognize that the attendance of any person equipped to provide defibrillation (including a paramedic, fire fighter, police officer or other first responder) to a sudden cardiac arrest patient will “stop” the response-time clock;
• May include municipal public safety & prevention education and promotion campaigns that could contribute to meeting municipal response time performance plans, such as:

• Fire and Police Defibrillation
• High School CPR Programs
• Community-Based First Aid Programs
• Fire Prevention and School Safety Programs
• Cardiac Safe City
• Police Safe Community Programs
• Public Health Safety & Prevention Programs, including programs to educate the public on the appropriate use of 9-1-1.

In providing performance reports to the ministry, each municipality, in addition to identifying its performance specific to the targets identified in its submitted plan, must also report on:

• The percentage of times that sudden cardiac arrest patients received assistance from a person equipped to provide defibrillation (e.g., paramedic, fire, police, or other first responder) within six minutes from the notification of a call by an ambulance communication service.
• The percentage of times that an ambulance crew has arrived on-scene to provide ambulance services to sudden cardiac arrest patients or other patients categorized as CTAS 1 within eight minutes of the of the time notice is received respecting such services.

Responsibilities of Ambulance Dispatch Centres
Beginning 2011, the time that a call requesting emergency ambulance response is first received at the ambulance communication service will be included in the overall response time reported by the ministry  (“Time 0” to “Time 4” in the illustration above).

This change acknowledges that up to the first two minutes of all calls for emergency ambulance response is utilized by the ambulance communication service call taker to elicit call and patient information, and to determine and dispatch the closest and most appropriate ambulance to the call.

The framework’s recognition of evidence-based response time to CTAS 1 and sudden cardiac arrest calls includes this two minute dispatch “call processing” time.

Consequently, to reinforce the responsibilities of land ambulance communication services to meet the two minute dispatch response time for emergency calls, every land ambulance communication service will develop an annual response time plan beginning in October 2012, provide this plan to the ministry, and report on its achievement in meeting the plan.

The land ambulance sector already works closely with dispatch centres in the development, implementation and tuning of land ambulance deployment plans and multi-agency tiered response agreements. It is expected that this strong collaboration will continue as ministry-, hospital- and municipally-operated communication services develop response time performance plans in conjunction with the municipalities they serve.

Responsibilities of the Ministry
The ongoing stewardship role of the Ministry of Health and Long-Term Care will be enhanced through strategic management, monitoring, regulatory compliance, and investigation of land ambulance services, and through the publication of municipal land ambulance and dispatch service response time plans and achievements on this web site.

The ministry will continue to deal with the matter of response times through a Regulation made under the Ambulance Act. This regulation will require that each upper tier municipality, delivery agent and ambulance communication service establish, maintain, enforce, evaluate, update and report on, a plan for setting and meeting response time targets to emergency ambulance calls.

Municipally-established response time performance plans will not replace the need for land ambulance service operators to meet a response time standard as part of the ministry’s land ambulance service certification review. However, the existing response time standard will be replaced.

As of January 1, 2011, land ambulance services will be required to follow the response time targets set out in municipally-established response time performance plans, rather than meet the 90th percentile response times from 1996. Once land ambulance services are operating under the response time performance plans established by municipalities and delivery agents, those land ambulance services who respond in accordance with municipally-defined response time performance plans would be deemed to meet the ministry’s land ambulance response time certification requirement.

The ministry will continue to monitor and enforce land ambulance service compliance with the Ambulance Act, Regulations and Standards:

• Ensuring that upper tier municipalities and delivery agents responsible for land ambulance services and ambulance dispatch centres have response time plans in place for all emergency calls;
• Annually receiving, assessing and making available to the public the response time plans and the performance in meeting each plan’s targets;
• Assisting the land ambulance sector to promote response time best practices that are identified from other jurisdictions.