Questions Remain Over ‘Laudable’ 911 Service Change Proposal

The provincial government’s proposal to amend regulations around how ambulance and the 911 services work has some laudable goals along with potential hotspots, says Elyse Sunshine. Sunshine says the proposed bill — which amends regulations under the Ambulance Act and Health Insurance Act — is intended to provide 911 patients with alternative care options other than transport to a hospital’s emergency department.

“It’s complicated,” she tells AdvocateDaily.com. “Obviously, Ontario’s hospitals are crowded. When people are in crisis in the community, and they or others with them call 911, they are and have always been most often taken to hospital. However, 911 is called in a wide variety of circumstances, and the hospital may not be the best place for the person in distress. Until now, however, there have been no real alternatives.”

The province has made a commitment to ensure patient safety and reduce hallway health care, says Sunshine, but more consultation and details are needed.

The regulation, posted Sept. 5, notes the Ministry of Health is planning to enable new patient care models for select 911 patients to provide timely access to definitive care where options other than transport to the emergency department may be done safely and appropriately.

“New models of care will help end hallway health care and ensure the delivery of high quality, integrated care,” the regulation states.

New models of care include:

• transporting patients to destinations other than the emergency department where they can receive appropriate treatment

• treating patients on-scene and referring them to another health-care provider

• treating and releasing patients on-scene

• referral of select low-acuity patients during the 911 call to appropriate care in the community

Sunshine says it’s crucial that callers to 911 receive meaningful triage over the phone.“It can be difficult to assess information from people over a phone,” she says, pointing to the government’s Telehealth Ontario phone service where callers can receive health advice or information from a registered nurse.

Health Minister Christine Elliott told CityNews that 911 call centres would have registered nurses on staff to help make these decisions.

“Currently, 911 operators are trained, but they’re not necessarily health professionals themselves,” Sunshine says. “They’re collecting information and dispatching ambulances. They’re well-trained in crisis management and providing advice until paramedics arrive, but they’re not diagnosing or assessing the patient.”

When it comes to paramedics deciding whether to transport a patient to an emergency room or another health-care provider, as the regulation suggests, Sunshine can envision logistical issues that would need to be addressed.

"It is not clear where ambulances will be taking people if the calls come in the middle of the night or on weekends. Currently, there are no facilities that can provide after-hours emergent care except an emergency room, so more work will be required to accomplish what the government is proposing,” she says.

Depending on how the legislation is written, there could be a risk to the paramedic of having to make that judgment call, Sunshine says.

“When you call 911, and an ambulance comes, you don’t have to give consent to the paramedic — your consent is implied — they stabilize or assist you, take you to the hospital, or release you,” she says. “Now, if you’re going elsewhere, they will probably need some form of express consent or protection in the legislation so they are not at risk.

“The government states the proposed bill is not anticipated to have any financial impacts on businesses, but Sunshine wonders if other legislation will need to be amended.”

For example, suppose a registered nurse is the one making the judgment call at the outset of a 911 call,” Sunshine says. “There are certain issues for which a nurse requires a physician’s orders to provide treatment. So, are they suggesting that nurses will have the authority to do whatever is necessary to deal with this emergency situation?

“The province states it is accepting public comments until Oct. 6, 2019, but Sunshine hopes the regulated professions involved in emergency care are going to be involved in further consultation.

“I think there are some laudable goals in looking at how we can deal with hospital overcrowding,” she says. “It will be very interesting to see how it actually plays out.”