The Curious Case of the Tidal Wave

The escalating burden of Paramedic Services.

"Respond Code 4 for a male patient, complaining of a sunburn. Red, itchy, no blisters."

This is a real call. Similar calls happen on a daily basis in Ontario and across the country. The demand for Paramedic Services is rapidly increasing, straining the capacity of Paramedics across the country. While this rise is driven by a number of factors, a significant contributing factor is the increasing number of calls for non-urgent medical needs.

The problem is that our system is not prepared for it. In the majority of services across Ontario the solution to every single 9-1-1 call is quite singular: sending out two Paramedics in an ambulance.

The influx of calls for minor illnesses and injuries, often stemming from a lack of accessible primary care options, is diverting resources away from true emergencies. This trend is putting significant pressure on Paramedic systems, leading to longer response times, increased wait times at emergency departments, and a growing strain on the mental and physical well-being of Paramedics. Understanding the complex interplay of factors contributing to this escalation is crucial for developing effective solutions.

Before I go further I'd like to highlight that I'm not one of those burnt out Paramedics who believe these calls are "underneath" them. In fact some time ago I authored an article just the opposite of that, and I think that context is important:

"The Curious Case of the Blue Pill: https://www.dhirubhai.net/pulse/curious-case-blue-pill-jeffrey-bilyk/ "

Historically, Paramedic systems were primarily designed to respond to life-threatening emergencies, such as heart attacks, strokes, and severe trauma. However, in recent years, there has been a dramatic increase in the number of calls for non-urgent medical conditions, such as minor injuries, chronic pain, and mental health concerns. This shift in call volume is largely attributed to several factors, including:

• Increased reliance on 9-1-1 for primary care. This trend is driven by a shortage of primary care providers, particularly in rural areas, leading individuals to rely on Paramedics for basic medical needs.
• Aging population with higher rates of chronic diseases. The increasing number of seniors in the population has contributed to a rise in calls related to chronic conditions such as diabetes, heart disease, and arthritis. These conditions often require frequent medical attention, which can strain Paramedic resources. Quite often this population is truly unable to get into a vehicle and drive to their GP's office.
• Growing awareness of mental health issues. Increased awareness of mental health issues has led to a greater willingness to seek help, but access to mental health services remains limited in many communities. This has resulted in an increase in calls for mental health emergencies, which often involve individuals experiencing anxiety, depression, or suicidal thoughts.

The influx of calls for minor illnesses and injuries poses a significant challenge to Paramedic systems. In Ontario - much like most of Canada - we are behind the 8-ball. These calls often require the same resources as life-threatening emergencies, diverting ambulances and paramedics away from more critical cases. This can lead to longer response times and increased wait times for patients experiencing true emergencies. A revamped dispatch system is a solid answer to this specific issue, more on that below.

This trend of utilizing 9-1-1 for non-urgent conditions is not only financially unsustainable from a taxpayer perspective, but also detrimental to the overall efficiency of emergency response systems. By understanding the root causes of this influx and implementing targeted solutions, we can ensure that Paramedic resources are effectively allocated to address life-threatening emergencies while also providing appropriate care for individuals with minor illnesses and injuries.

While increasing the number of ambulances might seem like a logical solution to the growing demand, it is not a sustainable or effective approach. Adding more ambulances can temporarily alleviate the strain on the system, but it does not address the underlying problem of non-urgent calls. The influx of non-emergency calls continues to put a strain on Paramedic resources, even with more ambulances available. Furthermore, increasing the number of ambulances would lead to increased costs without a corresponding increase in efficiency. This is because the core issue is not a lack of resources but a lack of effective utilization of existing resources. For example, if ambulances are constantly being dispatched for minor illnesses or injuries that could be treated by primary care providers, the additional ambulances would be underutilized and the cost of operating them would be a burden on the system. Now I'm not an apologist for lack of proper Paramedic staffing. Since the provincial download of Paramedic Services in 2000, services have largely been understaffed and under-resourced with budgets 1/3rd to 1/4 of their police/fire counterparts. What I'm suggesting rather is that if you look at forecasted staffing models to 2030 and beyond the numbers required to maintain with call volume is nearly impossible to achieve. Even today we struggle with enough graduates to maintain available open positions. We can fix that too, but I'm simply suggesting this: We cannot "add truck" our way out of the issue with skyrocketing low acuity call volume. The solution lies with changing our system.

It's important to remember that adding more ambulances also increases staffing needs, which further contributes to the cost. Furthermore, it can lead to a perception that Paramedics are readily available for non-urgent issues, potentially encouraging even more unnecessary calls. A more effective approach is to address the underlying causes of the influx in non-emergency calls and create a system that prioritizes true emergencies while also providing appropriate care for those with minor illnesses and injuries at the same time.

To effectively address the escalating burden on Paramedic Services, a systemic approach is required. This approach must involve identifying the root causes of the increasing call volume, improving triage and prioritization of emergency calls, enhancing community education and alternative care pathways, and fostering collaboration between Paramedics, healthcare, and community partners.

This systemic approach requires a multifaceted strategy that addresses the various factors contributing to the increasing demand for Paramedic Services. It involves understanding the root causes of this trend, which may include factors such as a lack of access to primary care, inadequate community education about non-emergency medical services, and social determinants of health that influence individuals' reliance on Paramedics for non-urgent needs.

A thorough analysis of call data is crucial to understanding the specific factors driving the increase in call volume. This analysis should identify the types of calls that are most frequent, the demographic characteristics of callers, and the geographic areas with the highest demand. By pinpointing the specific drivers of call volume, stakeholders can develop targeted interventions to address those factors directly. In this regard every single service in Ontario is different. We cannot use one data-set and apply this to everywhere else.

• Lack of Access to Healthcare - Individuals without adequate healthcare coverage or access to primary care providers may rely on 9-1-1 for basic medical needs.
• Social Determinants of Health - Factors such as poverty, lack of education, and limited access to healthy food can contribute to higher rates of chronic conditions and illness.
• Aging Population - As the population ages, there is an increased demand for healthcare services, including ambulance.

Triage is the process of sorting patients based on the severity of their condition. Effective triage is essential for ensuring that the most critical patients receive immediate attention while less urgent calls are addressed appropriately. Implementing robust triage systems can help to prioritize calls, optimize resource allocation, and ensure that ambulances are available for true emergencies.

1) Enhanced Dispatch Protocols

Implement standardized dispatch protocols to better assess the urgency of calls and direct patients to appropriate levels of care. This is finally happening across Ontario as we roll out MPDS - something other jurisdictions in Canada and the US have used for literally decades. This solves some of our issues but it's not valhalla. A call is still a call, whether it waits 5 minutes or 5 hours.

2) Telemedicine Consultations

Utilize telemedicine to provide remote medical consultations for non-emergency cases, reducing unnecessary ambulance trips and providing patients with appropriate care alternatives. Niagara Region years ago placed nurses in their ambulance communication centre with very positive results. These "ECNs" triage low acuity calls and have alternative pathways with what to do with those calls.

3) Community Paramedicine Programs

Expand community paramedicine programs that provide non-emergency medical services to patients in their homes, reducing the need for ambulance transport for less urgent needs. This is already a well oiled machine almost everywhere in Ontario. Some CP programs are doing point-of-care bloodwork, remote patient monitoring, mental health treatment, and more. The Ontario government continues to open their pocketbook for CP.

4) Early Intervention

Develop strategies for early intervention, addressing chronic health conditions and mental health issues before they escalate into emergencies, reducing the number of calls for urgent care.

The answer.

We need a collaborative approach involving establishing strong partnerships that leverage the expertise and resources of various stakeholders. Paramedics, with their immediate response capabilities and knowledge of community needs, play a crucial role in this collaboration. Healthcare professionals, including physicians, nurses, and social workers, contribute their clinical expertise and access to healthcare resources. Community organizations, such as social service agencies, faith-based groups, and community centers, offer valuable insights into the social determinants of health and provide access to support services that complement emergency medical care.

By working together, these partners can develop comprehensive strategies that address the root causes of the increased call volume. They can identify vulnerable populations within the community and implement targeted interventions to prevent health issues from escalating into emergencies. This collaborative approach can also lead to the creation of alternative care pathways that divert patients with non-urgent medical needs to appropriate resources, such as urgent care clinics, telehealth services, and home healthcare providers.

Despite my hatred for public relations campaigns and spending any budget money on "9-1-1 education" (I believe it doesn't accomplish much), when you are looking to overhaul your system as a whole I acknowledge that it warrants some attention. A strong emphasis on community education is vital especially as we shift towards a model where not everybody who calls 9-1-1 is going to get an ambulance in ten minutes like the days of old. Collaboration allows partners to develop and disseminate information on appropriate use of 9-1-1, providing guidance on accessing alternative care options and promoting self-care practices. I still caution against spending too much budget dollars in this category however - human factors tell us despite education, a certain portion of the population will not change their ways.

A work in progress

There are a number of services across Ontario and Canada that have already realized that this is something that needs to be addressed now. In Niagara region, they have piloted a taxi program. As mentioned above, ECN nurses triage low acuity calls and if they believe you do in fact need to be seen in an ED, however don't require Paramedic assessment and/or ongoing care they'll send out a taxi. The interim results of this pilot project showed that it reduced costs from approx 500-1000 dollars per call, down to 50 dollars per call. Most importantly there were no adverse events.

BCEHS has developed a number of Low Acuity Response Units (LARUs). These units are singular Paramedic staffed, and tackle the issue of lower acuity calls. In some cases they can assist with care on scene, provide referrals, and overall lower the number of transports to the ED. You can read about these units here (https://www.bcehs.ca/about/news-stories/stories/new-response-units-innovate-to-better-serve-patients)

Essex-Windsor EMS has a "Community Assessment Triage Team" (CATT) which has similar functions to the BCECH LARU. From Chief Justin Lammers "When a CATT unit responds to a call, it reduces transports to hospital emergency departments by 60 percent compared to traditional ambulance response."

Addressing the escalating burden on Paramedic Services requires a comprehensive and multi-faceted approach. Simply adding more ambulances is not a sustainable solution. Instead, we need to invest in strategies that improve triage, prioritize emergency calls, enhance community education, and promote alternative care pathways. By working together, Paramedics, healthcare professionals, and community partners can ensure that emergency services are available for those who need them most.

This requires a shift in how we think about Paramedic Services. Rather than solely focusing on reactive responses, we must invest in proactive strategies that prevent emergencies from occurring in the first place. This could involve expanding access to preventive care, promoting healthy lifestyles, and addressing the underlying social determinants of health that contribute to health disparities and emergency needs.

The future of EMS lies in building a more resilient and responsive system. This involves embracing technology, such as telehealth and mobile health applications, to expand access to care and improve efficiency. It also requires ongoing investment in training and education for Paramedics to equip them with the skills and knowledge needed to effectively address the evolving needs of the community.

I've always said let our community call 9-1-1 for whatever they please. We won't stop them. And there's no amount of public education that will force function and change human factors. But let's change and modernize our system so that we can do 15 different things with that call and our primary solution of "Two Paramedics in an ambulance" becomes a thing of the past.