System Pressures Update

1
System Pressures Update

• Emergency Protective Services Committee
• September 4, 2008

2
Presentation Topics

• System Drivers
• Community Impact
• Paramedic Impact
• Offload Impact
• Local and Provincial Strategies
• Hospital Nursing Program
• Current actions and next steps

3
Three Basic System Drivers
Productive Time Offload Delay
UHA
Total Coverage Hours

• Productive Time driven by call growth, traffic
  patterns, deployment plan
• Offload Time driven by hospital patient
  processing capacity, broad h-care
• Unit Hour Activity/UHA .320 to .380 range
  recommended by Fitch/Health Analytics for safe,
  livable conditions

4
What is Unit Hour Activity?

• UHA is basic measure of how busy a unit, an area
  or a system is
• Total Time on Calls / Total Staff Time
• Does not take into account all other work
  cleaning, restocking, paperwork, meals/staff
  breaks, etc

5
PRPS Unit Hour Activity - 2003-2008 Projected
6
2007 OMBI Unit Hour Activity avg .310
7
Productive Time

• Driven by
• Call volume (population growth, aging population)
• Traffic and geography
• Deployment plan (ie reduce response time)
• Values are estimated by
• Historical growth in productive time
• Average annual growth since 2001 7
• 2007/08 average 10

8
Call Volume Years to Date and Projected 2008
9
Offload Delay

• Driven by
• Call volume
• Hospital resources and systems
• Broader health care capacity
• Values are estimated by
• Historical growth in offload delay time
• Average annual growth since 2001 26
• 2007/08 average 36

10
Unit Hour Activity Relates to

• Community
• Paramedic
• Offload

11
Community Impact Code 3, 90th Response Time
(min)
12
Community Impact Code 4, 90th Response Time
(min)
13
Community Impact

• The wait times for ambulances are longer for both
  emergency and non emergency calls (survival,
  suffering)
• In increasing frequency, there are no Peel
  ambulances available in the Region of Peel to
  respond to 911 calls. 78 occurrences of Code
  Capacity in 2007. Minimum should be about 10
  ambulances. YTD 2008 is 39 events.
• Paramedics doing the calls are subjected to
  chronic stresses and this may have an effect on
  overall citizen satisfaction with service

14
Paramedic Impact - Every day

• 9 paramedics dont get lunch
• 30 get held past end of shift paid overtime
• Offload is time at hospital gt 30 minutes
• 36 medics experience offload delay gt 2 hrs
• 10 medics experience offload delay gt 4 hrs
• 6 medics experience offload delay gt 5 hrs

15
Offload Impact

• Increased hospital wait times
• Decreased system performance (response times,
  code capacity)
• Increased costs

16
Offload Hours in Peel - 2006 2008 Projected
17
Current Offload Strategies

• Community Referral by EMS (CREMS)
• Transfer of care protocols
• Increase patient to paramedic ratio
• Waiting room protocol
• Real time negotiation with hospital Emergency
  Department staff
• On Provincial Steering committee for Patient
  Destination Software

18
Offload Strategies contd

• Hospital Nursing Program
• EPSC direction May 2008 to investigate
• Bill hospital for lost time?
• Recover 45.00 billing fee from MOHLTC?

19
Provincial Picture of ED Wait Times April 2008

• 2,900 patients across Ontario are waiting daily
  in hospital for Alternative Level of Care
  placement
• Rehabilitation
• Home care
• Long term care
• Hospice
• Peel has 80 patients daily waiting in hospitals
  for placement
• 850 patients in Ontario admitted in Emergency
  Department waiting for in-patient beds daily

20
Provincial ER Strategy 2008 - 2011
Accountability for improvement must rest with
Hospital Boards and CEOs, LHIN Boards and CEOs
and community partners such as CCACs
Increasing Supply of Services
Reducing Demand for Services
Improving Processes within the ER
OR
Alternate Levels
Alternate Levels
of Care
of Care






Community and home-based services
ED
ER
Home
Home
Home






















H








H






Rehabilitation
Rehabilitation
Rehabilitation
Rehabilitation








































Complex and Continuing Care
EMS is ONLY 20














































Long Term
Long Term Care
Long Term
Long Term
Care
Care
Care

• Aging at Home
• Family Health Care for All
• Chronic Disease Prevention and Management
  (Diabetes)
• Mental Health and Addiction

• Aging at Home (ALC)
• High Growth Hospital Funding

• Emergency Room Strategy
• HHR - Emergency Department Coverage

Presentation to Mississauga Halton LHIN,
Provincial Wait Times, Dr. Alan Hudson, March
2008
21
Recent Announcements to Support ER Strategy

• 40 acute transitional beds at Trillium and Halton
  Health Care hospitals to care for Alternative
  Level of Care patients
• Programs to help seniors to move from hospital to
  the community
• Daily living supports for seniors in the
  community who are at risk of hospitalization eg.
  homemaking, caregiver supports
• Nurse Practitioner assigned to long term care
  homes to prevent transfer to ER

22
Hospital Nursing Program Update

• Province announced 4.5M to address offload
• Peel received 375K one time funding
• Start Fall 2008
• Peel requested 685K
• Peel has to reduce scope / improvement targets
• Individual agreements with Region/Province and
  Region/each hospital
• Operating funds and/or capital
• Expected partnership where Region pays for hours,
  hospital pays for capital
• Stretchers, oxygen, defibs, chairs etc

23
Will Strategies Solve Offload in the Short Term?

• Will offload be fixed in the short term? No
• WHY NOT?
• Growth of call volume 10
• Offload growth increasing more rapidly than
  MOHLTC interventions can solve
• Takes time for system change impacts to be
  realized
• What are Peels options?
• Add more service hours to address growth in call
  volume
• Expand Hospital Nursing program _at_ 100 Peel
  dollars to address offload growth

24
Assumptions for Nursing Program to Successfully
Address Offload

• Execution of agreements with hospitals and
  province to participate for current MOH-funded
  program
• Hospital support to participate in Region-funded
  expanded program
• Hospitals have physical space
• Implementation is effective
• Implementation 100 hours captured
• Lag time to achieve full effect so start now and
  implement expanded program in 2008

25
2009 Budget Considerations

• Even with current Hospital Nursing Program, need
  to add more service hours to address
• Call volume growth 10
• Offload growth 30
• Considerations
• 1. Substantial service hour increase to address
  both growth and offload delay (70,000 service
  hours)
• 2. Fewer service hours for growth plus expanded
  Peel Funded Nursing Program
• As Provincial wait times are reduced through
  Provincial ER strategy the service hours tied
  up with offload can be redeployed into the system
  to address response time and phase out expanded
  nursing program - this will lessen impact on
  future budgets

26
Current Activity and Next Steps

• Finalize negotiations with hospitals for current
  provincial Hospital Nursing Program
• Explore hospital willingness for expanded program
  if Option 2 is selected
• EPSC endorsement to proceed with Peel-funded
  enhancement to Hospital Nursing Program in Fall
  2008 and prepare for expected fall spike in
  offload delays
• Advocate with province to get assurances that
  they will continue with base funding for current
  nursing program
• Request 50/50 funding on enhanced Nursing program
  hours

27
Presentation Summary

• Productive Time Growth
• Offload Issues
• What were doing to mitigate
• Peel Options
• Add service hours only
• Add service hours and fund enhanced nursing hours