Friday, January 31, 2014
A.J. Heightman, MPA, EMT-P
The British Columbia Ambulance Service is the largest provider of emergency healthcare in Canada and the second-busiest EMS service in North America. The BCAS serves more than 4.6 million British Columbians and responds to more than 504,000 EMS calls, covering a whopping area of 364,764 square miles of urban, suburban, rural and wilderness areas.
This is done with 4,017 staff and emergency medical responders (EMRs), made up of: primary care paramedics (PCPs); advanced care paramedics (ACPs); child, maternal health and ITTs; and air-and-ground critical care paramedics (CCPs), all deployed from 184 ground stations via 504 ambulances. These units travel more than 12 million miles per year, responding to 486,138 events in the 2011/12 fiscal year: 92,069 inter-facility transfers and 394,069 prehospital (9-1-1) events.
The BCAS Evolution
Similar to the evolution of EMS in the United States, ambulance service in British Columbia has roots dating back to the early 1900s when it was provided by a wide range of commercial and municipal operators: transport might be provided by anyone from funeral home operators, volunteer fire departments and first aid squads, or agencies subsidized by municipalities or by paid subscriptions from the public.
This diversity in service providers resulted in great variations in response times and patient care standards. Compounded by a lack of central coordination, standardized training, staffing and resource deployment, the ambulance services in British Columbia suffered the same kind of inconsistencies in service delivery and differences in the quality of ambulances and equipment that was being experienced across the U.S.
In 1970, the same year that saw the U.S. create national EMS standards leading to the formation of the National Registry of Emergency Medical Technicians, Canadian physician and hospital administrator R. G. Foulkes developed “Health Security for British Columbians report for the Minister of Health,” a document that identified and attempted to address many of the healthcare issues existing in the province at the time.
A key recommendation of this report was that British Columbia should assume responsibility for all privately and municipally operated ambulance services in the province. Specifically, the report advised that “the fractionated ambulance services provided by private companies, volunteer agencies and municipal fire departments be amalgamated under one jurisdiction.”
This approach is a major departure from how most major U.S. city and county EMS systems operate or govern. With the exception of New York City, most U.S. EMS systems operate BLS/ALS emergency resources separately from routine transportation, aeromedical and critical care inter-facility services. Often these services are managed outside the 9-1-1 emergency response system, with separate dispatch centers, personnel and medical protocols. The Fire Department of the City of New York (FDNY) EMS system contractually integrates private hospital EMS assets into the city system and those resources are regulated and required by the city to follow FDNY dispatch, response and incident command protocols.
Following the Foulkes report recommendation, the province enacted the Health Emergency Act (HEA), which endowed the Emergency Health Services Commission (EHSC) with the legislated mandate to ensure the provision of high-quality and consistent levels of prehospital care throughout British Columbia. On July 4, 1974, the EHSC formed the new provincial BCAS to carry out the mandate.
Since its inception, the BCAS has evolved into a single unified operation, decentralized by design, but providing the organizational structure necessary for system improvements in operational efficiency, effectiveness and quality of care.
The period of 1974–1980 saw the establishment of training and patient care standards. Cross-boundary disputes were eliminated. Also during this time, ALS units were implemented in a number of communities: Infant transport team (ITT) paramedics were established to care for pediatric, neonatal and high-risk obstetrics patients, centralized dispatch/communications centers were built and the BC Air Ambulance Service was integrated so the agency could service remote communities that, at one time, had no form of emergency healthcare.
Understanding Size & Weather
The workforce numbers and sheer geographic area covered by the BCAS is impressive on its own, but, with videographer Criss Swabb by my side, I took a trip to British Columbia to see and experience first-hand how the BCAS accomplishes its monumental task. I was impressed not only with the scope of the BCAS system but its communications capabilities, field managers’ personal approaches, depth of services and, most importantly, its personnel and their dedication to patients.
As we drove from the bustling, thriving, heavily populated city of Vancouver and through the beautifully lush and green rural forests and white-capped mountains to remote, rural areas of the province, I got a true appreciation for just how big British Columbia is. It’s nearly four times the size of Great Britain, 2.5 times larger than Japan and larger than every U.S. state except Alaska. It’s bigger than California, Nevada and Oregon combined.
Not surprising given its size, British Columbia’s geography and climate are diverse. While the coast and certain valleys in the south-central part of the province have mild weather, the majority of British Columbia experiences a cold winter climate similar to the rest of Canada. The northeast corner that borders Alaska has a sub-arctic climate with very cold winters. The rugged coastline is dotted with nearly 6,000 islands, only some of which are inhabited. In these remote areas, the nearest BCAS station may be eight hours away.
Most of the population, however, is concentrated near Vancouver, the province’s most populous city located in the southwest corner of the mainland on the Pacific coast.
The BCAS is overseen by a board of directors and is comprised of an Operations Division and a Corporate Services Division.
The Operations Division includes separate departments for Metro Operations (ground operations in the Vancouver area) and Rural Operations (ground operations in all other areas), and also includes Service Delivery (dispatch) and Provincial Programs.
Provincial Programs cross all BCAS regions, including: ITTs, the Emergency Management Office (EMO), Fleet Operations, Logistics/Special Operations, the Assessment and Investigation Unit, and the Air Ambulance program. The EMO, based in Vancouver, provides provincial oversight and direction in the planning of multi-casualty incidents. The team also provides guidance in the areas of hazard recognition and risk assessment by identifying and documenting hazards that pose the greatest threat at station, regional and provincial levels, and by developing strategies to manage these risks. In addition, the EMO provides direction and advice regarding major incident support, plus hazardous substance and chemical, biological, radiological, nuclear and explosive (CBRNE) response.
Dispatch Operations are spread across three centers located in Kamloops, Vancouver and Victoria (Vancouver Island). Emergency medical dispatchers and call takers in the centers dispatch all ground and air ambulances across the province and work closely with dozens of other municipal and regional emergency services such as police and fire departments. The department is also responsible for dispatch training, system and administrative development and quality improvement.
The Corporate Services division includes: communications, finance, human resources, information management/technology, labor relations, medical programs, organizational health and safety, and the quality, safety, risk management and accreditation office. The BCAS also has a specialized Technical Advisor Program that launched in 2006 and provides real-time technical information to on-site supervisors and crews that respond to CBRNE events.
Technical Advisors are trained CBRNE graduates educated in hazardous material awareness and operations, dangerous goods, suspicious package guidelines, National Fire Protection Act 472 EMS Standards and explosive disposal procedures.
Working in close conjunction with Regional BCAS dispatch/Communications Centers, technical advisors gather and analyze vital on-scene information, such as patient symptoms, to determine which chemicals may be involved.
Based on this intelligence, a treatment plan for the suspected agent is developed and communicated to the frontline staff, who for safety purposes remains off site until the technical advisor, designated supervisor or other qualified lead agency deem the scene safe, or an appropriate action plan is developed.
General Care Providers
In British Columbia, licensed medical responders are all broadly referred to as emergency medical assistants and are licensed by a provincial governing agency. BLS care is delivered by EMRs and PCPs. EMRs fill an entry-level, community-focused role and are typically based in remote, rural areas where they are on-call on a part-time basis. PCPs are stationed throughout the province and are a career-focused position similar to the U.S. advanced EMT. The majority of BCAS staff practice at the PCP level. ALS care is delivered by ACPs.
Specialized Care Providers
In addition to the first responders, the BCAS has two levels of highly specialized caregivers. There are 77 CCPs and ITT members responsible for caring for inter-facility treatment and transport for patients across British Columbia on ground ambulances, helicopters and airplanes. One of only two paramedic units of its kind in the world, the ITT was formed by the BCAS in 1976 to provide expert care and transport to patients under 16 years of age who require a higher level of care. ITT paramedics are based at B.C. Children’s Hospital in Vancouver and provide specialized care to pediatric, neonatal and high-risk obstetric patients while en-route to specialized care units in hospitals throughout British Columbia, the Yukon territories, other parts of Canada and the U.S., if necessary. All paramedics serving on the ITT are required to complete a specific training program focused on providing care to children, where they learn additional advanced skills and the use of a wide variety of monitors, specialized medications, ventilators and IV pumps.
ITT paramedics are also certified as PCPs with training in cardiac, respiratory, trauma, anaphylaxis, seizure and diabetic problems for adults and pediatrics.
In addition to their deployment on BCAS helicopters and aircraft, four ground ambulances outfitted with specialized equipment to care for young patients are dedicated solely for use by the ITT and include built-in air pumps, high-intensity lighting and a 1,000 watt inverter to ensure full battery levels on equipment.
Patient Transfer Services
Patient transfers account for 30% of all BCAS transports and are handled by the patient transfer coordination center (PTCC)at the Vancouver Dispatch Operations Center. The PTCC serves as the central coordination hub for the nearly 350 daily patient movements (including air and ground critical care transports) between dedicated hospital facilities in the entire province. These transports are primarily within British Columbia, but can be international.
The BCAS has a number of dedicated ground ambulances available for patient transfers, but also utilizes emergency fleet ambulances between 9-1-1 calls to transfer patients among health care facilities.
Aviation & Water Resources
With the main location of specialty care centers in the southernmost section of Vancouver, the BCAS uses a very robust “medical air force” of helicopters and fixed wing aircraft to transfer critical patients throughout the province.
The system also uses a unique combination of part-time, full-time and paid-on-call personnel and unit chiefs, as well as full-time supervisors.
The BCAS aviation program provides critical transportation linkages between hospitals and referral centers across the province via dedicated air resources that include: six airplanes (two turboprops and one jet in Vancouver, two turboprops in Kelowna and one turboprop in Prince George), and four helicopters (two based in Vancouver, one based in both Prince Rupert and Kamloops).
The BCAS also utilizes approximately 40 prequalified charter carriers throughout British Columbia. All requests for critical care transport services, including neonatal, maternal and pediatric transfers, are processed through the BCAS PTCC in Vancouver.
The ITTs utilize helicopters and fixed-wing airplanes outfitted with 2,000 liters of medical oxygen, air pumps and electrical outlets; and enough equipment to care for two acute care patients.
The BCAS also has specialized water response capabilities throughout the province to provide EMS response along its 17,000 miles of shoreline, multitude of waterways and 6,000 islands.
The BCAS operates a high-powered open water response boat on the Vancouver Island Sicamous Station 333 with a Royal Canadian Marine Rescue Boat staffed along with a crew and boat pilot.
The treatment guidelines represent an innovative way of thinking about how paramedics approach decisions to provide the best, most appropriate care for their patients. They’re not a linear step-by-step approach, but rather provide options within the appropriate scope of practice to allow paramedics to address the patient’s specific needs.
Each BC treatment guideline consists of two core documents: medical principles and intervention guidelines:
>> Medical principles: Key components of information that paramedics should understand in consideration of their critical decision-making process. These guiding principles form the basis of supporting paramedic treatment decisions and provide guidance to either reaffirm or enhance paramedic root training in emergency care.
>> Intervention guidelines: Describe the logical treatments that may benefit patients with these presentations. All are within the scope of practice for the given license level. The intervention guidelines are about options. They contain elements of treatment aimed at attaining a specific goal within the context of the patient’s needs.
The intervention guidelines are formatted to provide perspectives of care from the first-responder level to in-hospital case management. This way paramedics are informed about potential care in all medical education levels and their role in that continuum of care.
Under Constant Improvement
The BCAS is under constant improvement, from its training and response capabilities to its implementation of completely redesigned e-ambulances with telematics, auto-vehicle locators and electronic recordkeeping province-wide.
The BCAS completed a number of initiatives, including improved trauma bypass protocols; new station facilities and communications centers; increased transparency and accountability to the public via the creation of a Patient Care Quality Office; and more rigorous evaluation tools to enable better decision making. The organization also has an innovative emergency physician online support program, very active public support of AEDs, EMS bike teams and constantly active special event teams.
The BCAS is also utilizing Resuscitation Outcomes Consortium research to develop best practices for patient care and resuscitation, and is continually upgrading its response system mutual aid training, coordination and response to ensure seamless patient care and inter-facility patient transfers across British Columbia. Fire departments in each area of the province are also treated as integral partners in the emergency response system.
A Successful Visit
When I visited British Columbia and spent four days traveling and meeting with crews and key management and staff at all levels of BCAS, I was impressed with the spirit and professionalism of all the crews, communications center staff, operational managers and personnel. Everyone was dedicated to their mission and enjoyed telling me about their jobs and life in British Columbia.
Most impressive was that, despite the call volume (high or low) of stations or units, BCAS personnel were all truly concerned about rendering quality care and customer service. It’s not always easy. Many of the BCAS staff can be working on a busy Vancouver ambulance one week and then working in a remote area of the province the next week.
Concerned with providing top-quality care, some providers expressed frustration that BCAS hasn’t implemented all aspects of BLS and ALS services and upgrades. (Training staff and updating medical protocols takes time in such a large system.) However, I found the crews to be understanding of these inherent implementation obstacles particularly because they operate in a system that provides them with safe and reliable ambulances, modern equipment and communications, and exceptional maintenance of their vehicles and equipment.
The value of a no-boundary EMS system (meaning the system isn’t constricted by territorial lines) is evident in British Columbia, particularly when the coordinated delivery model is put to the test of responding to major incidents.
British Columbia Ambulances Redesigned for Maximum Efficiency & Safety
Two years ago, BCAS leaders made a big decision to replace their 500-plus ambulance fleet with custom-designed ambulances to optimize space, maximize fuel efficiency and the electric components, and, most importantly, ensure optimal safety for their crews and patients.
In an effort to get staff buy-in, BCAS involved employees, union and fleet management experts in the development of these new specifications.
The successful bidder was Demers Ambulance. Demers customized the new ambulances and will be delivering 50 Mystere, Type III, Chevrolet G3500, MX151D ambulances per year under the current contract.
More significantly, Demers made a commitment to continue to make enhancements to the model. Once the crews and managers have spent enough time using the vehicles, they can request additional modifications based on need or new technology.
Based in Beloeil, Quebec, Demers is the oldest continuous ambulance manufacturer in North America. The Demers family has been providing vehicle customization since the pre-automotive era, building custom buggies, carriages and ambulances since 1892.
With half a century in the ambulance business, the company has built more than 15,000 ambulances distributed to over 20 countries. It’s now the largest ambulance manufacturer in Canada and second largest in North America.
During the development of this article, I visited Demers’ 54,000 square-foot facility and was impressed with not only the manufacturing processes, but also the team of more than 200 highly motivated employees that carries out Demers’ goal of building innovative, customized and efficient ambulances.
“Our main focus is always on innovation,” says Demers CEO and President Alain Brunelle. “Our mission is to build innovative ambulances that deliver on customer expectations and assist paramedics in saving lives. Our expertise comes from understanding the EMT and paramedic protocols, assisting them in saving lives, and we keep true to this mission.”
“Demers is in constant contact with its clients, learning about new protocols and seeking opportunities for improvement. For example, following an ambulance accident in Alberta where the paramedic was seriously injured while executing a protocol, the chief’s mandate was to design an ambulance where a paramedic could execute care protocols while seated—with the seatbelt fastened. Since then, the province of Alberta, as well as British Columbia, has opted for this ambulance layout. Every request from a customer is part of our mission,” says Brunelle.
He also adds that balancing customization and compliance to all testing and certification requirements remains the biggest challenge in maintaining an industry-leading position in safety-oriented innovation. “The majority of our customers require very specific designs, heightening the level of standardization complexity.”
It’s no easy task meeting the specifications and standards of dozens of countries worldwide, but all Demers ambulances meet or exceed the highest international standards, including ISO 9001:2008 (Certified Quality Management System); DOT: US Department of Transportation; FMVSS: U.S. Federal Motor Vehicle Safety Standards and Regulations; CMVSS: Canadian Motor Vehicle Safety Standards; QVM: Qualified Vehicle Modifier (Ford); AMD: Ambulance Manufacturers Division of the National Truck Equipment Association (NTEA); KKK: Federal Specification for the Star of Life Ambulance (KKK-A-1822F); BNQ: Bureau de normalisation du Québec (NQ1013); Ontario Ministry of Health and Long-Term Care; applicable certifications for Western Canada; and the Approved Upfitter for Mercedes Benz Sprinter Customer Assurance Program.
What follows is a brief look at the innovative, custom ambulances built by Demers to meet the demands of the BCAS. Please click here to view.