Message froM the executive

bcehs overview

bc patient transfer net work

trauMa services bc

bc aMbulance service

prograM overview and highlights

Medical prograMs

quality, safety, risk ManageMent and accreditation prograM

bcehs patient care quality office

inforMation ManageMent/ inforMation technology

huMan resources

coMMunications

organizational challenges

budget

public outreach

fees

Contents

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Message from the Executive

This fiscal year has been one of change, challenge and accomplishment.

One of the biggest changes has been passage of the legislation enabling BC Emergency Health Ser-vices to become officially aligned with the Provincial Health Services Authority (PHSA). Together, we will focus our energies on improving patient care. In fact, we have already started on a number of changes in that regard:

• Creation of the Patient Transfer Network: This coordinated approach improves the inter-facility trans-fer process to ensure patients throughout the province receive the appropriate care at the appropriate facility in a timely, efficient way by working collaboratively across all health authorities.

• Introduction of Emergency Physician Online Support: This ‘real-time’ clinical support provides BCAS ground paramedics with 24/7 rapid access to consultation with an emergency physician. Paramedics will select the appropriate pre-programmed toll-free number on their cell phone to connect with a either a Primary Response Physician (PRP) during 9-1-1 events or an Emergency Transfer Physician (ETP) during inter-facility transfers.

• Pursuit of excellence: Accreditation is a key marker of excellence in today’s world. We have started Ac-creditation Canada’s Q-Mentum process, which is designed to help emergency medical service agen-cies increase performance, accountability and efficiency, increase clinical quality and decrease risk. The accreditation process provides a template for organizations to improve their overall performance.

The coming fiscal year is full of promise for the dedicated employees of BCEHS and the patients we serve. We will work to maintain the momentum we have developed as we continue our alignment with PHSA and the health sector.

Carl Roy

Interim President, BC Emergency Health Services

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The three agencies under the BC Emergency Health Services (BCEHS) - the BC Patient Transfer Network, Trauma Services BC and BC Ambulance Service - provide both pre-hospital emergen-cy medical services and inter-facility patient transfer coordination and transport services.

BC Patient transfer networkOn April 1, 2013, BC Bedline transitioned to become the BC Patient Transfer Network (BCPTN) - a 24/7 provincial service that works with hospital physicians to ensure the timely transfer of acute care patients between health care facility by:

• Facilitating physician-to-physician confer-ence calls;

• Coordinating calls between physicians and specialist services;

• Facilitating air or ground ambulance trans-port in partnership with BC Ambulance Service;

• Arranging transfer of patients back to their community hospitals; and

• Coordinating interprovincial and interna-tional transfers when required.

The BCPTN expands on the previous services offered by BC Bedline by increasing the clinical oversight involved in patient transfer planning. BCPTN features registered nurses that provide medical advice when coordinating high acuity/complex patient transfers as well as access to emergency transfer physicians and other specialists when needed. A new triage process ensures patient transfer coordinators connect sending and receiving physicians as quickly as possible while linking in other appropriate resources as required.

The BCPTN is being phased in and the goal is that it will eventually serve every health author-ity-operated facilities in the coordination of all inter-facility transfers within BC, the repatriation of BC residents, and movements of BC patients out-of-province where required. BCPTN will manage and report on transfers of all acuities involving costs to the provincial healthcare system, namely BC Ambulance Service or contracted Alternate Service Provider transport companies, plus the repatriation of patients thus moved.

In 2012/13, BC Bedline/BCPTN received 25,355 transfer requests, and 24,488 of these cases resulted in patient transfers to another facility. Once the BCPTN is fully implemented it will feature:

BCEHS Emergency Transfer Physicians - these independent physicians will act as the ultimate owners of all transfer plans. For the most com-plex transfer requests, they will work with send-ing and receiving physicians to enable patient handover and establish the patient’s clinical care requirements during transport. They will act as an escalation route for any patient trans-fer.

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The three agencies under the BC Emergency Health Services (BCEHS) – the BC Patient Transfer Network, Trauma Services BC and BC Ambulance Service – provide both pre-hospital emergency medical services and inter-facility patient transfer coordination and transport services. BCEHS, previously the Emergency and Health Services Commission, was established in 1974 and carries out its legislated mandate in accordance with the Emergency Health Services Act.

On March 14, 2012, the provincial government passed the Emergency and Health Services Amendment Act, officially aligning the newly-named BCEHS with the health sector and the Pro-vincial Health Services Authority.

As outlined in the BCEHS organization chart, a number of program areas and corporate services are direct components of the BCEHS, including: Medical Programs; Quality, Safety, Risk Manage-ment and Accreditation; Communications; Finance; Human Resources; and Information Manage-ment. BC Ambulance Service, the BC Patient Transfer Network and Trauma Services BC are the organization’s operating entities.

BCeHs overview

Clinical Transfer Nurses – these registered nurses will manage the patient transfers, reduc-ing patient risks by providing clinical oversight to the transfer planning process. They will also act as the escalation route for low acuity trans-fers.

A single telephone number for all transfer re-quests - a centralized triage process will ensure all requests are recorded, tracked and allocated to the correct level of clinical oversight.

Structured transfer planning process - a stand-ard approach to determining patient needs and developing the appropriate transfer plan will result in a faster planning process. Clear ownership of the transfer plan, coupled with a new mechanism for setting transfer priority, will eliminate confusion. Clear communication of

plans to facilities will support care planning.

Integrated repatriation planning - developing repatriation plans early will assist with setting expectations about transfer timelines. Regular monitoring of patient status and communica-tion of repatriation plans will assist facilities in planning for patient return.

Patient flow coordination - facilities will provide daily updates on bed occupancy vs. acuity of patient to help identify patient flow priorities and enable updates to repatriation plans to be clearly communicated. This will be a structured data collection and communication process and the collated provincial picture will inform transfer planning processes.

trauma serviCes BC

During 2012/13, our first full year of service, Trauma Services BC (TSBC) put the services, personnel and strategic direction in place to begin realizing our vision for a high-performing, standardized, comprehensive, integrated and inclusive trauma/injury system for BC.TSBC leaders and council members include:

• administrative and medical directors of trauma from each of the health authorities;

• BC Ambulance Service representatives from both air and ground services;

• BC Patient Transfer Network; • BC Emergency Health Services Medical

Programs;• Provincial Health Services Authority Mobile

Medical Unit; and• other ad hoc members to support key

initiatives.

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TSBC has focused on key changes to trauma care both nationally and provincially, specifically:

• Improving data collection - The inclusion of more sources of data in the BC Trauma Registry will better quantify the breadth of traumatic injury in BC which will provide a more accurate picture of the burden on injury on provincial health care services.

• Pilot a process to establish a provincial plan of standardized care (clinical practice guidelines) and transport destinations for specialized trauma patients. The newly-formed Provincial Burns Working Group are working to identify benchmark burn care protocols and to create a provincial burn program.

• Trauma destination protocols define which hospitals are best equipped to handle certain levels of trauma patient injuries sustained. Research indicates that some types of traumas have better outcomes when taken directly to Level I or Level II Trauma centres rather than after referral from a lower level facility. These destination decisions will align with policies of the BC Provincial Transfer Network and BC Ambulance Service to ensure the patient is transported to the facility that can provide the most appropriate care as soon as possible.

• TSBC is also working to improve clinical support for rural health care facilities for critical trauma patients. BC Telemedicine is an innovative solution whereby the excellence of care brought by expertise provided at designated trauma centers centres can be supported via video feed, supporting the practitioners at rural hospitals.

In addition, a new partnership between the Trauma Association of Canada and Accreditation Canada has been formed, aimed at creating a trauma distinction program within the accreditation process. This work will significantly impact TSBC by developing provincial data collection metrics and standards that will form the basis of a truly provincial trauma care standard and system design.

Trauma care in BC has matured from a set of disparate site-based protocols for severe injury, to regionalized efforts at coordination to a new provincial trauma coordinating office and leadership over this past year. Despite the progress over the past 25 years of trauma care in BC, there is still more to be accomplished in the areas of injury prevention, rehabilitation, burn care, and overall integration. TSBC will continue to have a leadership role in improving trauma care for patients across B.C.

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In 2012/13, BCAS employs

4,396staff - 3,808 paramedics and dispatch-ers and 588 clinical management and

support personnel.

Responses to ground and air ambulance events are coordinated through dispatch centres in

VANCOUVER, VICTORIA & KAMLOOPS

In 2012/13, BCAS responded to an average of

56events per hour throughout

the province.

BCAS’s ground ambulance fleet travels

more than

20,200,00kilometers every year - equivalent

to more than 500x around the world.

413,123 pre-hospital (911) events: through dispatchers, dispatch staff and paramedics, expert patient care is delivered from the time a call for help is placed to 911 to treatment at the scene and trasport to hospital;

90,920 inter-facility transfers: BCAS ensures that patients are closely monitored while enroute to a medical facility that is equipped to meet their needs; and,

6,700 air ambulance calls

BCAS covers the

944,700square kilometres of the

province of British Columbia with a ground fleet of 562 vehicles - 500 ambulances & 62

support vehicles.

In 2012/13, BCAS resonded to more than 504,000 events throughout the province. An ambulance is dispatched to an emer-gency call nearly every minute, of every hour, in British Columbia.

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For 39 years, BC Ambulance Service (BCAS) has been providing patients throughout BC with safe, high quality, emergency medical and inter-facility transfer services. BCAS is proud to serve as the largest provider of emergency medical services in Canada and one of the largest in North America. BCAS responds to the needs of 4.4 million British Columbians and attends calls for service across six health authorities covering almost one million square kilometres.

Patient Care and serviCe imProvement initiativesA number of operational enhancements were undertaken in 2012/13:

• The BCAS Patient Transport Coordination Centre goes live, operating out of the Van-couver Dispatch Operations Centre. The PTCC coordinates all inter-facility transfers, both ground and air, for patients throughout British Columbia. Centralizing all transfer dispatch services enables the other three ambulance communication centres to focus exclusively on 9-1-1 calls and co-locates the transfer planning at BCPTN with ambu-lance dispatch operations.

• BCAS Dispatch Operations Centres began the ‘Race to ACE’, a process to become an Accredited Centre of Excellence (ACE) by the International Academy of Emergency Dispatch (IAED). Only 80 emergency dis-patch centres in the world have achieved this level of accreditation. The aim is for BCAS Dispatch Operations to be accred-ited by the end of 2013/14.

• BCAS expanded the Early Fixed-Wing Acti-vation Program throughout the north fol-lowing a successful pilot in the Terrace area in 2011/12. The program enables paramed-ics to ‘reserve’ an air ambulance airplane based on their on-scene assessment of the patient. Previously, a physician would need to access the patient in hospital and then call an air ambulance. This new process reduces the time it takes to get a critically ill or injured patient to a higher level of care.

• BCAS joins the Heart and Stroke Founda-tion – BC & Yukon and the provincial gov-ernment in implementing the Public Access to Defibrillators (PAD) program. This initia-tive will provide 450 AEDs to public places across the province over three years. Para-medics throughout B.C. have volunteered to train venue staff and provide ongoing support to the facility and staff with regards to maintaining and utilizing the AED.

• BCAS’s extensive fleet operations experi-ence and robust maintenance program continues to expand and include other areas of the provincial health care system. Within the last two years, BCAS has under-taken fleet maintenance for the Northern Health Authority (April 2011) and the Pro-vincial Health Authority (June 2012) in order to ensure consistent, robust and thorough fleet maintenance throughout the province. In October 2013, BCAS will also begin fleet maintenance for the Justice Institute of Brit-ish Columbia.

• BCAS established the Assessment and Investigations Unit (AIU) to track and trend all operational concerns and complaints within BCAS, provide logistical support to area managers in the completion of inves-tigations of those complaints and conduct investigations at the request of the BCAS Senior Operations Team. With its provin-cial scope, the AIU steers the process of a uniform, standardized response to all op-erational complaints and offers managers a timely analysis of complaint trends to better inform decision making for mitigation.

• In Greater Victoria, the location of ambu-lance calls has changed over time and the current stand-alone station model wasn’t providing the flexibility required to best serve the region. In 2012/13, BCEHS renovated an existing station to become a central reporting station. In 2013/14, para-medics will be deployed from this one large station and satellite locations throughout the region; the smaller stations can be more easily relocated to respond to changing demand and provide the fastest response

BC amBulanCe serviCe

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for patients.

• The BCEHS Billing department has been working diligently over the past number of years to decrease the time a patient receives ambulance service to when the invoice ar-rives in the mail. In 2012/13, BCEHS sur-passed our service targets and will have 40 per cent of our invoices distributed within in 20 days, and 90 per cent billable within 45 days.

major event resPonseLate at night on April 23, 2012, the BCAS Dis-patch Operations Centre in Kamloops received a report of an explosion and fire with multiple patients at the Lakeland Mill in Prince George. BCAS immediately began a coordinated emer-gency medical response.

BCAS responded with three ambulances from Prince George, up-staffed two additional lo-cal ambulances, dispatched two ambulances from both Vanderhoof and Quesnel as well as assigned the units and the Medical Support Unit. The BCAS Technical Advisor was engaged from the start of the incident, providing direc-tion on hazards and decontamination, first by phone and then by attending the scene. Two duty BCAS aircraft and one up-staffed aircraft responded. Behind the scenes, BCAS managers were coordinating activities and resources with Northern Health Authority and BC Bedline, now the BC Patient Transfer Network.

BCAS decontaminated and transported 16 pa-tients from the scene.

The integrated, seamless response to this inci-dent demonstrated the significant contribution that the provincial ambulance system makes to patients in need and the entire healthcare sys-tem.

BCas serviCesGround AmbulAnce BCAS responds to patients using two main types of pre-hospital emergency medical ser-vice: Basic Life Support (BLS) and Advanced Life Support (ALS). The most common ambu-

lance service provided by BCAS is BLS; these paramedic crews are responsible for providing care for medical emergencies and traumatic in-juries and are composed of Emergency Medi-cal Responders (EMRs) and Primary Care Para-medics (PCPs). BCAS employs some EMRs on an on-call, part-time basis but the majority of paramedics working across B.C. are employed as PCPs - working in both full-time and part-time positions in rural and urban communities. When more advanced care is required, BLS paramedic crews can be supported by ALS paramedic crews. ALS ambulances are staffed by Advanced Care Paramedics (ACPs) who re-ceive additional training which enables them to perform more advanced emergency care proce-dures and a higher level of patient care.

Service deliveryBCAS’s Service Delivery program assesses, prioritizes and coordinates ground ambulance responses from three separate but integrated dispatch centres in Kamloops, Victoria and Vancouver. Service Delivery also incorporates dispatch training, development and quality im-provement areas. Together, the three centres dispatched ground ambulances to 504,000 events in 2012/13 throughout the province, a four per cent increase compared to 2011/12.When a request for service is received, Service Delivery ensures that there is a timely, efficient and appropriate response of ambulances, para-medics and other resources to emergency calls. The centres are also responsible for ensuring appropriate resources are allocated and main-taining operational readiness for all areas of BC.

On April 11, 2012, the BCAS Patient Transport Coordination Centre (PTCC) came into being; prior to this the three dispatch centres operated independently when coordinating inter-facility patient transfers. Air coordination was managed by a Provincial Air Ambulance Coordination Centre which worked independent of the other dispatch centres in managing air and critical care coordination for the province.

The PTCC was created to allow a central coordi-nation centre to handle all requests, both ground and air, for transfers. At the PTCC, each call taker’s sole responsibility is coordinating inter-facility patient transfers; the staff are able to fully focus on the complexities of coordinating inter-facility transfers within the geographical chal-

StAtiSticS

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lenges of BC. Consolidating this business area allows for focus and efficiencies for inter-facility transfers while allowing the ground ambulance 9-1-1 dispatchers to focus on the pre-hospital emergency medical calls.

In September 2012, the Patient Transfer Net-work moved into the same facility and is locat-ed directly beside the PTCC, further enhancing

provincial inter-facility patient transfer system for health authorities and patients. BCAS’s inter-facility patient transfer service complements a number of other patient transfer operations used by health authorities to provide non-medical pa-tient transfers for stable patients who do not re-quire the skills of a paramedic during transport.Provincially, BCAS’s dispatch centres manage on average three million individual telephone calls a year.

HISTORICAL PROVINCIAL EVENT VOLUMES

2008/2009

371,766

2009/2010 2010/2011 2011/2012

Patient Transfers

2012/2013

372,106 379,713 394,069 413,123

133,605 106,852 91,855 92,069 90,920

Pre-Hospital Events

Pre-hospital events include all calls for pre-hospital call - both low acuity and high acuity - ‘lights and siren’ emergencies and ‘routine’ calls

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BCas stationsIn 2012/13, BCAS operated from 184 ambulance stations plus additional facilities:

• Provincial Headquarters in Victoria• Three Dispatch Operations Centers (Victoria, Vancouver and Kamloops)• Three Administrative Offices (Vancouver, Kamloops, and Prince George)• 12 local offices for District Managers (Campbell River, Castlegar, Chilliwack, Cranbrook, Nelson,

Clinton, Dawson Creek, Kelowna, Parksville, Smithers, Kelowna airport and Vancouver airport).

StAtion deSiGnAtionBCAS ambulance stations are classified as metropolitan, urban, rural or remote. Station classifica-tion is dependent on call volumes, geography, remoteness, proximity to other ambulance stations and health authority designation of facilities that are in the area. Thirty-six metropolitan stations are staffed 24 hours per day by full-time paramedic crews.

Thirty-five urban stations are also staffed 24 hours a day using a combination of full-time staff and paramedics working standby shifts.

Forty-eight rural stations are staffed using a stand-by model, where paramedics are paid a reduced rate to stand-by at the station ready to respond. When they respond to a call, they are paid their full hourly wage for three hours.

Sixty-five remote stations are staffed similar to volunteer fire departments where paramedics are called to respond by pager from the community. When on-call, paramedics receive a stipend to be available and their full hourly rate for four hours when responding to a call.

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faCility and station imProvementsBCEHS is continuing with a multi-year strategy to improve ambulance stations and other facilities throughout the province. In 2012/13, BCEHS spent $17 million on the following projects: • undertaking maintenance and repair work, heating, ventilation and air conditioning upgrades

and replacing of broken or worn-out furniture at 181 locations ($ 5.9 million);

• completing new facilities or significant renovations at a number of locations such as Victoria (Douglas Street), Fernie, Grassy Plains, Riondel, and Langford ($7.8 million); and

• renovating and providing new furniture to improve functionality in the Victoria, Vancouver, Kam-loops Dispatch centers and in Vancouver for the new Patient Transfer Network site, Scheduling and Clinical Education ($3.3 million).

In 2013/14, the BCEHS Facilities Department will be focussed on:• construction or renovation of facilities in North Vancouver, Bowser, Oceanside, Surrey, Rich-

mond, Mackenzie, Burnaby and Saanichton provincial head office; and

• continuing to source district manager offices in areas throughout the province, to support a closer working relationship with paramedics.

BCEHS is continuing a relatively new initiative of utilizing modular structures for the construction of new ambulance stations in a cost-effective approach to providing quality crew quarters. Modular crew quarters are now in place in Winlaw and Grassy Plains and on Saltspring Island, Quadra Is-land, Riondel and Denman Island. This ongoing commitment directly impacts the patients who are served by BCAS and the paramedics who provide this care on a daily basis.

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BCas Ground fleetThe BC Ambulance Service (BCAS) ambulance fleet is designed and equipped to support para-medics with providing patient care on the scene of an emergency and during transport to hospital in a multitude of diverse terrains and conditions throughout the province.

In relation to the fleet, BCAS uses:• 500 ambulances (including 16 4x4),• 62 support vehicles, • 46 bikes, and • 2 gators.

BCAS ambulances are currently manufactured by Crestline Coach Limited and Demers ambu-lances, based out of Saskatoon and Montreal respectively. Most ambulances are based on Ford or Chevrolet platforms.

The newest model of Demers Ambulances was designed by a committee of BCAS paramedics over the last two years. Modifications include: • a swivel chair in the back to replace bench seating;• the addition of light switches and oxygen access by the rear doors;• easier-to-use steps for elderly and mobility-challenged patients;• the installation of a back-up camera which allows the driver to see what is happening in the

back of the ambulance; and• heated spinal boards and clamshells that use latent energy in newly-installed solar heat ducts.

Green initiAtiveSThe 2013 Demers Ambulances use Eco-Smart technology which reduces idling by up to 40 per cent by monitoring the battery condition and interior temperature and shutting down or restarting the engine as needed to maintain electrical power or interior temperature.

There are currently five sprinter van ambulances in the Lower Mainland and on Vancouver Island with the Mercedes Benz Sprinter 2500 chassis. This chassis has a 3.0 L V6 BlueTEC Diesel engine, one of the cleanest diesel engines available. These ambulances are used throughout Europe and are ideal in urban areas that require short distance driving. Sprinter ambulances provide greater fuel efficiency and reduced nitrogen oxides and particulate emissions.

Fleet renewAlAfter being in service for four or five years, BCAS ambulances are refurbished and reallocated to stations with lower call volume in order to increase their useful lifespan. Generally BCAS ambulanc-es are decommissioned after reaching a mileage of 300,000 kilometres and 7.5 years of service. BCAS has one of the most efficient and detailed fleet replacement plans in North America:

Decommissioned ambulances are used as support vehicles, medical support units or training ve-hicles.

In 2011, BCAS began remounting older ambulance boxes on new chassis from the manufacturer. Remounted ambulances cost 50 per cent less than new ambulances.

Annually, 60-70 new or refurbished ambulances are brought into service.

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CritiCal Care transPort teamBCAS utilizes Critical Care Transport (CCT) paramedics to provide highly-specialized emer-gency care and long-distance transport be-tween health facilities for critically ill or injured patients. BCAS is one of only two ambulance services in Canada utilizing critical care para-medics. The CCT Program in BC essentially brings an intensive care unit to the patient and allows physicians and nurses to remain in their local hospitals.

In this model, highly-trained paramedics with specialized equipment and knowledge of the various transport environments, provide safe, effective and efficient patient transfer services. CCT paramedics perform advanced medical in-terventions and work with sophisticated moni-toring and ventilation equipment while enroute. The CCT program also relies on the expertise of critical care (physician) transport advisors for its functional medical oversight process.

Paramedics in BCAS’s CCT program work in specially-configured ambulances and utilize six dedicated airplanes, four helicopters and can call on approximately 40 pre-qualified char-ter aircraft across the province when required. Critical care paramedics are deployed from air bases and stations in Prince George, Richmond, Kelowna and Kamloops, Nanaimo, Langley and Vancouver; the team based in Langley was add-ed in 2012, the Nanaimo-based team was add-ed in 2011. Requests for fixed and rotary-wing air ambulance, neonatal, maternal and paediat-ric transfer services are processed through the Patient Transfer Coordination Centre based in Vancouver.

BCAS has two distinct protocols in place to ensure that aircraft are deployed and available when required to respond to a patient with an acute illness or injury. Autolaunch is the simul-taneous dispatch of both ground and air ambu-lances for specific emergency situations based on information provided from the scene by 911 callers. This protocol helps ensure that patients with life-threatening injuries are transported to a trauma centre as quickly as possible.

The Early Fixed-Wing Activation Program ena-bles responding paramedics at the scene to de-termine if the patient may need to be airlifted to an acute care hospital. They will activate the critical care transport (CCT) paramedics and air-craft to begin preparing for the emergency flight right away. Previously, only a hospital physician would have been able to activate the CCT team.

air amBulanCe auditIn March 2012, the Office of the Auditor Gen-eral (OAG) of British Columbia released an audit report related to the air ambulance service of BCAS’s Critical Care Transport (CCT) Program.

The OAG concluded that the BCAS is unable to demonstrate that it is providing timely, quality and safe patient care through the air ambulance service. The audit report recommended that BCAS takes steps to ensure it is providing pa-tients with the best air ambulance services pos-sible with the resources it has available by:

• actively managing the performance of its air ambulance services to achieve desired ser-vice standards for the quality, timeliness and safety of patient care;

• reviewing whether the distribution of staff and aircraft across the province is optimal for responding to demand for air ambulance services; and

• regularly identifying and reviewing a sample of air ambulance dispatch decisions to en-sure that resources are allocated with due consideration for patient needs and avail-able resources.

BCAS began work to establish service stand-ards, robust performance measures and report-ing for the critical care and aviation areas of the CCT Program. This work will address the OAG’s concerns and enable BCAS to demonstrate the efficiency and effectiveness of the air ambu-lance service.

ProGram overview and HiGHliGHts

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infant transPort teamBCAS’s Infant Transport Team (ITT) paramedics provide emergency medical care to BC paediat-ric, neo-natal and high-risk obstetrics patients while en-route to specialized care units in hos-pitals. Based at BC Children’s Hospital, these specialized paramedics are required to com-plete a specific training program focussing on providing care to children, and the advanced skills specific to those patients. ITT paramed-ics liaise with specialist physicians who provide support and guidance.

sPeCial oPerationsIn 1992, BCAS was one of the first North Ameri-can Emergency Medical Services agencies to organize and deploy a Special Operations team of paramedics deployed on bicycles for major public events where crowds can limit access and speed of response for normal ambulance vehicles. The primary objective of BCAS’s Spe-cial Operations is to provide rapid response care through congested areas allowing paramedics to arrive at the patient’s side faster than a tradi-tional ambulance vehicle.

BCAS’s paramedic bike squads are also sup-plemented by two Gators purchased to support ambulance coverage during peak crowd times. Gators are specialized all terrain vehicles that are used to transport patients from on scene to the ambulance, in situations where the ambu-lance is unavailable to reach the patient due to

ground conditions. The bike squad and Gators also provide contracted paramedic services at major public and international events, profes-sional sporting events, movie sets and commu-nity fairs when not otherwise needed.

emerGenCy manaGementBCAS actively participates in emergency plan-ning, mock disaster exercises and other joint training initiatives with other emergency man-agement organizations to ensure disaster pre-paredness and response capabilities are identi-fied and deployed quickly and effectively when they are needed most. To ensure paramedics are prepared to respond to and recover from major emergencies; BCAS is a strategic partner with the Province-wide Emergency Manage-ment Office (EMO).

Based in Vancouver, the EMO provides pro-vincial oversight and direction in the planning of multi-casualty incidents, major emergency situations that involve multiple patients at one scene. The team also provides guidance in the areas of hazard recognition and risk assessment by identifying and documenting the hazards that pose the greatest threat at the station, regional and provincial levels and developing strategies to manage these risks. In addition, the EMO provides direction and advice regarding major incident support and hazardous substance and Chemical, Biological, Radiological, Nuclear and Explosive response.

2008/2009

8,356

2009/2010 2010/2011 2011/2012

8,2097,732 7,756

2012/2013

8,190

*includes ground and air critical care transports

BCEHS Medical Programs provides the medical input, education and overshight to guide para-medics in the provision of quality patient care.

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BCEHS Medical Programs provides the medical input, education and oversight to guide paramed-ics in the provision of quality patient care. Medical Programs integrates four major functions: physician oversight, quality improvement, clinical education and research. By integrating all functions, Medi-cal Programs strives to provide the best support possible to paramedics to enable them to provide excellent patient care.

mediCal oversiGHtemerGency phySiciAn online (reAl time) Support BCEHS launched the Emergency Physician Online Support (EPOS) project in 2013 to provide reliable, consistent direct medical oversight for paramed-ics responding to 911 calls. EPOS is comprised of 45 emergency medicine specialists who provide immediate telephone support for paramedics during pre-hospital responses. This physician cohort also provides clinical guidance in the planning of trans-fers for complex patients requiring referral to tertiary care.

With EPOS, paramedics have one number to call for 24/7 physician support regardless of when or where clinical support is required. EPOS uses inno-vative telecommunications technology to route the call from a paramedic, who could be anywhere in the province, to the physician on-call. In order to support the project, a comprehensive change management program was undertaken to provide physician ori-entation to BC Ambulance Service policies and pro-cedures, paramedic scope of practice and BCEHS treatment guidelines. Paramedics were also trained to improve their communication skills when present-ing patient information to the physician.

Professional PraCtiCe BCEHS Medical Programs also made the following enhancements to paramedic practice and emer-gency medical services in 2012/13:

• Equipped and trained primary care paramed-ics to perform 12-lead electrocardiograms on patients suspected of experiencing a type of se-vere heart attack. BCAS worked with health au-thorities to established bypass protocols which enable paramedics to transport the patient to a hospital that can provide definitive care rather than the closest facility (if they are different).

• Worked with the BCEHS Quality, Safety, Risk Management and Accreditation and BC Ambu-lance Service Operations teams to revise the ambulance Resource Allocation Plan (RAP). The RAP prescribes the qualification, number and urgency of ambulances responding to almost 900 different call types.

• Pursuing accreditation from the Canadian Medi-cal Association for the BCEHS Critical Care Paramedic training program.

researCH The Resuscitation Outcomes Consortium (ROC) is a clinical trial network focusing on research in the area of pre-hospital cardiopulmonary arrest and se-vere traumatic injury. BCEHS and other EMS agen-cies from across North America are partners in the ROC and undertake clinical trials for pre-hospital cardiopulmonary arrest and severe traumatic injury. ROC is the first large scale effort to conduct clinical trials that focus on the very early delivery of inter-ventions by EMS teams to better optimize patient survival.

The ROC office coordinates with BCEHS to ensure the requirements of the research protocols are be-ing met while collating enrollment data specific to the ROC studies. Together, BCEHS and the ROC office are conducting clinical trials that will rapidly lead to evidence-based change to enhance clinical practice and better optimize patient outcomes.

In 2012/13, BCEHS is participating in three clinical trials:

• Comparing outcomes associated with CPR provided with continuous chest compressions versus a 30:2 compression to ventilation ratio. Paramedics in a number of metropolitan and urban areas are participating in this study.

• For trauma patients, there are no valid and reli-able clinical indicators in the pre-hospital setting that help identify which injured patients require rapid surgical interventions or resuscitation. Bio Lactate in Shock Trauma (BLAST) is a simple study intended to determine if blood lactate readings taken in the pre-hospital setting are an early predictor of shock and the need for ag-gressive in-hospital interventions. BLAST is the second clinical trial involving BCEHS.

• ROC is comparing the efficacy of two differ-ent antiarrhythmic drugs or no drug at all. The

MEDICAL PROGRAMS

22

Amiodarone Lidocaine Placebo (ALPS) study is looking at victims of sudden cardiac arrest who demonstrate a shockable rhythm that will not convert with defibrillation. Patients are receiving one of two different antiarrhythmic drugs or a placebo followed by further attempts at defibril-lation to determine the most effective therapy in these situations.

Data collected through the research partnership between the ROC and BCEHS has resulted in 11 publications in peer reviewed journals, including publications in the New England Journal of Medi-cine. BCEHS investigators continue to be actively involved in publishing research in top tier medical journals.

Beyond the ROC partnership, BCEHS is also con-ducting a trial looking at Primary Care Paramedic acquisition of 12 lead electrocardiograms to detect acute myocardial infarction and whether perfor-mance in the overall medical management of these patients can be improved by providing transport to a designated facility and early access to primary percutaneous coronary intervention.

BCEHS also partners with academics and gradu-ate students throughout British Columbia. During 2012/13, seven research partnerships were com-pleted or ongoing. These studies involved such diverse topics as cardiovascular health risks associ-ated with paramedic occupational exposures, work-place stress and coping, out of hospital midwifery practice, and studies of the perceptions of patient safety among paramedics.

CliniCal eduCation The BCEHS Clinical Education Division (CED) pro-vides educational oversight through program design and development, delivery and evaluation. CED aims to improve patient care through learning and education.

In 2012/13, CED was focussed on the following:

• Dealing with Death and Dying Course – Devel-oped a new course for paramedics to enhance their skills in providing comfort for the next of kin of the deceased patient and increase confi-dence in delivering death notification while man-aging the call and scene. The team won the BC Patient Safety & Quality Council 2012 Coping with End of Life Award.

• International Trauma Life Support (ITLS) – BC Emergency Health Services became an ap-proved ITLS Chapter and adopted ITLS as the trauma education standard for paramedics. ITLS is a non-profit organization dedicated to excellence in trauma education and response

and coordinates trauma training world-wide.

• Emergency Physician Online Support – CED created an online orientation course for the new BCEHS physician support network for ground paramedics during 9-1-1 and inter-facility trans-fer calls. Paramedics on 9-1-1 calls and call-takers arranging inter-facility transfers now have 24/7 access via telephone to an emergency physician to assist with the patient’s care.

• College of BC Midwives – A new course was developed and delivered that will improve para-medic’s awareness of midwives’ educational level, medications within their scope of practice, and responsibility when midwife is on the scene.

first resPonder ProGram First Responders (FRs) are an important part of pre-hospital care in BC; they provide basic first aid such as control of potentially fatal bleeding, CPR and AED in conjunction with BCAS paramedics. In small communities, volunteer fire fighters most often pro-vide FR services; in medium and large communities, career fire fighters most often provide FR services for the public. Participation in the FR program is voluntary.

BCEHS oversees the FR Program in British Colum-bia and is responsible for ensuring all participants in the program have signed consent agreements and stay within the scope of practice of FRs. There are approximately 6,500 FRs in BC and each holds an Emergency Medical Assistant – First Responder (EMA-FR) license issued by the provincial Emergen-cy Medical Assistants Licensing Board.

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The BCEHS Quality, Safety, Risk Management and Accreditation program (QSRMA) supports and guides the provision of the best care possible by facilitating patient-centered improvement projects, reviewing patient safety events and coordinating systems-level changes to the pre-hospital care system. The QS-RMA team works closely with all programs and the BCEHS executive to ensure patient safety is at the forefront of organizational decision-making. QSRMA focuses on building a culture of safety.

In 2012/13, QSRMA launched an adverse event re-porting system to enable staff to report concerns re-garding patient safety events through to the Patient Care Quality Office (PCQO). The PCQO logs the is-sue in the provincially-supported Patient Safety and Learning System for (PSLS) for management, track-ing and learning.

Last year, QSRMA also coordinated BCEHS prepa-ration for a Primer accreditation process through Ac-creditation Canada. BCEHS previously participated in a national pilot program as part of the develop-ment of Accreditation Canada’s Emergency Medical Standards. Work undertaken in the lead-up to the

Accreditation Canada Primer survey, a readiness assessment for the broader QMentum process, in-cludes an organizational self-assessment and Pa-tient Safety Culture survey, both designed to provide a baseline for focused ongoing improvement based on evidence-driven best practice. With the contin-ued support of staff, front-line paramedics, call-tak-ers and all levels of organizational leadership, BC-EHS anticipate a successful Primer process in June of 2013.

QSRMA collaborates with the PCQO which provides a clear, consistent, timely and transparent process for patients and various healthcare partners to regis-ter compliments and complaints about patient care.

The Risk Management Program works with BCEHS leaders to identify and assess risks, develop and monitor mitigation strategies and manage pre-hospi-tal event-related litigation activities include working with legal counsel and the BC Coroners Service. The Risk Management Program also supports patients and their access to health care information through the Patient Records Office.

QUALITY, SAFETY, RISK MANAGEMENT AND ACCREDITATION PROGRAM

BCEHS has a management services agreement with the Provincial Health Services Authority (PHSA) to support effective and efficient corporate services and patient care quality and safety services. The following BCEHS program areas provide services for the three operating entities and report directly to PHSA.

Since April 1, 2011, the Provincial Health Services Authority Patient Care Quality Office (PCQO) ex-panded to include the BCEHS. The PCQO oper-ates in keeping with the legislative requirements of the Patient Care Quality Review Board Act and the related ministerial directives. The PCQO ensures care quality complaints are managed consistently, responded to in a timely fashion and accounted for transparently.

Between July 1, 2012-June 30, 2013, the BCEHS PCQO processed and responded to 173 compli-ments, 126 complaints and 856 requests for infor-mation or questions (from government, the public, internal/external stakeholders).

The PCQO supports service improvements through feedback from patients and helps BCEHS agencies

achieve its mission to provide safe, reliable and ef-ficient care. In addition to care quality complaints, compliments and requests for information, and by leveraging the PCQO’s expertise and centralized sys-tem, patient safety events are now reported through the BCEHS PCQO toll-free line. Events are triaged by the patient care quality officers and sent to the most appropriate handler via the Patient Safety Learning System (PSLS). Since July 1, 2012, the PCQO has received and triaged 253 events.

All health authorities in BC each have PCQOs and each are represented by their leads at a provincial table whose membership includes the Ministry of Health and the lead for the Patient Care Quality Re-view Board Secretariat. BCEHS is represented by PHSA Patient Care Quality Offices’ Director.

BCEHS PATIENT CARE QUALITY OFFICE

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eamBulanCeThe eAmbulance concept began with a vision in 2010 to create a ‘mobile communications unit’ by incorporating updated medical technol-ogy supported by a secure wireless network in ambulances and stations throughout British Columbia. The eAmbulance system enables immediate and secure transmission of dispatch information to paramedics enroute to a call and patient care information from paramedics to health authorities while enroute to hospital. There are three essential components of the eAmbulance system.

in-veHiCle Gateway (ivG)IVG provides secure mobile network connectiv-ity that can be used by multiple ambulance-based systems by establishing:• a secure Local Area Network (LAN) that

connects devices within and around an ambulance using Ethernet or Wi-Fi,

• a secure Wide Area Network (WAN) con-nectivity to provincial networks using cel-lular network technology while the ambu-lance is in motion,

• Wi-Fi connectivity while the ambulance is at the station, and

• GPS coordinates for dissemination to local and remote devices.

IVG allows BCAS to utilize communications technology that isn’t dependent on any one commercial cellular carrier, uses multiple wire-less and cellular technology solutions and is scalable for easy readability on mobile devices. IVG enables connections to a variety of elec-tronic devices including in-vehicle computers, portable computer/tablet devices and medi-cal devices such as ECG monitors. IVG was deployed in 445 ambulances in 2012/13 to support the MobileCAD and ePCR systems (below).

moBile ComPuter aided disPatCH (moBileCad)MobileCAD is a computer in the cab of BCAS ambulances that connects with the CAD sys-tem in all three BCAS dispatch centres. Mobi-leCAD allows paramedics in the ambulance to receive pre-hospital and patient transfer event assignments and updates from dispatch and send back status code updates to dispatch in real time via a touch-screen computer. In addition to event information, MobileCAD also provides paramedics with maps and routing information. MobileCAD communicates with the CAD via the IVG network. Phase two of the MobileCAD implementation was started in 2012/13 with installation in 351 ambulances completed by yearend. Implementation in the remaining units in the fleet will continue in 2013/14.

information manaGement/ information teCHnoloGy

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ePCrThe Electronic Patient Care Record (ePCR) system replaces BCAS’s current paper-based electronic PCRs which are completed following each call paramedics respond to and scanned into the database at the ambulance station. Paramedics will use 430 hand-held devices to complete and upload the ePCRs remotely.

When the ePCR system is implemented in Spring 2014, paramedics will be able to collect and input data into the ePCR system in real time and upload the patient’s information for staff to use in the hospitals through the provin-cial eHealth Viewer. Each of BCAS’s devices will be equipped with Bluetooth and WiFi, camera, bar code reader, magnetic strip reader for gathering driver licence and care card infor-mation directly and a LifePak adapter enabling uploads of patient defibrillator data.

For ePCR, the benefits are patient-care fo-cussed; when implemented, sharing patient information between health care providers and BCAS will be secure, seamless and timely:

• Receiving hospitals will have up-to-date care information, such as vital signs, medi-cines and procedures administered when a patient arrives in the emergency depart-ment,

• BCAS will be able to accurately report on patient care allowing trends to be identified and finding opportunities to enhance pa-tient care; and,

• Realize increased operational efficiency and security due to less typing and no manual scanning.

The implementation of ePCR has been delayed several due to challenges with the IT infrastruc-ture. The goal is to have the first ePCR pilot in four BCAS stations in Winter 2013/14. The province-wide roll out will take three months to complete and includes coordination of many logistics such as technology installations, train-ing of 3,600 staff and excellent internal commu-nication support to ensure that the ambulance service is not impacted.

In order to support BCEHS’ transition to the health sector, the Human Resources Division is working closely with PHSA to ensure that the right people, are in the right jobs, at the right time, doing the right thing. Human Resources

has undertaken a comprehensive leadership development program to further develop the skills of the organization’s front-line and cor-porate leaders in order to deliver or directly support the best possible patient care. Leaders

Human resourCes

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The BCEHS Communications department provides a wide range of professional pub-lic relations and corporate communications services. The objective of the department is to enhance awareness of BCEHS’ role, operations and services provided within the context of the health care system and support internal staff and change management communications province-wide.

In 2012/13, BCEHS Communications under-took a number of initiatives aimed at refining the internal communications infrastructure and processes including:

• Undertaking the second organization-wide communications survey to better under-stand what mediums are preferred and utilized by staff to receive information;

• Updating communications tools and distri-bution based on staff feedback; and

• Refreshing the employee intranet to im-prove the navigation.

Sustaining a robust public safety education program comprises a large segment of BCEHS Communications resources. The department supports the Vital Link and Good Samari-tan, Public Access to Defibrillation, and ACT Foundation-BCAS High School CPR programs; issues public service announcements and provides and responds to request from news media for corporate and operational informa-tion; and leads a safety campaign to reduce the instances of children falling from doors and windows.

CommuniCations

across the organization were provided with two courses, one to define personal leadership style through self-assessment, and another aimed at creating a coaching culture. The courses have been well-received from staff and this work will continue in 2013/14.

In 2013/14, Human Resources focussed efforts in the following areas:

• Employee engagement – the staff recogni-tion programs were more closely aligned with those in the health sector as the long service awards and Employee Awards of Excellence were merged into the same event. Four separate recognition events were held around the province in the late fall. Additionally, BCEHS will be included in the health sector’s employee engagement survey for the first time in 2013/14 providing a baseline of information to support plan-ning.

• Recruitment and Retention – BCEHS, along

with many other health care providers and employers, continues to be challenged to hire staff in rural and remote areas. Hu-man Resources has partnered with BCAS Operations to develop targeted recruitment campaigns in communities with persistent staffing shortages. BCEHS and BCAS will continue to work with communities, indus-try, first responder groups and the health sector to fill vacancies in rural and remote areas.

• Health and Wellness - BCEHS is taking advantage of the opportunities afforded by being part of the health care system to use existing information infrastructure to track employee absences, disability management and workplace health. As part of a com-prehensive cccupational safety and health strategy, Human Resources is leading the development of a multi-faceted paramedic safety initiative that includes programs re-lated to musculo-skeletal injuries, violence in the workplace, exposures to communica-ble diseases, and slips/trips/falls.

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ProBlem strateGy

Increasing paramedic workload, particularly in the Lower Mainland

BCAS added two additional ambulances based in Sur-rey, changed shift start and end times to ensure cover-age during peak hours and reduce overtime, and com-pleted the work to update the Resource Allocation Plan

Recruitment in remote communitiesStrategic hiring practices, engaging community leaders and working with health authorities to expand paramed-ic roles in the community health care system

Staff morale/engagementEmphasize importance of in-person communication with leaders, commitment to including front-line staff in the development of new initiatives, leadership training

There are several ongoing challenges that BCEHS and BCAS are working to address:

orGanizational CHallenGes

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The 2012/13 budget for BCEHS was $307 million.

Of this amount, the majority, $241 million, related to BCAS as follows:

BudGet

Lower Mainland Ground Operations $81.5

Other Ground and Corporate Operations $84.4

Provincial Programs (includes Fleet and Air Programs) $73.9

Service Delivery (Dispatch) $23.1

BCAS estimated revenue recoveries from inter-facility transfers $21.8

Total $241

BC Patient Transfer Network $2.6

Trauma Services BC $2.0

Medical Oversight and Clinical Education $7.3

Corporate Services• Information Management / Information Technology• Ambulance and Corporate Facilities• Other (Finance, Human Resources, Communication, Quality Office)

$56.1

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In 2012/13, the Heart and Stroke Foundation – B.C. & Yukon, the Province of British Columbia and BCEHS launched the BC Public Access to Defibrillation (PAD) Program which makes Automat-ed External Defibrillators (AEDs) available in public places where large amounts of people gather. BCAS paramedics provide on-site orientation, on-going program oversight and stewardship. The PAD AED registry is linked to BCAS dispatch, where emergency medical dispatchers are able to ac-cess the location information of the AEDs and direct callers to access and use them. The program will instill 450 AEDs in recreation centres, arenas, parks and other public places over the next three years.

BCAS paramedics and dispatchers are also involved in a number of other initiatives that support the health and safety of the public:

vital link and Good samaritan award ProGramSupport provided by quick-thinking members of the public can often mean the difference be-tween life and death for patients. Whether performing bystander CPR, providing critical informa-tion to dispatchers or assisting paramedics on scene, British Columbians are an important link in the health care system. To recognize the significant contributions made by citizens during medi-cal emergencies, BCAS supports two community award programs: the Vital Link Award and the Good Samaritan Award. The Vital Link Award is presented to citizens who are involved in saving a life through successful cardio-pulmonary resuscitation (CPR) efforts. The Good Samaritan Award is presented to individuals who have provided unselfish and humanitarian assistance during a medical emergency. It is BCAS’s hope that by recognizing contributions and reinforcing the im-portance of bystander support, similar behaviour will be encouraged.

aCt foundation - BCas HiGH sCHool CPr ProGramCardiovascular disease is the second leading cause of death in B.C., accounting for more than one-fifth of all deaths in the province. Since 2005, BCAS has worked in partnership with the ACT Foundation to ensure that students in B.C. are becoming well-versed in this life-saving skill through the ACT Foundation-BCAS High School CPR Program. Through this partnership, over 40,000 high school students in British Columbia receive training in CPR each year. Research shows that a cardiac arrest victim is four times more likely to survive if CPR is administered by a bystander while paramedics are enroute to the scene. With most out-of-hospital cardiac arrests occurring at home, early recognition of a cardiac emergency by a family member, early access to medical help (calling 911) and early citizen CPR are critical to saving lives.

window and door safetyWith the support of industry and health sector, BCEHS created a decal to remind parents to lock doors and windows in order to keep children safe during the warmer months. The decals are sup-plied to paramedics attending community events across the province and distributed to daycares and public health units throughout Fraser Health. BCAS also partnered with BC Children’s Hospi-tal to raise awareness of this serious issue and distribute the decals.

P.a.r.t.y ProGramTogether with local partners, BCAS is helping to educate B.C. youth about how to stay safe through the P.A.R.T.Y. Program (Prevent Alcohol and Risk-Related Trauma in Youth). P.A.R.T.Y.

PuBliC outreaCH

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is a one-day, in-hospital, injury awareness and prevention program designed to reduce death and injury due to alcohol, drug and risk-related behaviours. Open to students ages 16 and older, par-ticipants follow the path of a trauma patient from the time of injury until discharged from hospital. During these sessions, paramedics hold a mock-crash demonstration and describe in detail the process they go through when they attend a serious motor vehicle collision. The program is struc-tured to bring them face to face with the consequences of risky behaviour.

Community suPPortMany paramedics throughout BC play prominent roles in their communities by volunteering and fundraising for many non-profit and charitable organizations, participating in blood and food drives, travelling to other countries for disaster relief support, 9/11 memorials and coaching sport teams.

PartnersHiPs

ShuSwAp lAke BCAS responds to many calls in the summer due to the popularity of houseboats in the summer. Working with the volunteer society, Coast Guard Auxiliary, Emergency Management BC and the Columbia-Shuswap Regional District, BCAS is part of a multi-agency partnership that greatly increases public safety and emer-gency patient care.

heAvy urbAn SeArch And reScue teAmS BCAS is included in a Vancouver-based team that locates people entrapped following a disaster. HUSAR includes search, medical and structural assessment capacity.

inteGrAted tActicAl SAFety unit Based in Vancouver and developed along England’s model of tending to patients in a soccer riot, the Van-couver Police Department officers work their way through a crowded event to form a line and create a safe workspace for BCAS paramedics to attend to patients. Patients are then rushed from the scene to a staging area that ambulances and gators could access and then to hospital.

BCAS fees are heavily subsidized for persons with a valid BC Care Card and who are covered by the provincial Medical Services Plan (MSP). The ambulance service fee for MSP beneficiaries is $80. Fees are not an insured benefit under MSP or the Canada Health Act. Further information on ambulance fees in BC is available at www.bcas.ca.

fees