An EMS Transfer Authorization Centre in Response to SARS in Toronto, Canada

1
An EMS Transfer Authorization Centre in Response
to SARS in Toronto, Canada

• Russell D. MacDonald, MD MPH FRCPC
• Medical Director, Central Region
• Ontario Air Ambulance Base Hospital Program
• Assistant Professor, Faculty of Medicine
• University of Toronto
• Toronto, Ontario, Canada

2
Thank you

• National Disaster Medical System
• Chesapeake Health Education Program
• Ministry of Health and Long-Term Care, Government
  of Ontario
• Ontario Air Ambulance Base Hospital Program
• Toronto EMS
• EMS agencies in Ontario

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Outline

• Introduction to City of Toronto and Province of
  Ontario
• SARS outbreaks in Greater Toronto Area
• EMS response to mitigate risk of SARS
• Lessons Learned
• Future Prospects
• Summary

4
Welcome to Province of Ontario
5
Welcome to Province of Ontario
Toronto
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Welcome to Province of Ontario
Minneapolis
Toronto
Detroit
Chicago
Syracuse
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Welcome to Province of Ontario
1000 km / 600 miles
1600 km / 1000 miles
Minneapolis
Toronto
Detroit
Chicago
Syracuse
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Welcome to City of Toronto

• Ontarios capital city
• Canadas largest and most populous city
• 641 square kilometers
• 2.5 million people
• CN Tower, SkyDome
• Greater Toronto Area
• city and 4 neighbouring cities
• 5.1 million people

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Healthcare in Toronto

• Canadas largest hospital network
• 15 acute care hospitals
• Canadas largest pediatric hospital
• gt100 other health care facilities
• long-term care, alternate level of care
• largest medical school
• in Canada

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EMS in Toronto

• Canadas largest EMS provider
• 400,000 calls per year
• 800 paramedics and 200 support staff
• headquarters for North Americas largest air
  ambulance program
• 20,000 calls per year
• 250 flight paramedics
• 8 rotor and 18 fixed wing aircraft

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SARS in Toronto

• Feb 23 woman returns from Hong Kong
• March 5 woman dies at home
• EMS respond and attempt resuscitation
• others in family also ill
• March 7 son admitted to hospital
• ill family members visit him in hospital
• March 12 WHO issues first alert
• March 13 son dies in hospital
• March 16 Toronto case cluster identified

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SARS in Toronto

• March 25 second wave of cases peaks
• March 26 Provincial Government declares Health
  Care Emergency
• Provincial Operations Centre activated
• code orange at GTA hospitals

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SARS in Toronto
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SARS in Toronto
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SARS in Toronto
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SARS in Toronto
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SARS in Toronto
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SARS in Toronto
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SARS in Toronto
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SARS in Toronto

• March 27 interfacility patient transfers halted
  to prevent spread of SARS
• March 30 Government identifies urgent need to
  resume transfers yet mitigate risk of spread of
  SARS

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SARS in Toronto
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EMS Response to SARS

• stakeholders meet
• command and control of all transfers
• appropriate medical oversight
• develop and implement solution in 72 hrs
• 3 phases
• needs assessment
• design and implementation
• expansion and ongoing operations

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EMS Response The PTAC

• Provincial Transfer Authorization Centre
• single centre with medical oversight
• oversee all interfacility patient transfers
• implement directives
• retrospective epidemiologic tracking if needed
• paramedic based decision-making
• on-site physician backup

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Needs Assessment

• estimated 1300 requests / day
• peak volume 8am 4pm
• locate at Toronto EMS HQ
• expand existing dispatch infrastructure
• algorithms for decision-making
• no existing industry model
• must go live within 72 hour timeline

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PTAC Proposal Fast-tracked

• March 30 proposal developed
• March 31 proposal approved
• April 1 proposal implemented
• regionalized health care delivery
• urgent need for patient transfers

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Design and Implementation

• PTAC activated on April 1 at 1430
• space, equipment, and personnel not in place
• algorithms not fully developed
• process flow not developed
• temporary phone and fax being installed
• dispatch and support personnel reassigned
• Torontos existing EMS dispatch centre carried
  initial load while temporary PTAC set up

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Design and Implementation

• By 1700
• temporary PTAC operational and meeting demand
• EMS command staff develop job positions
• physician trains paramedic screeners
• physician and paramedic supervisors refine
  algorithms
• By 2300
• demand decreased
• meet to further develop decision algorithms and
  process flow
• Within 36 hours
• handling gt 500 request per day
• infection control measures implemented

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Design and Implementation
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Decision Algorithm

• Sending and receiving physicians agree to
  transfer.
• Infection control at both facilities agree to
  transfer.
• Healthcare facility categories match.
• Emergent transfer is medically necessary.
• Bed available and held for patient.

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Decision Algorithm

• Sending and receiving physicians agree to
  transfer.
• Infection control at both facilities agree to
  transfer.
• Healthcare facility categories match.
• Emergent transfer is medically necessary.
• Bed available and held for patient.

PTAC will not authorize transfer unless all
criteria are met or there are circumstances that
mandate transfer. PTAC physician arbitrates
decision with sending and receiving physicians,
and infection control personnel.
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Decision Algorithm

• Sending and receiving physicians agree to
  transfer.
• Infection control at both facilities agree to
  transfer.
• Healthcare facility categories match.
• Emergent transfer is medically necessary.
• Bed available and held for patient.

Sending facility faxes transfer request form to
PTAC
Sending facility advised to follow up fax with
phone call if necessary
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Decision Algorithm

• Sending and receiving physicians agree to
  transfer.
• Infection control at both facilities agree to
  transfer.
• Healthcare facility categories match.
• Emergent transfer is medically necessary.
• Bed available and held for patient.

Sending facility faxes transfer request form to
PTAC
Patient passes SARS screening tool
If patient does not pass SARS screening tool,
PTAC physician reviews call, and arbitrates with
sending and receiving physicians
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Decision Algorithm

• Sending and receiving physicians agree to
  transfer.
• Infection control at both facilities agree to
  transfer.
• Healthcare facility categories match.
• Emergent transfer is medically necessary.
• Bed available and held for patient.

Sending facility faxes transfer request form to
PTAC
Patient passes SARS screening tool
PTAC approves transfer and issues authorization
number
Authorization number not issued unless transfer
is authorized
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Decision Algorithm

• Sending and receiving physicians agree to
  transfer.
• Infection control at both facilities agree to
  transfer.
• Healthcare facility categories match.
• Emergent transfer is medically necessary.
• Bed available and held for patient.

Sending facility faxes transfer request form to
PTAC
Patient passes SARS screening tool
PTAC approves transfer and issues authorization
number
Toronto EMS CACC dispatches call OR transfers
request to local ambulance service
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SARS Screening Tool

• unprotected contact with person with SARS in past
  10 days?
• fail screen if answer is yes
• in a health facility closed due to SARS in past
  10 days?
• quarantine or under investigation for SARS?
• in southeast Asia in past 10 days?
• symptoms of viral illness?
• temperature checked gt38oC?
• fail screen if yes to any two of the above

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Process Flow
Sending facility faxes request to PTAC
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Process Flow
Sending facility faxes request to PTAC
Requests logged, time-stamped, given request
number
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Process Flow
Sending facility faxes request to PTAC
Requests logged, time-stamped, given request
number
Requests collated and checked sending facility
contacted for missing information
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Process Flow
Sending facility faxes request to PTAC
Requests logged, time-stamped, given request
number
Requests collated and checked sending facility
contacted for missing information
Completed requests forwarded for medical
clearance algorithm used to determine
authorization
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Process Flow
Sending facility faxes request to PTAC
Requests logged, time-stamped, given request
number
Requests collated and checked sending facility
contacted for missing information
Completed requests forwarded for medical
clearance algorithm used to determine
authorization
If criteria met, authorization number assigned
and forwarded to sending facility
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Process Flow
Sending facility faxes request to PTAC
Requests logged, time-stamped, given request
number
Requests collated and checked sending facility
contacted for missing information
Completed requests forwarded for medical
clearance algorithm used to determine
authorization
If criteria met, authorization number assigned
and forwarded to sending facility
Request forwarded to data entry to complete record
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Process Flow
Life-threatening?
Sending facility faxes request to PTAC
Requests logged, time-stamped, given request
number
Requests collated and checked sending facility
contacted for missing information
Immediate attention and clearance
Completed requests forwarded for medical
clearance algorithm used to determine
authorization
If criteria met, authorization number assigned
and forwarded to sending facility
Request forwarded to data entry to complete record
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Expansion Ongoing Operations

• April 7 permanent location
• 280 m2 in Toronto EMS HQ
• accommodate 40 staff and up to 1500 requests/day
• permanent telephone and fax installations
• computer network with database
• 50 new staff recruited
• total staff now 80

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Expansion Ongoing Operations

• April 14 government relaxes transfer
  restrictions
• gt1000 request / day
• emergent processed immediately
• non-emergent processed within 45-60 minutes
• peak demand requires
• 20 clerical staff
• 5 paramedic supervisors
• 1 manager
• 1 physician

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Expansion Ongoing Operations

• early May outbreak over?
• only sporadic cases in health care workers
• no new community cases in gt20 days
• health care system shifts to new normal
• sustained level of infection control practices
• high index of suspicion
• PTAC maintained as tracking system
• gt1300 requests / weekdays

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SARS 2

• May 20
• patients from a rehabilitation hospital
  transferred to 2 hospitals for ongoing care
• patients pass screening tool prior to transfer
• May 22
• respiratory illness outbreak in rehab hospital
• public health investigation
• PTAC prevents further transfers
• facility continued to make requests despite
  outbreak

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SARS 2

• May 23-24
• 9 patients from rehab under investigation for
  SARS
• 2 hospitals fully or partially closed
• health care staff become ill with respiratory
  illness
• PTAC records used to identify and locate
  transfers between affected institutions
• public health issue new quarantine orders
• some hospitals close to new patients

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SARS 2

• Toronto in its second outbreak
• government creates SARS hospital alliance
• June 12
• last new case of SARS
• August 18
• hospitals return to new normal

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(No Transcript)
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PTAC Requests
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PTAC Requests
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Outcomes

• no reported iatrogenic spread of symptomatic SARS
  due to interfacility transfer
• PTAC identified 13 new SARS cases
• transfers would have taken place if PTAC not in
  place

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Lessons Learned

• infection control practices and public health
  resources caught off guard
• EMS is vector for spread in regionalized health
  care model
• EMS command and control system can mitigate risk
  of spread

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Lessons Learned

• factors in PTAC success
• good stakeholder representation
• accurate forecast of demand
• appropriate staff selected
• incorporated into existing dispatch network
• used existing technology (phone, fax, radio)
• no prolonged burden on existing system

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Lessons Learned

• ways to improve future efforts
• adequate pre-implementation time
• sufficient staff
• end-user notification
• information dissemination
• formal policies and procedures

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Ongoing Developments

• web-based application developed and implemented
• users enter requisite information
• authorization number given immediately if medical
  decision rules are met
• if approved, information forwarded to appropriate
  EMS dispatch centre electronically
• if not approved, information queued and sent to
• physician on call electronically (Blackberry,
  pager)
• for review
• Microsoft .net award for web application

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Ongoing Developments
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Ongoing Developments

• web-based application reduced staff requirements
  and improved throughput

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Future Prospects

• PTAC remains part of due diligence in transport
  medicine
• enables rapid contact tracing
• EMS-public health collaboration to determine PTAC
  efficacy and ongoing role
• potential role in real-time syndromic
  surveillance
• first to detect outbreaks in long-term care
  facilities

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Summary

• Introduction to Toronto
• SARS outbreaks in Greater Toronto Area
• EMS response to mitigate risk of SARS
• Lessons Learned
• Future Prospects

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Summary

• Manuscript available in
• Prehospital Emergency Care
• 2004 8(2) 223-231

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Questions