https://www.thestar.com/news/gta/2022/08/26/rushed-to-hospital-stuck-in-an-ambulance-why-its-taking-longer-to-hand-off-patients-to-hospitals-in-ontario.html

Paramedic Sara MacGregor pulled into Ottawa’s Queensway Carleton Hospital this week with a patient needing urgent medical care.

To her dismay, she learned that she and her partner were one of seven ambulance crews waiting to transfer care of their patients to the emergency department.

Part of her job is to stay with a patient, monitoring vital signs and ensuring they remain stable, until they can be safely handed over to hospital staff.

As the wait dragged on, a paramedic began reading a book to their elderly patient to help pass the time. And what should have been a quick turnaround turned into six hours.

It’s a stark difference from what the province says should take 30 minutes or less.

MacGregor’s experience, and that of other paramedics who spoke to the Star, is borne out in never-before-published figures from Ontario Health showing that ambulance offload times — the average amount of time it takes for a patient to be transferred from paramedics to the care of a hospital emergency department — have nearly doubled over the past three years.

Figures provided to the Star by Ontario Health show that average ambulance offload times have increased from 21 minutes in May 2019 to 37 minutes in May 2022. Individual regions vary by the degree of increase, but all have gone up during this period. In Eastern Ontario, average offload times have more than doubled during this period, from 19 minutes in 2019 to 44 minutes in 2022.

These increased offload times are another indication of the enormous stress Ontario’s health-care system is under, with severe nursing staff shortages, emergency room closures and frail patients stuck in hospitals awaiting discharge to a long-term-care home.

“These kinds of delays don’t happen every day, but they are no longer rare occurrences. Over the last two years, these delays have become astronomically longer,” said MacGregor, who has been working on the front lines in Ottawa for six years.

She noted that patients suffering from anything from fractures, dislocations, falls, liver failure and strokes — all medical emergencies that require urgent care — are being forced to wait because hospitals aren’t able to take over care from paramedics right away.

And when ambulances are stuck at hospitals, fewer are available to get to potentially life-saving 911 calls.

Ontario’s average offload times may not seem very long, but what’s noteworthy, says Dr. Andrew Petrosoniak, an emergency physician at St. Michael’s Hospital in Toronto, is that these times have increased nearly 100 per cent in the past three years. It’s a signal that emergency departments are struggling to keep up with demand.

“Whatever we were doing in 2019, we’re no longer able to deliver that same level of care in 2020, 2021 or 2022,” he said, adding that key stakeholders should really be looking at these increases “as a marker that there is a problem and that we are in a crisis.”

“The people of Ontario deserve better.”

Those on the ground argue the Ontario Health averages don’t paint the full picture of what paramedics are seeing.

Paramedic services use a different metric as an industry standard that they argue provides a more accurate indicator of wait times.

For example, in Toronto, offload times at the 90th percentile hover around two hours. This means that 90 per cent of offload delays are about two hours or shorter. But that also means 10 per cent of delays are longer than two hours.

Dineen Robinson, a spokesperson for Toronto Paramedic Services, says the 90th percentile is a more appropriate measure than the average “as it provides a more fulsome understanding of hospital offload delay performance and reliability. This allows us to better understand what resources are required to provide our service to the community.”

In Ottawa, offload time at the 90th percentile in July was 133 minutes. That’s up from 113 minutes in January.

Ottawa Paramedic Chief Pierre Poirier says that when ambulances are held up at hospital for this long, or longer, the service can’t provide timely responses to emergencies that the community expects.

As of the end of July, the Ottawa Paramedic Service experienced 1,104 “level zero” incidents in 2022 when there is no ambulance crew available to transport a patient to the hospital.

“Years ago, we would have level zero and it would last five, 10 minutes and it would resolve,” said Poirier, noting that in the course of four days during the last week of July, his service had nearly 2,000 minutes, or just over 33 hours, of level zero.

“To put that in context, there were days when we had 10 hours of level zero. So every time that a call would come in, the next available crew, which was usually coming out of a hospital, would be sent. And they could be sent two kilometres or 40 kilometres to that call,” Poirier said.

“This is a matter of life and death.”

Toronto Paramedic Services does not track data classified as level zero, but Robinson said the service does run into situations when ambulance availability is low.

During busier periods, paramedics are routinely diverted from lower-priority calls to higher-priority calls,” she said. “Higher-risk and higher-priority calls will always be responded to first.”

Though staffing shortages and increased demands in ERs are a large reason why paramedics say they are waiting too long to safely hand over patients, they also note the number of calls requiring ambulances has also gone up in recent years, putting strain on the land ambulance system.

A study published this month in the Canadian Journal of Emergency Medicine that analyzed data on patients triaged in Ontario emergency departments during a 10-year period, between 2010 and 2019, found a substantial increase in demand for ambulances and that “growth in paramedic demand outpaced population growth” in the province.

The provincial government’s recently released plan to stabilize the health system, now buckling under more than two years of pandemic strain, states that it will expand models of 911 care in an effort to help divert patients away from emergency departments.

The move builds on the first phase of the program, launched in February 2020, that gives paramedics more options to treat palliative care and mental health and addictions patients, rather than only being able to take them to a hospital ER.

The program, initially rolled out to 40 municipalities across the province, allows paramedics to take eligible patients to a nonhospital destination, including mental-health crisis centres, hospices or urgent-care centres, or to treat patients for immediate concerns, before referring them to a community-based setting, such as a primary care physician, said Ministry of Health spokesperson Bill Campbell.

Going forward, patients with diabetes, epilepsy or those who’ve had a minor fall will be eligible for the “treat and refer” program. The new model will also allow paramedics to “treat and release” patients. This means patients can be treated on the scene by paramedics and released with a recommendation for followup care with a primary care physician or a home and community-care provider.

When asked how these expanded 911 care models will relieve pressure on crowded ERs, Campbell said they “leverage the existing duties of 911 paramedics, and allows them to assess and treat the patients on scene for minor and chronic conditions and offer community-based care options rather than bringing the patient to the ER.”

These changes can’t come soon enough for the paramedic community.

The provincial announcements have opened doors to allow paramedics to keep low-acuity patients cared for but away from emergency departments, says Peter Dundas, chief of Peel Regional Paramedic Services.

“A lot of patients we transport don’t need to be in an emergency department,” he said.

For Mike Nolan, chief paramedic and director of emergency services for the County of Renfrew, the solutions to backups in emergency rooms aren’t likely to be found in emergency rooms.

“Before someone needs to go to the emergency department, let’s help them prevent the need in the first place, let’s give them good care options in the home,” he said.

Petrosoniak, the Toronto emergency physician and trauma team leader, said patients with life-threatening conditions — trauma patients or those in cardiac arrest — do receive immediate intervention.

But when paramedics are stuck at hospitals, waiting to hand over their patient, “that means that there’s somebody at home, who if they call 911, they may not have access to an ambulance,” he said.

“We’re just rolling the dice hoping nothing bad will happen when we stretch a system beyond its full capacity.”

Kenyon Wallace is a Toronto-based investigative reporter for the Star. Follow him on Twitter: @KenyonWallace or reach him via email: kwallace@thestar.ca

Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie or reach her via email: mogilvie@thestar.ca