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A matter of minutes

It’s 10:31 a.m. when a paramedic crew gets rolling to an emergency call with lights and sirens. But as crew members leave the base, speeding down a busy city street toward a residential neighbourhood, they know five minutes have already passed since a middle-aged man collapsed in cardiac arrest.

Critics of Ontario’s ambulance dispatch system say it’s inferior to those used in other Canadian cities and often unnecessarily sends ambulances rushing to calls, putting patients and paramedics at risk. Photo by John Riddell

The man’s wife had called for help at 10:26 a.m.

Central Ambulance Communication Centres (CACC) are expected to dispatch ambulance crews within two minutes of receiving an emergency call. But historically, Ontario has had some of the poorest response times in Canada.

By the time the ambulance reaches the hospital, the three-minute delay has at least tripled. The patient’s chance of survival has plummeted — a devastating reality for awaiting emergency room doctors.

In Oxford County, an urban-rural municipality in southwestern Ontario, it took 20 minutes or more to get an ambulance rolling 27 times in the first half of 2008.

“This is negligent,” says Carmen D’Angelo, who managed the county’s emergency medical services for eight years.  He says the current patient priority system in Ontario is to blame. “It’s in disarray,” says D’Angelo. 

In 2004, two-thirds of the province’s communications centres were not meeting the Ministry of Health and Long Term Care’s response times. Four of the 18 centres exceeded the two-minute standard by more than 30 seconds — one centre by as much as 110 seconds, as noted in an auditor general’s report. “Failure to arrive in as timely a fashion as possible will result in potentially avoidable deaths,” says London Health Sciences Centre emergency room physician Dr. John Dreyer, who has been pressuring the government to improve its dispatch system. 

He says Ontario’s unique system, implemented in the early 1990s, is inferior to that used elsewhere in Canada and abroad. He says it often unnecessarily sends ambulances rushing to calls with lights and sirens, putting patients and paramedics at risk.

And with most municipalities working on a tiered-response system, the problem is passed down to firefighters, who may be called out for improperly assigned calls.

Dreyer describes Ontario’s system, known as the Dispatch Priority Card Index (DPCI), as a “home-grown product” that has “surpassed its usefulness.”

“If you want a Ferrari, you don’t start building it yourself with parts from Ford,” says Dreyer, adding that many physicians in Ontario have concerns about the DPCI

But changes are underway at all provincial dispatch centres. And ministry spokesperson Mark Nesbitt says it’s a goal to learn from past mistakes and prevent future such events. Last year, 28 investigations were launched into land ambulance dispatch-related matters out of about 1.5 million calls. “As in any organization, human error will occur despite sophisticated quality assurance and other related programs,” says Nesbitt.

An enhanced DPCI system has been operational at Hamilton’s CACC since August 2008. A pilot project is also ongoing at Niagara’s CACC.

“Initial operational results of DPCI II are very positive,” says ministry spokesperson Andrew Morrison.

“Consistent with the ministry’s commitment to continual improvement of its business practices, the current dispatch system is being upgraded together with a quality assurance program.”

These improvements have been gradual since the auditor general identified deficiencies in Ontario’s dispatch system in 2000 and again in 2005. 

“We were concerned with the number of issues with respect to ambulance dispatch,” says Ontario’s auditor general, Jim McCarter.

He says the ministry dumped a lot of money into its land-ambulance service — almost doubling its costs over four years — but was still not meeting response time standards.

“Ambulance response times increased in about 44 per cent of municipalities between 2000 and 2004, even though the ministry had provided about $30 million in additional funding,” he notes in his 2005 report, the last provincial audit on ambulance service.

D’Angelo, now director of a regional base hospital program in Hamilton, is attempting to help the province determine the best communication system for Ontario after growing frustrated with the province’s lack of quick action.
“We have had a problem for eight years and nobody was fixing it,” he says. 

D’Angelo has prepared extensive research on the issue (www.county.oxford.on.ca/site/2871/default.aspx), comparing Ontario’s dispatch system with that used elsewhere in Canada and abroad. 

For example, in Nova Scotia, paramedics are notified in less than two minutes, 90 per cent of the time.

“We average 31 seconds from time call received to unit assigned for emergency calls and 36 seconds for urgent calls,” says Paul Maynard, of the Nova Scotia Emergency Communications Centre. “Overall (emergency and urgent) is an average of 32 seconds.”

Richmond, Va., is not far behind with a call processing time of 58 seconds. Nova Scotia and Richmond use an internationally recognized system, known as Medical Dispatch Priority (MDP). Toronto has also been using MDP since 1992. The program, Maynard says, provides immediate call triage and medical telephone advice to support safe and appropriate patient care while responders are on their way to the scene. 

“This immediate intervention is often referred to as zero response time, because paramedic communications officers use the caller as their eyes and hands to begin interventions while the ambulance is responding,” he adds. 

Dispatch response times may not literally be zero; however, they have been reduced at 15 communication centres since Ontario slowly began making changes. Today, 90 per cent of the time ambulances are on their way to an emergency in less than two minutes. Two CACCs still lagged behind the two-minute standard in 2008.

But new legislation, which takes effect in 2010, may be a solution as each municipality and dispatch centre will be required to develop an annual response time performance plan to be submitted to the ministry. Results will be made public.

While Dreyer says Ontario is taking a step in the right direction, he would like to see Ontario implement MDP.
“It’s a standardized system and is proven, tried and true,” says Dreyer, adding MDP more accurately fleshes out real emergency calls while boosting public confidence in what would be a state-of-the-art product.

With the current system, he says an ambulance is automatically sent out with lights and sirens if a patient is bleeding.

“It could just be a paper cut but would signal an emergency response,” says Dreyer. “MDP will tease out which calls you really need to get to in a hurry.”

And those minutes do matter.

“Brain damage may start after only four minutes of cardiac arrest and irreversible brain damage is certain after 10 minutes,” says Dr. Christian Vaillancourt, a scientist at the Ottawa Health Research Institute. “Likewise, with every minute delay in instituting CPR, chancesto recover from a cardiac arrest decrease in a non-linear fashion.”

He refers to a study, which shows a person’s survival rate drops from 98 per cent if reached within one minute to 11 per cent at six minutes. 

Morrison, calls Ontario’s system “a world leader in many areas” and says the province’s new call screening tool coming to dispatch centres by the end of this year will “systematically elicit vital location, scene and patient condition information necessary for the rapid, accurate dispatching of ambulances.”