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	Corporate Report
DEPARTMENT/	CAO's Office
DIVISION	Emergency Medical Services	REPORT NO.	2005.141
DATE PREPARED	May 25, 2005	FILE NO.
MEETING DATE	June 6, 2005
SUBJECT	Proposal to train new Advanced Care Paramedics in Thunder Bay

REPORT SUMMARY

To recommend an action plan to ensure adequate levels of Advanced Care Paramedics (ACPs) in the City of Thunder Bay for the provision of Emergency Medical Services.

In 1994, the Ontario Ministry of Health (MOH) launched the Ontario Pre-hospital Advanced Life Support study to identify the impact on mortality and morbidity of providing advanced paramedic skills during emergency response. Initially, 21 communities were identified as target cities. In Northern Ontario, Thunder Bay and Sudbury were included in this research project. Thunder Bay needed a minimum of 18 ACPs to cover three emergency ambulances on a 24 hour per day; 7 days a week basis The MOH decided to train 12. Local paramedics were selected and sent to Toronto’s Michener Institute to be trained in the following advanced skills:

IV initiation,
Intubation,
Sedation Protocol,
Cricothyroidotomy (surgical opening of airway added later),
Manual Cardiac Defibrillation,
Administration of up to 17 emergency drugs, including narcotics and controlled drugs, and
Chest decompression.

The study did not show the expected improvements in overall survival from sudden cardiac arrests. The study did show improvements in patient outcomes for other medical conditions, such as different respiratory emergencies and chest pain. It also showed that significant survival improvements could be obtained if ACPs arrived on scene within four minutes.

During the training period, paramedics were sent to Toronto for seven weeks. Each was paid, accommodated and given a meal and travel allowance. All costs were funded by the MOH. The previous employer subsequently agreed to contract language which prevents the employer from hiring new ACPs. They also agreed to language which would require that any costs associated with future training would be paid for by the employer. The City inherited this language when it assumed responsibility for service delivery.

Since downloading, ACPs, combined with primary care paramedics (PCPs) have become an expected level of care across Ontario. The program has grown and is now taught independently in many community colleges.

Since 1994, the number of Thunder Bay ACPs has decreased from twelve to seven, mainly through promotions and attrition. In 2002, a fourth 24 hour ambulance was added to improve emergency coverage and reduce response times. To ensure all four on duty ambulances have an ACP on board would require a total of twenty two ACPs.

The workload of ACPs is very high when compared to the PCPs. This stems from a combination of factors. Firstly, the MOH did not approve sufficient training funds to fully meet our original ACP needs. Secondly, the increasing number of emergency calls in Thunder Bay has resulted in the need to provide one additional ambulance. Finally, the loss of ACPs has transferred an additional burden on to the remaining seven ACPs.

The ACP medical director, Dr. Andrew Affleck has advised Superior North EMS that the ACP program is no longer sustainable. Between 2003 and 2004, the number of emergency patients who received this level of care decreased from 61% to 42%. The provincial average was 65% in 2003 and is expected to eventually level off at around 80% as more ACPs graduate from colleges and enter the workforce.

Under the current collective agreement, the cost of training an ACP at an out of town institution is in the range of $65,000 each. In 2001, the Collective Agreement was modified to require that only those full time employees who were working at the time of negotiations be completely trained at the employer’s expense. This does not address the high cost of training ACPs. Since 2001, efforts have been made to reduce cost delivery and have the training delivered in Thunder Bay by developing local expertise using internal resources.

During the past few months, the union and management met to identify possible alternatives which could result in ACP training taking place at a reduced cost. A new memorandum of understanding that offers a negotiated solution has been prepared for Council’s consideration at a closed session meeting.

A partnership with Cambrian College in Sudbury has been identified as a much lower cost approach to delivering ACP training to Superior North EMS staff. The course may only be delivered through colleges that have provincial Medical Advisory Committee and national Canadian Medical Association approvals. Confederation College is not approved at this time to deliver this program. The Thunder Bay Regional Health Sciences Centre is reviewing allotting clinical times to Superior North EMS in the operating rooms, intensive care units, emergency rooms, obstetrics, etc to meet course requirements. The Base Hospital Medical Director, Dr. Affleck, has approved of the proposed program delivery. The cost of delivering this program can be reduced from the estimate of $65,000 for out of town training to $42,605 for local delivery using this approach. This amount can be further reduced by 50% through the arrangements suggested in the memorandum of understanding mentioned above.

The training includes six weeks of classroom instruction, six to seven weeks of hospital clinical time and thirty three twelve hour shifts of field preceptorship with an experienced Advance Care Paramedic. Students must pass written, practical and oral college examinations as well as a written provincial examination and be certified by the local Base Hospital Medical Director.

After four years of ongoing efforts, this proposal represents the best option available to train additional ACPs for the City of Thunder Bay. If successful, it will be the first time this level of training has been offered locally. The timelines are extremely short to be able to begin the intensive training by September of 2005, and paramedics have already begun to study for the entrance exam to qualify for selection. To initiate training in September the qualification process must be completed by August.

To improve the outcome of medical emergencies in Thunder Bay and provide what has become the expected level of care across the Province of Ontario more ACPs are required. The ultimate goal should be to provide one ACP in each of four ambulances 24 hours per day, 7 days per week. This proposed solution negotiated with the assistance of the union, management, hospitals and colleges provides an effective approach to delivering the required training program for Superior North EMS.

Paramedics have shown a very strong commitment to this method of delivery. An information session has been presented to them to ensure they know the intensity of this training. They understand that their commitment to the training must be total for the duration of the process.

Should Council endorse the memorandum of understanding, the EMS Division proposes that a one time appropriation of $255,631 be taken from the equipment reserve account to provide advance care paramedic training for 2005-2006 as per the Memorandum of Understanding mentioned earlier.

THAT with respect to Report No 2005-141 (Emergency Medical Services Division), we recommend:

THAT Council approve the Memorandum of Understanding between Canadian Auto Workers Local 229 and the City of Thunder Bay on the Implementation Agreement For Advanced Care Paramedic Training for 2005-2006;

AND THAT funding in the amount of $255,631 be transferred from the the Vehicle and Equipment Reserve to facilitate this training in 2005-2006;

AND THAT savings identified in the Memorandum of Understanding be used to replenish the Vehicle and Equipment Reserve;

AND THAT the Mayor and Clerk be authorized to execute all necessary agreements, in form and content satisfactory to the City Solicitor;

AND THAT any necessary by-law be presented to Council for ratification.

Please refer to separately distributed closed session memorandum.