Delta Fire & Emergency Services Departme

The Corporation of Delta COUNCIL REPORT Regular Meeting To:

Mayor and Council

From:

Delta Fire & Emergency Services Department

Date:

April 13, 2017 A Review of Delta's Emergency Medical Responder Program

The following report has been reviewed and endorsed by the Chief Administrative Officer. •

RECOMMENDATION: THAT a copy of this report be provided to the Honourable Terry Lake, Minister of Health, Scott Hamilton, MLA Delta - North, and Vicki Huntington, MLA Delta South.

•

PURPOSE:

The purpose of this report is to provide a summary of the findings from a third-party review of Delta's Emergency Medical Responder Program. •

BACKGROUND:

On June 15, 2016, Delta Fire & Emergency Services completed its first year of providing enhanced pre-hospital care to Delta residents. As a result, a sufficient amount of corresponding data was also available to undertake a comprehensive review of Delta's Emergency Medical Responder Program. Delta commissioned Dr. Martha Dow to complete a third party review of Delta's Emergency Medical Responder Program to provide feedback on the outcomes of the program. Dr. Dow is a researcher and consultant working in the areas of public safety, education, and organizational change. She is also an Associate Professor in the Department of Social, Cultural and Media Studies at the University of the Fraser Valley. Findings and con'clusions from Dr. Dow's report will be used to support decision-making relative to the Emergency Medical Responder Program over the next few years. Delta's Emergency Medical Responder Program was established in response to BC Emergency Health Services' implementation of changes to the BC Ambulance Services' Resource Allocation Plan which resulted in a significant number of codes being downgraded to Code 2 (routine) calls instead of their previous designation as Code 3 (lights and sirens). Following these changes, Mayor Lois E. Jackson, Delta Council and Chief Administrative Officer George V. Harvie saw a need to improve pre-hospital

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Page 2 of 5 A Review of the Emergency Medical Responder Program

April 13, 2017

medical care delivery for the municipality. Delta's Emergency Medical Responder Program would not have been possible without their unwavering support and collective determination to break through a number of difficult barriers, including meetings with provincial ministers and MLAs, and unsuccessful negotiations with British Columbia's Emergency Health Services and the Provincial Health Services Authority. This program would not be here today without their leadership efforts and Delta residents are better served because of it. •

DISCUSSION:

Dr. Dow's report, "Delta Fire & Emergency Services: A Review of the Emergency Medical Responder Program" (Attachment A) reviews the first 15 months of the Emergency Medical Response Program in Delta (June 2015 - September 2016). Report findings are based on a review of extensive documentation (e.g., legal opinions, memos, press releases, council reports) and data collection including emergency incident data, census statistics and discussions with key stakeholders. Lessons Learned: The report provides a number of Emergency Medical Responder Program lessons learned from over the last 15 months. This framing of best practices is summarized below: 1. Implementation - cooperation between the union executive and senior management was needed to ensure commitment to the program. It was also essential to have a temporary training position to develop a training plan, coordinate examination schedules and acquire equipment and supplies. 2. Licensing - after holding initial practical evaluations to certify Emergency First Responders off-site, it was determined that having Emergency Medical Assistant Licensing representatives come to Delta allowed for more efficient processing of members through the licensing process. It was also important to implement a data management system to satisfy licensing requirements and track the completion of required educational credits. 3. Emergency Medical Responder Curriculum - Delta built its own Emergency Medical Responder curriculum based on Red Cross material. It specifically targeted the licensing requirements. This made-for-Delta model created an environment where responders were more open to adopting the program. 4. Accountability - monthly statistic reports are provided to Carl Roy, President and CEO, Provincial Health Services Authority who in turn sends them to Dr. William Dick, Vice President, Medical Programs BCEHS to ensure full disclosure (e.g., patient care information, response types and times, and treatment protocols administered). Dr. Dick reviews Delta Patient Care Report Forms and monitors the patient care that is occurring and says that he does not have any concerns. When there is an issue, Dr. Dick says that there has been no problem calling Delta Fire & Emergency Services to discuss the concern and asking for changes. In addition, the program is also overseen by Delta Fire & Emergency


April 13, 2017

Services' medical oversight physician Dr. Allan Holmes who ensures that Delta's Emergency Medical Responders remain up to date with current protocols. Dr. Holmes also assists with ensuring operational usage guidelines are relevant for items such as Epipens and Naloxone. 5. Continual Improvement - Patient Care Reports filed by Delta's firefighters are reviewed and used to provide individual feedback and provide training and refresher curricular opportunities. Delta Fire and Emergency Services' independent contracted physician also provides medical oversight and recommendations to improve the program.

Emergency Medical Responder Program Outcomes: Dr. Dow acknowledges that the daily flow of people using the highway network to commute into or through the municipality during the day, coupled with a large geographic response area and an aging demographic necessitates the collective rethinking of municipal and provincial responses to pre-hospital health care in Delta. The Dow report suggests that Emergency Medical Responder Program provides a lowcost initiative aimed at supporting this collective response and that Delta's Emergency Medical Responders represent an integral part of the pre-hospital emergency health care matrix. The Dow report notes a number of positive program outcomes, including: . Enhanced Skill Set Through emergency medical responder level training, Delta's firefighters now have enhanced abilities to assess, triage and treat patients with a wider array of options, including the ability to: • • • • • •

Perform chest auscultation Establish nasopharyngeal airway Take blood pressure Perform pulse oximetry Use glucometer to measure glucose Deliver Entonox

• • • • •

Provide IV maintenance Provide enhanced traction and splinting Assist in childbirth Use a common Patient Care Form Administer Nitroglycerin and ASA

. When Delta's firefighters are able to use these emergency medical responder skills to respond to non-emergency related calls, it allows BC Ambulance Service to divert paramedics to more urgent call types. Delta firefighters have also been able to utilize these skills when extricating a patient from a situation that is not accessible to BC Ambulance Service (e.g., a motor vehicle accident). This allows for a faster medical response resulting in quicker treatment for the patient. Improved Service Delivery The Emergency Medical Responder Program has provided patients with an enhanced response. During the period of June 15, 2015 and September 12,2016, Delta Fire and Emergency Services responded to 8540 incidents - 3119 incidents of which were medical calls (e.g., breathing problems, feelings of sickness, falls onto ground,


April 13, 2017

unconscious/fainting, etc.). During these medical calls, Delta's firefighters used their emergency medical responder skills 75% of the time. It should also be noted that there have been no formal complaints and no Emergency Medical Assistants Licensing Board investigations associated with any of these incidents. Between this same reporting period, Delta Fire and Emergency Services responded to calls within an average of 5 minutes. They waited on average for an additional 10 minutes and 49 seconds for Be Ambulance Service to arrive on scene. The ability to respond quickly means that Delta Fire and Emergency Services is able to expedite the triage, treatment procedure and provide updates prior to the arrival of Be Ambulance Service and in some cases where the patient self-releases, Be Ambulance Services can divert to a higher acuity call.

Supports Delta's Emergency Plan The Dow report found that the Emergency Medical Responder Program plays an integral role in the corporate Municipal Emergency Plan. Delta's geography and ,its reliance on transportation and utility infrastructure make it susceptible to isolation in the event of a disaster (e.g., earthquake). Delta's Emergency Management Office is well served to have Delta firefighters with enhanced assessment, triage and treatment capabilities. This will be beneficial during the response phase of a mass casualty event where the municipality may need to be self-sufficient. Positive Public Feedback To reinforce Dr. Dow's findings, Delta has also received positive feedback from the public regarding response times and patient care. This service enhancement has been of particular benefit to Delta seniors - especially as their demographic continues to increase year over year. Delta's Emergency Medical Responder system will always be viewed as adding value to the system of emergency support. It is not intended to devalue the critical role that Be Ambulance Service plays in this municipality. Moving Forward with Next Steps: Dr. Dow offers a number of next steps as the Emergency Medical Responder Program advances into its second year. These next steps are reflected in the following table: Areas Patient Experience

Delta's Firefighters

Potential Next Steps

•

Develop and administer an instrument to assess patient experience and satisfaction with the EMR service delivery

•

Develop and administer a pain scale instrument to assess patient comfort prior to and after the administration of Entonox.

•

Explore on-scene experiences of Delta firefighters in regard to utilization of EMR interventions in instances differentiated by wait times less than and more than 10 minutes

• Assess effects of EMR training on increased confidence and scene assessment skills in relation to circumstances not requiring EMR skills


April 13, 2017

• Assess the perceptions of Delta firefighters with respect to preparation, training, and comfort in utilizing EMR skills in the field Delta's Firefighters

•

Examine usage data related to EMR skills by Delta Fire and Emergency Services to determine if these patterns are congruent with incident characteristics or if they might be related to other considerations such as programmatic and/or participant factors

• Work with BC Emergency Health Services to assess the effectiveness of EMR skill utilization with a view to developing best practices Inter-agency Cooperation

•

Explore mechanism to improve inter-agency communication

•

Encourage, in collaboration with pre-hospital care partners, ongoing review of governing legislation and regulations to ensure that in the rapidly developing field of pre-hospital health care, the scope of practice dictated by those legal and regulatory parameters is congruent

Given the complex interplay of stakeholders and organizations involved collaboration, transparency and evidence-based decision-making has and will continue to be used to move forward with this value added program. Implications: There are no financial implications. •

CONCLUSION:

A third party review of Delta's Emergency Medical Responder Program was commissioned to review the first 15 months of Delta's Emergency Medical Responder Program. Dow's report presents the lessons learned during program implementation, outlines a number of positive outcomes, and offers a list of next steps. These report findings will support senior management decision-making as Delta advances its Emergency Medical Responder Program over the next two years. Delta's Emergency Medical Responder Program has demonstrated that Delta Fire & Emergency Services is committed to being a progressive, responsive change agent and partner in the provision of emergency pre hospital care services in the province.

Dan Copeland Fire Chief Department submission prepared by: Paula Kolisnek, Senior Corporate Policy Analyst, and Christine Nenno, Delta Fire and Emergency Services Administrative Assistant

•

ATTACHMENT: A. A Review of the Emergency Medical Responder Program - Martha Dow PhD, University of the Fraser Valley Centre for Social Research

Attachment A

UNIVE~~dI OFTHE FRASER VALLEY CENTRE FOR SOCIAL RESEARCH

Attachment A Page 2 of26

Executive Summary

Delta Fire and Emergency Services' Emergency Medical Responder (EMR) program was implemented after extensive 'stakeholder consultation and in response to Delta Council's commitment to responsive pre-hospital care for the citizens it serves. Additionally, the EMR program is viewed as a critical component of a comprehensive and integrated emergency preparedness plan. The EMR program was implemented in June 2015 and this report outlines the experiences to date. Overall, the EMR program in Delta has enhanced the skills and knowledge of Fire First Responders in a manner that supports patient care and is a proactive and evidenced-based approach to improving pre-hospital care capabilities.

Introduction

On June 15, 2015, Delta Fire and Emergency Services (DFES) transitioned from a First Responder level to an Emergency Medical Responder (EMR) level of certification. To date, 130 (79%) firefighters with DFES have been trained to EMR level. The EMR license enhances the Emergency Medical Assistant (EMA) skillset by providing First Responders with: • •

Increased foundational knowledge in human anatomy, physiology, pathophysiology and ph~rmacology; and, Enhanced patient assessment skills.

And, the ability to: • • • • • • • • • •

Perform chest auscultation; Establish nasopharyngeal airway; Take blood pressure and perform pulse oximetry; Utilize a glucometer to measure and treat low blood glucose levels; Deliver Entonox for pain management; Administer select drugs induding Nitroglycerin and ASA; Provide IV maintenance; Provide enhanced traction and splinting; Assist in childbirth; and, Use a common Patient Care Report form.

A key benefit of upgrading Fire First Responders to EMR level certification is their enhanced ability to assess patient needs and communicate effectively with other pre -hospital care personnel in a manner that supports patient care. The purpose of this report is to review the first 15 months of the EMR program to provide

Attachment A Page 3 of 26

information to senior management to support decision-making as the City moves forward with the program. Extensive documentation associated with the program was reviewed, incident data since inception was examined, and discussions with key stakeholders were held.

Context

On May 25, 2015, after extensive discussion and ultimately unsuccessful negotiations with British Columbia's Emergency Health Services (BCEHS), undertaken since the fall of 2013, Delta Council enacted the "Delta Fire Regulation Bylaw No. 5855, 2001 Amendment (Ancillary Health Services) Bylaw No. 7426, 2015". The new bylaw outlines that (1.2) 'Ancillary Health Services' means the provision of health care to an injured or sick person that supports, supplements or complements, or that is related or ancillary to, one or both of the following: i) 'Ambulance Services', or ii) Emergency Health Services', including, but not limited to, 'EMA FR Services' and 'EMR Services', until Ambulance Services, Emergency Services, or services provided by, from, in or through a Facility are willing and available to provide health care to that person. Delta received independent legal counsel confirming the municipality's legal authority to provide EMR services through the bylaw amendment. In June 2015, Delta's Fire and Emergency Services implemented its EMR protocol. In response, BCEHS sent its Metro Operations Staff a memorandum dated June 11, 2015 noting that "Delta [had] taken these actions unilaterally BCEHS does not support these initiatives and has serious concerns about their implementation". There has been some debate regarding the appropriateness of Delta's decision with questions raised regarding need, authority, legality, oversight, downloading, and the lack of system -wide response. The balance of this report reviews the rationale, implementation, lessons learned and next steps.


Why Emergency Medical Responder Certification? Municipal Vision

The Corporation of Delta has asserted that the EMR program aligns with the DFES's vision of being "[a] dynamic fire service, always responsive to community needs, delivered by well trained personnel with broad roles and skills". Additionally, DFES's corevalues 1 are often cited in support of this initiative as they relate to innovation, continuous improvement and timely and effective response. Demographic Changes

Delta's population grew from 96,635 in 2006 to 99,863 in 20.11 representing 3.3% growth compared to 5.9% growth nationwide. 2 While Delta's historic and projected population growth is slightly below the national average, a more meaningful representation of the population served by Delta Fire and Emergency Services must take into account the flow of people into and out of the municipality due to the industrial complexes, ferries, and shopping malls located within its boundaries. These residential and daily population ~stimates in conjunction with an aging community, necessitate the collective rethinking of municipal and provincial responses to pre-hospital health care. Figure 1 illustrates the upward trend of both of these factors with the projected population growth resulting in a provincial population of 4,988,900 and a median age at death of 80.8 in 2020. 3 The aging population presents significant cha~lenges for any system of pre-hospital care and necessitates high levels of interoperability. Adding to these unprecedented demographic stressors on the system are emerging health issues such as fentanyl overdoses that further strain the various components of emergency health services in Delta and the province at large.

Core Values: Quick response with compassion and professionalism; Public safety and community self-reliance; Positive, supportive, and safe work environment; Courage to innovate; Continuous improvement of community services; Quality leadership with vision, honesty, integrity, and open communication. 2 Focus on Geography Series, 2011 Census. https://www12.statcan.gc.ca/census-recensement/2011/as-sa/fogsspg/Facts-csd-eng.cfm?LANG=Eng&GK=CSD&GC=S91S011 . 3 http://www.bcstats.gov.bc.ca/StatisticsBySu bject/Demography/Population Projections.aspx 1

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Figure 1: Be Population and Aging Population Projections (2000 to 2020)

It is in response to these realities that initiatives such as Delta's EMR program, Surrey Fire Service's and Vancouver Fire and Rescue Services' leading efforts with respect to Naloxone administration, and BCEHS's attention to demand modelling are critical elements of a progressive and responsive emergency services system. Geography

By virtue of its geography and associated land use, Delta is especially vulnerable in large scale and complex emergency situations. Delta is located on 180.11 square kilometres 4 of mixed urban, agricultural and industrial land use. While the population of Delta is 101,546 5 resulting in comparatively high per capita fire expenditure assessments, analysis based on municipal sprawl and land use paints a different picture in regard to the reasonableness of these costs. The geographic spread across the three residential areas of Ladner, North Delta and Tsawwassen coupled with some of the specific features of the area including Burns Bog, significant agricultural areas, the Tilbury and Annacis Island industrial parks, Deltaport, Roberts Bank, and Boundary Bay Airport, provide important challenges to fire and emergency services responsiveness.

Statistics Canada, Focus on Geography Series, 2011 https://www12.statcan.gc.ca/census-recensement/2011/assa/fogs-spg/Facts-csd-eng.cfm?LANG=Eng&GK=CSD&GC=5915011 5 2015 Esti mate, http://www.bcstats .gov.bc.ca/Statisti csBySubject/Demograp hy /Popu lation Estimates.aspx

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Service Demand

The population trends, including both permanent residents and non-permanent visitors and traffic, discussed above will continue to stress the health care system and necessitate innovative and collaborative approaches to providing care to the citizens of Delta. Prehospital events are particularly susceptible to these pressures as the proportion of seniors, a Significant user group, continues to grow. Importantly, pre-hospital incidents have been steadily increasing over the last decade and are projected to outpace population growth at an increasing rate (Figure 2). The strategic placement and staffing of fire halls coupled with the tactical review of utilization rates highlights the integral role that highly trained Fire First Responders play in the pre-hospital system of care in Delta.

Figure 2: Be Population Projections and Pre-Hospital Events (2000 to 2020) 6000000

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