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	Corporate Report
DEPARTMENT/	CAO's Office
DIVISION	Emergency Medical Services	REPORT NO.	2006.118
DATE PREPARED	May 17, 2006	FILE NO.
MEETING DATE	June 5, 2006
SUBJECT	Proposal for Advanced Care Paramedic Training

RECOMMENDATION

THAT with respect to Report No. 2006.118 (Emergency Medical Services Division), we recommend that the Advanced Care Paramedic Training program as outlined in this Report be approved;

AND THAT the Implementation Agreements “For Advanced Care paramedic training” (City of Thunder Bay; Rural and Remote) between Canadian Auto Workers Local 229 and the City of Thunder Bay be approved;

AND THAT funding in the amount of $285,314 be transferred from the EMS Vehicle, Equipment and Facility Reserve Fund to facilitate this training in 2006-2007;

AND THAT funding in the amount of $24,686 be transferred from the EMS Severance Reserve Fund to facilitate this training in 2006-2007;

AND THAT the EMS Severance Reserve Fund be closed off;

AND THAT savings identified in the Memorandum of Understanding and from particpation in the Research Outcomes Consortium be used to replenish the EMS Vehicle, Equipment and Facility Reserve Fund;

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

AND THAT the training be funded in accordance with the attached Source of Financing;

AND THAT Appropriation Change Order #26 be approved;

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

In the City of Thunder Bay today, there are 11 front line Advanced Care Paramedics (ACPs) in ambulances and an additional 2 ACP supervisors responding to 911 emergencies in Paramedic Response Units (PRUs). In the City of Thunder Bay, 22 ACPs would be required to staff 4 ambulances on a 24 hr / 365 day basis. An ACP training program beginning in September 2006 would add another six ACPs by spring of 2007, bringing the total to 17 Thunder Bay ACPs.

There are no ACPs in any other community in the District of Thunder Bay.

Armstrong is an isolated community located 300 kilometres north of Thunder Bay. Our Armstrong Primary Care Paramedics (PCP) deal with high acuity levels in both trauma and medical cases, and are required to transport ill and injured patients to either a health clinic staffed by a Nurse Practitioner with limited resources, or in the off hours to Thunder Bay’s Regional Health Sciences Centre. A 2006 training program start would bring two ACPs to Armstrong by spring 2007.

An ACP with a PCP partner has become the expected level of EMS care across the Province of Ontario. Because of this, ACP programs have proliferated and they are now taught independently in many community colleges province-wide. Thunder Bay’s Confederation College does not offer an ACP program, and they are not expected to provide one soon. The CAW and their members have agreed to a unique cost sharing proposal which would reduce the cost for this training to Superior North EMS.

DISCUSSION

Superior North EMS management has worked closely with the paramedic’s union, the Canadian Auto Workers Local 229, to achieve a unique cost sharing arrangement to facilitate an Advanced Care Paramedic (ACP) training program in Thunder Bay in 2006-07. Six of the current Thunder Bay ACPs were trained in 2005-06 under a unique cost-sharing arrangement with the paramedic’s bargaining unit, the Canadian Auto Workers (CAW) union local 229.

This very successful program was delivered by Superior North EMS under the aegis of Cambrian College in Sudbury utilizing Thunder Bay ACPs with in-house equipment. An advanced training/simulation manikin valued at $250,000 was utilized for the program under an agreement with the Department of National Defence at no cost to the Corporation.

Although the Ontario Pre-hospital Life Support Study (OPALS), conducted in the late 1990s, did not show improvement in overall survival from sudden cardiac arrest when ACPs assessed and managed the patients, there was an improvement in patient outcome in other areas when those patients were managed by ACPs. In particular, improvements in patient outcomes for medical conditions such as respiratory emergencies (asthma, shortness of breath, emphysema, etc.) and chest pain (acute myocardial infarction, congestive heart failure, angina, etc.). It also showed that significant survival improvements from cardiac arrest could be obtained if ACPs arrived on scene within four minutes.

ACPs are paramedics with critical thinking and advanced assessment skills and the following additional skills:

IV initiation and fluid therapy;
intubation;
sedation of certain patients;
cricothyroidotomy;
manual cardiac defibrillation;
cardioversion;
the administration of up to 17 emergency drugs, including narcotics; and
chest decompression.

In 1996, Thunder Bay’s original 12 ACPs were sent to Toronto’s Michener Institute for seven weeks of didactic training followed by four months of clinical time in Thunder Bay. Each ACP student was paid, accommodated and given a meal and travel allowance. These costs were fully funded by the Ministry of Health (MoH). Since the downloading of services to municipalities, the MoH has determined that they will no longer provide 100% funding for additional ACP training.

The workload of ACPs is very high when compared to the PCPs. This stems from a combination of factors. At the outset of OPALS, the MoH did not approve sufficient numbers of ACPs to meet City of Thunder Bay’s needs. The Thunder Bay Regional Health Sciences Centre Base Hospital Program requested a minimum of 18 ACPs to respond to 6844 high priority emergencies in 1996. The province approved only 12... The situation is exacerbated by the increasing number of emergency calls in which an ACP would have a positive impact. In 2005, there were 12,526 high priority emergency demands for service. Additional ACPs would reduce the burden on our existing ACPs and also the service to better meet the demand of for ACT response to 911 emergencies.

In 1998, the previous employer, Nipigon District Memorial Hospital, agreed to contract language with the union which prevents the City from hiring new ACPs. The previous employer also agreed to language which would require that any costs associated with future training would be fully funded by the employer and/or Ministry of Health. The City inherited this language when it assumed responsibility for service delivery.

In 2001, the City negotiated changes to the Collective Agreement to require that only those full time employees who were working at the time of negotiations be completely trained at the employer’s expense. The result is that Superior North EMS must train those remaining before hiring already trained ACPs.

This, however, 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. Under the collective agreement, the cost of training one ACP at an out of town institution is approximately $65,000. The cost-sharing arrangement we have negotiated with the CAW has resulted in a significantly lower training cost per ACP: $42,608 in 2005-06, and the 2006-07 cost per ACP is projected to be $38,750. The 2006-07 increase to 8 students results in a lower cost per student, because of a higher student/instructor ration.

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 under the guidance of an experienced Thunder Bay ACP. ACP students must pass written, practical and oral college examinations before writing a provincial examination. They then require certification by the local Base Hospital Medical Director.

The paramedics and the CAW have agreed to continue with the cost-sharing aspect of an ACP program for 2006. The CAW has agreed to two Implementation Agreements (CTB and Rural and Remote), similar to the ones used in 2005-06 for the ACP training program. The overall impact of this agreement is a training cost of $19,375 per ACP.

The two ACPs allotted for Armstrong will be placed on opposing 24 hour rotations, thus ensuring that an ACP is available 24 hours a day, 365 days per year, excepting vacation and authorized leave.

The total cost for the 2006 ACP program will be $310,000. This program would produce six ACPs for Thunder Bay, and two ACPs for Armstrong.

Should Council endorse the Implementation Agreements, the EMS Division proposes that a one time appropriation of $285,314 be taken from the EMS Vehicle, Equipment and Facility Reserve Fund; and the remaining balance be provided from the EMS Severance Reserve Fund which had a balance of $24,686 on January 1, 2006. This will effectively close off of the EMS Severance Reserve Fund as was intended in Report 2003.207.

Savings identified in the 2006-07 Implementation Agreements will be used to replenish 50% of the training costs to be returned to the EMS Vehicle, Equipment and Facilities Reserve Fund. This is the same arrangement agreed to by council in 2005-2006. This reduces the cost to the municipality from $310,000 to $155,000 one time cost over the next three years. The current balance of the EMS Vehicle, Equipment and Facilities Reserve Fund has a balance of $2,000,570 and can absorb these costs without jeopardizing upcoming capital purchases.

Superior North EMS continues to seek opportunities to access other sources of funding to replace capital equipment at less cost to the taxpayers. EMS is now working with the Research Outcomes Consortium (ROC), an international EMS research organization to examine the quality of CPR performed by paramedics, and to examine if improving the quality of paramedic CPR will increase the survival rate for those suffering an out-of-hospital cardiac arrest.

In exchange for Superior North EMS’ participation in ROC, suppliers may agree to replace our defibrillators at no or reduced costs. Superior North EMS has budgeted $277,000 for replacing our defibrillators in 2006. Should this project be successful, Superior North EMS could apply any remaining portion of the $277,000 towards replenishing the reserve account sooner and therefore reducing the impact of future capital purchases.

Introducing these eight ACPs in 2007 would require approval on a classification enhancement from 8 Primary Care Paramedic to 8 Advanced Care Paramedics for the 2007 budget year. Each ACP has a salary differential of $6,100 per year. Total ongoing budget impact would be $48,800 per year.

To improve the outcome of medical emergencies in Thunder Bay and Armstrong and to provide what has become the expected level of EMS service across the Province of Ontario, more ACPs are required.

This proposed solution negotiated with the assistance of the union, management, Thunder Bay Regional Health Sciences Centre and Cambrian College 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 and funding.

It is concluded that the ACP training proposal as outlined in this report be approved.

In 2004, ACPs responded to 42.55% of 911 emergency requests for EMS.

In 2005, ACPs responded to 36.95% of 911 emergency requests for EMS.

In March of 2006 (with the additional 6 ACPs from the 2005-06 training program), ACPs responded to 56.5% of 911 emergency requests for EMS. Since the 6 new ACPs were certified at the start of March, we have only one month of data to use for comparison purposes.

In March of 2007 (with the anticipated additional 6 ACPs from the 2006-07 training program), we predict that ACPs will respond to more that 60% of 911 emergency requests for EMS. In 2004, the provincial ACP capture rate was 65.7%.

These figures may be compared to other Ontario Municipalities’ percentages for ACP responses to 911 emergency requests. The graph below shows the percentages of actual emergency calls ACPs responded to for specific municipalities, with Thunder Bay in the last column.



This data was collected from the Ontario Municipal Benchmarking Initiative (OMBI).

Attachment A - Source of Financing

Attachment B - Appropriation Order Form #26