The Curious Case of the Overlook

What if you could snap your fingers tomorrow and instantly have thirty percent more ambulances on the road in your community with minimal cost? They say when something sounds too good to be true it probably is. But hyperbole aside, with a deep dive we have this capability just lying in wait in Ontario Paramedic Services.

Paramedic services in Ontario are facing a growing challenge: a significant proportion of calls result in patients refusing transport to the hospital. While patient autonomy and the right to refuse care are paramount, the high rate of sign offs or refusals of transport raises concerns about resource allocation and the sustainability of the emergency medical system. My latest diatribe delves into the issue of low acuity ambulance calls in Ontario, exploring the potential causes, impact, and possible solutions to mitigate this growing concern.

The Growing Demand for Paramedic Services

Research indicates a substantial increase in demand for paramedic transportation in Ontario. One study revealed that between 2010 and 2019, the demand for paramedic services increased by almost 40%, exceeding population growth. This surge may be attributed to factors such as population growth, an aging population with complex medical conditions, and pre-existing issues affecting Ontario's healthcare system . For instance, the Ottawa Paramedic Service reported a 4.9% increase in response volume in 2023 compared to the previous year, with an average annual increase of 5.2% over the past decade.

The Rising Tide of Refusals

While specific data on sign off rates in urban centers in Ontario is limited, anecdotal evidence suggests that these rates are nearing 30%. This high volume of refusals, combined with the increasing demand for paramedic services, presents a significant challenge. There is a very small portion of these calls that are high acuity and simply have no interest in seeking further medical care and/or transport to hospital. But this is a small sliver. The overwhelming majority of patient refusals are due to extremely low acuity complaints that require minimal healthcare all the way to requiring zero healthcare at all. This, in turn, can negatively impact response times to emergency calls.

Patient Refusal Standards and Protocols

In Ontario, when a patient or their substitute decision-maker refuses treatment or transport, paramedics must adhere to the BLS-PCS Patient Refusal of Treatment Standard. This standard requires paramedics to: 1) Make reasonable efforts to inform the patient or substitute decision-maker that treatment and/or transport are recommended and explain the possible consequences of refusal 2) Confirm that the patient or substitute decision-maker has the capacity to make an informed decision, utilizing the Aid to Capacity Assessment as outlined in the Ambulance Call Report Completion Manual 3) Advise the patient or substitute decision-maker to call 911 again if further concerns arise and 4) Obtain signatures and complete additional documentation requirements as per the Ontario Documentation Standards and the Ambulance Call Report Completion Manual.

Unpacking the Why Behind Refusals

Understanding the reasons behind high refusal rates is crucial to addressing the issue. While some refusals are legitimate, others may stem from various factors:

• Fear of hospitals: Primarily occurred during the COVID pandemic but persists to some degree today, some individuals may hesitate to go to the hospital due to anxiety about medical procedures, fear of contracting infections, or concerns about non-OHIP covered costs. In some cases, patients may be unaware of the co-payment structure for ambulance services in Ontario, where a $45 fee applies for those with valid Ontario Health Insurance.
• Lack of alternative care options: Patients may call 9-1-1 due to a lack of awareness or access to alternatives like urgent care clinics or telehealth services . This highlights the need for better public education on available healthcare options and when it is appropriate to call for an ambulance.
• Misunderstanding of Paramedic Services: Public perception of paramedics as solely transport providers may lead to calls for non-emergency situations where alternative care would be more appropriate . This misconception can contribute to unnecessary ambulance calls and strain on resources.
• Increased Utilization by Older Adults: Studies suggest a growing trend of older adults utilizing paramedic services for non-emergent needs, such as lift assists or falls without significant injuries . This may be due to factors such as limited mobility, social isolation, or lack of support at home.
• Transportation Barriers: Difficulties with transportation, especially in rural areas, may lead individuals to rely on ambulances as a means of accessing healthcare, even for non-urgent issues . This highlights the need for accessible and affordable transportation options for non-emergency medical needs.

The Impact on Paramedic Services

The high rate of low acuity calls (not just patient refusals but as a whole) has a cascading effect on paramedic services:

• Resource Allocation: Ambulances and paramedics attending to non-emergent calls are diverted from potentially life-threatening situations, leading to delays in response times for critical emergencies . This is further compounded by increasing in-hospital wait times which is always a ebb and flow scenario.
• Increased Workload and Burnout: The constant pressure of responding to a high volume of calls, including those that result in refusals, contributes to increased workload and stress for paramedics, potentially leading to burnout and staff shortages. Paramedic services in Ontario already face high attrition rates, with many services competing for a limited pool of qualified applicants.
• Financial Strain: Unnecessary calls place a financial burden on the healthcare system, with costs associated with ambulance dispatch, paramedic time, and hospital resources, even when transport is refused. For example, the utilization of Paramedic Services for lift assists, where individuals require help getting up but do not need medical transport, has substantial financial consequences.
• Increased Liability: The increase in refusal rates, coupled with the potential for misinterpreting patient conditions, can increase the legal risk for paramedics. Failing to properly assess and document a refusal, especially in cases with time-sensitive conditions, can lead to liability if the patients condition deteriorates.

The Data Gap: A Need for Deeper Analysis

While paramedic services collect extensive data on all patient encounters, including refusals of transport, there is a significant gap in the capacity to analyze this data effectively. Historically, paramedic services have not had dedicated data analytics staff to perform in-depth analysis of refusal calls and identify trends, patterns, and underlying causes. This lack of analytical capacity hinders the ability to understand the why behind refusals and develop targeted interventions to address the issue. Investing in data analytics expertise and infrastructure is crucial for paramedic services to gain a deeper understanding of refusal calls. This includes: Hiring dedicated data analysts: Employing data analysts with expertise in healthcare data analysis can enable paramedic services to extract meaningful insights from their data. Implementing data analysis tools: Investing in software and tools for data visualization, statistical analysis, and predictive modeling can facilitate data exploration and identification of trends. Developing data-driven decision-making processes: Integrating data analysis into decision-making processes can ensure that interventions and strategies are informed by evidence and targeted effectively. By bridging this data gap, paramedic services can move beyond anecdotal evidence and gain a comprehensive understanding of the factors driving refusal rates. This will enable them to develop and implement data-driven solutions to reduce unnecessary calls and optimize resource allocation. Ontario Paramedic Services are sitting on a literal gold mine of data but are they really looking at it and how we can take these refusal rates down to near zero?

Strategies for Reducing Patient Refusal Calls

Addressing the issue of low acuity patient refusal calls requires a multi-pronged approach. As I said above we need to dig deep and identify our problem first. We must find the theme and trends in these calls and then tackle those results specifically. But generally speaking:

• Public Education Campaigns: Educating the public about appropriate use of 911, alternative care options, and the role of paramedics can help reduce calls for non-emergency situations . This can be achieved through public service announcements, community outreach programs, and online resources. As much as I am not a fan of the "results" this solution gets I do recognize it's an important part of service identity. Most urban centre services that have these high rates of low acuity patient refusal calls also have somebody that handles public relations/communications.
• Community Paramedicine Programs: Continue to fund our ever expanding community paramedicine programs which can provide proactive care for frequent callers, older adults, and individuals with chronic conditions, reducing their reliance on emergency services. Community paramedics can provide services such as medication management, wound care, and health education in patients homes, potentially preventing unnecessary hospital visits and 911 calls. This approach has been shown to reduce 911 calls, emergency room visits, and hospital readmission rates. We are indeed doing this really well in Ontario and it will continue to evolve and flourish.
• Alternative Transportation Programs: Implementing or improving transportation services for non-emergency medical needs can reduce reliance on ambulances for transportation to healthcare facilities . This could include expanding public transportation options, providing subsidized transportation services, or partnering with community organizations to offer rides to appointments. Consider the success of the Niagara EMS pilot taxi program. It brings the operational cost of a medical call down to 40 or 50 bucks as opposed to 800-1000. And in it's first iteration had absolutely zero adverse patient outcomes as a result. This solution is perfect for a specific subset of patient population and should be expanded.
• Alternative Destinations: Another work in progress around Ontario. Paramedics are being given access as we speak to transport to mental health facilities, urgent care centres, and detox centres. This can help ensure that patients receive the most appropriate level of care and reduce overcrowding in emergency departments. I will make the argument this does not require two paramedics in an ambulance. Case in point, the BCEHS "LARU" or Low Acuity Response Units. This requires a bit better of the following step though...
• Enhanced Call Triage and Dispatch: Improving call triage and dispatch systems, such as implementing the Medical Priority Dispatch System (MPDS), can help prioritize calls and ensure that ambulances are dispatched appropriately. MPDS uses a standardized set of questions and protocols to assess the urgency of calls and determine the appropriate level of response. This can help reduce response times for critical emergencies and improve resource allocation.
• Collaboration with Healthcare Providers: Strengthening communication and coordination between paramedic services, hospitals, and other healthcare providers can facilitate alternative care pathways and reduce unnecessary transports. This could include establishing direct referral systems, where paramedics can refer patients to specialists or primary care providers, and implementing shared decision-making protocols to ensure that patients receive the most appropriate care. Direct referrals to hospitals, for example, have been shown to improve patient care and increase paramedic confidence in their decision-making.
• Data Analysis and Performance Measurement: And we circle back to my beginning. We absolutely must do a deep dive and analyze data on refusal rates, call types, and patient demographics which can help identify trends and inform targeted interventions to reduce low acuity and patient refusal calls. This data can be used to develop targeted solutions that are specific to the trends in each geographic area. Is it a transportation issue? Is it a primary care issue? Is it a poor policy by an allied agency to tier EMS that can be changed? Is it a housing issue? The answer is probably all of the above but everybody's gold mine of data will show slightly different results. We must identify the problem before we identify solutions. And then we need to evaluate the effectiveness of those interventions.

The high rate of sign offs or refusals of transport in Ontario's Paramedic Services presents a complex challenge with significant implications for resource allocation, patient care, and the overall sustainability of the emergency medical system. While respecting patient autonomy, it is crucial to address the underlying causes of unnecessary calls and implement strategies to mitigate their impact. By investing in public education, community paramedicine, alternative care pathways, and data-driven decision-making, Ontario can move towards a more efficient and effective paramedic system that prioritizes timely care for those who truly need it. To achieve this, policymakers, paramedic services, and healthcare providers must work collaboratively to: Develop and implement comprehensive public education campaigns to promote appropriate use of 911 and awareness of alternative care options. Invest in and expand community paramedicine programs to provide proactive care for frequent callers and those with non-urgent medical needs. Explore and implement alternative transportation programs to reduce reliance on ambulances for non-emergency medical transportation. Enhance call triage and dispatch systems to prioritize calls and ensure appropriate resource allocation. Strengthen communication and coordination between paramedic services, hospitals, and other healthcare providers to facilitate alternative care pathways. Conduct ongoing data analysis and performance measurement to identify trends and inform targeted interventions. By taking these actions we can ensure that its Paramedic Services are equipped to provide timely and effective care for all those who need it, while optimizing resources and promoting the long-term sustainability of the system.