An ambulance leaves St. Michael’s Hospital in Toronto on July 14.Fred Lum/The Globe and Mail
As a number of hospitals across Canada cut back the hours of operation of their emergency departments amid staff shortages, some veteran paramedics say an innovative form of paramedicine could help take the pressure off a buckling health care system.
Typically, a call to 911 means an ambulance is dispatched, regardless of the severity of injury or illness, and the patient is taken to hospital for treatment. But community paramedicine programs treat a significant portion of patients outside a hospital setting, with calls deemed low-acuity – that is, non-urgent or less severe – generally answered by a single paramedic in a personal vehicle.
Such calls can range in scope and function from simple medical checkups to on-scene treatment – refilling a prescription for a senior with mobility issues running low on heart medication, for instance, or monitoring the blood sugar levels and vital signs of a patient with diabetes or another chronic illness. Community paramedics can also handle certain types of mental health calls, with some responders trained to deal with panic attacks and addiction issues or work in tandem with social workers who are better equipped to help people in crisis.
Advocates of such a system say community paramedicine not only better serves under-represented populations, such as new immigrants and rural communities, but it can also take the strain off emergency departments, which are usually the first line of health care for people without a primary care physician.
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EMS units across the country have been struggling to keep up with higher call volumes amid staffing shortages. A 65-year-old Montreal man died in May after reportedly waiting hours for an ambulance; he had told emergency services that he hit his head and was unable to get out of bed. In July, a 91-year-old woman, also in Montreal, died after hurting her leg and waiting seven hours for paramedics to arrive.
As reports of similar stories continue to emerge, some paramedics are calling for an expansion of community paramedicine as a way to free up ambulances for people who really need them.
“I’ll be blunt: We’re stuffing these ERs with patients that could be better suited to be somewhere else or be treated in their home,” said Ryan Woiden, the president of Winnipeg’s Local 911 paramedic union.
Mr. Woiden cites his city’s EPIC program – short for emergency paramedics in the community – as an example of how effective the approach can be, with data showing that patients treated by EPIC are half as likely to visit the hospital. In the month of May last year, when the city introduced a phone triage system specifically for EPIC called EPIC 9, only 37 per cent of calls resulted in a hospital visit.
With EPIC 9, emergency calls are first triaged by a regular 911 dispatcher. If the dispatcher thinks it’s appropriate to transfer a call to EPIC 9, a new dispatcher will determine if a community paramedic should be sent to the caller’s location. If one is dispatched, they will perform their own on-scene triage, and if they determine that the acuity of the situation is higher than originally thought, the call can be upgraded to one requiring an ambulance or the patient can be transported to the hospital via other means.
“I think that the public would appreciate a better and improved patient experience,” Mr. Woiden said – an alternative to waiting hours to see a doctor in the ER.
Mr. Woiden notes that community paramedicine is not monolithic; there are different types of programs to service different needs. Some communities only have home visit and remote monitoring programs, for people with chronic conditions and patients in rural communities who may need regular checkups or prescription refills. Others primarily use community paramedics to write referrals for other medical professionals.
Such programs have grown exponentially in recent years, especially during the early days of the pandemic, when restrictions kept many vulnerable people from seeking treatment at hospitals and other health care settings.
But availability can vary greatly across the country. In Ontario, dozens of municipalities have functioning community paramedical teams.
Mike Nolan, the director of emergency services and the chief paramedic for Ontario’s Renfrew County, says that can mainly be attributed to significant investment from the province. According to Ontario’s Ministry of Health, the government has allocated as much as $252-million for paramedical services, primarily to serve seniors on wait lists for long-term care homes.
Mr. Nolan, a former co-chair of the Ontario Community Paramedicine Secretariat, which has consulted with the government since 2018 to implement community paramedical services across the province, says the need for such services is greater than ever. In Renfrew County, for example, 30 per cent of people do not have a family doctor, which Mr. Nolan says is an example of how community paramedics carry a burden that otherwise might be passed onto hospitals – both in terms of patients coming into emergency departments for checkups or prescriptions, as well as more severe outcomes for people who do not get preventative care.
The elderly and people with chronic conditions such as cardiovascular disease, diabetes and respiratory problems are most in need of at-home care, Mr. Nolan said, adding that the worst health care outcomes – stroke, heart failure, sudden death – can be mitigated with regular monitoring by a trained medical professional.
Over the past 10 years, research has demonstrated significant reductions in overall health care costs and improved outcomes for patients who receive community paramedical services. A randomized control trial conducted partly in Renfrew County and published in 2017 also found that self-reported quality-of-life scores of patients suffering from late-stage chronic illnesses were as much as 20 per cent higher among people who had received community paramedical care.
“If there’s a silver bullet right now for this hospital crisis, it’s upstream, it’s not in the hospital,” Mr. Nolan said, arguing that too much focus has been placed on what’s happening inside hospitals as opposed to what is happening in the lead-up to someone arriving at one.
“Waiting for people to call 911 or go to the emergency department is too late. We need to engage them in their homes, on their turf, and help them earlier on. And I know it’s not nearly as sexy as running around with lights and sirens and doing the other things that we do, but that’s not the point.”
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