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Chief of paramedics thinks new program can reduce offload delays

Fit2Sit will allow paramedics to leave non-urgent patients in emergency waiting rooms if no beds are available
Chief of paramedic services for the Region of Waterloo John Riches at headquarters on Erbs Road in Waterloo.

Editor's note: This story was first published by 

WATERLOO — Waterloo region's new chief of paramedic services John Riches thinks a "Fit2Sit" program the region plans to introduce this fall will help reduce the delays paramedics experience when offloading patients at local hospitals.

It's a problem that has plagued the service for years, but reached a breaking point during the pandemic as short-staffed hospitals grappled with a surge of patients. 

Fit2Sit aims to reduce offload delays by formalizing the criteria by which a patient is deemed fit to be left on their own, speeding up the transfer of care from paramedics to hospital staff.

"It's not the golden egg. It's not going to solve everything," Riches says of Fit2Sit, which has been implemented in a number of regions around the province over the last few years to varying degrees of success.

Right now in Waterloo region, when no beds are available and hospital staff can't assume care, paramedics must sit and wait with patients until that transfer can happen.

In worst case scenarios, the temporary stop to patient flow prevents paramedics from responding to other calls.

Staff at Cambridge Memorial Hospital say it's too early to comment on how or when Fit2Sit might be implemented.

Riches, however, says the plan is to have staff trained and the process nailed down sometime this fall for possible implementation before the end of the year.

The sooner, the better. 

Ambulance calls in Waterloo region grew an "unsustainable" 11 per cent from 2021 to 2022, nearly double the annual growth rate of 6.5 per cent experienced in the four years before the pandemic. 

Also among the findings in Riches' April report on key performance indicators in paramedic services was the 2022 stat on ambulance utilization, which at 48.3 per cent is well above the recommend threshold of 35 per cent.

In 2022 offload delays resulted in a loss of 601 ambulance days.

In some situations called "code reds," the flow of patient care stalled to the point that no other ambulances were available to respond to calls. 

Waterloo region experienced 210 code red events last year with a median length of 15 minutes 16 seconds per day. That's compared to 42 events of a median length of 12 minutes 23 seconds in 2021. 

The total time spent in code red increased 571 per cent in 2022 from the previous year.

During those events, patients that required resuscitation from cardiac arrest, stroke and severe trauma could have been forced to wait.

Cambridge Memorial Hospital spokesperson Stephan Beckhoff says to cope with code reds, the hospital has developed internal processes to expedite off-loads and create capacity in the emergency department when they occur.

But it's not always enough.

In the spring, paramedic services was still losing the equivalent of more than three 12-hour ambulance shifts per day to offload delay, although the situation has improved since then with the addition of three 12 hour ambulances last October.

Four new 12 hour ambulances were added this month and four more 12 hour ambulance units will come on line on Jan. 1, 2024.

Part of the problem is the large number of 911 calls that come in for middle-to-low acuity patients, Riches says.

The Canadian Triage and Acuity Scale (CTAS) ranks injuries, illness and conditions on a scale of 1 to 5 with 1 being the most serious.

Those are the really sick patients, Riches explains, and typically require resuscitation.

Hand off from paramedic to hospital staff for CTAS 1 and 2 patients happens immediately after they arrive at the emergency department. 

It's the CTAS 3 to 5 patients that can lead to offload delays.

Riches offers the example of a patient with broken wrist.

Treated en route to hospital with a splint and pain meds, that CTAS 5 patient would easily fit the criteria for Fit2Sit.

Once the program is in play, paramedics transporting non-urgent patients would hand a form to hospital staff, ensure the patient is comfortably seated, and quickly be back on the road, available for the next call.

Low acuity patients arriving by ambulance will end up waiting for care the same as everyone else who made it to emergency department on their own, Riches says.

Non-urgent patients who would be excluded from the program are those with more complex issues or medical conditions that require paramedics to stick around until hospital staff are able to take over.

Someone suffering from dementia, for example, requires supervision while waiting for transfer of care to happen.

"They're not acutely ill but they can't be put in a waiting room," Riches says, adding Waterloo region's aging population is one of a number of factors exacerbating offload delays.

Adults 65 and older represented 43 per cent of call volume for paramedics in Waterloo region last year.

Riches says Fit2Sit won't solve the healthcare crisis or fix the problem of offload delays entirely. The problem is much more complex than it appears on the surface.

And what sounds like an obvious solution isn't always easy to implement due to everything from liability concerns to provincial approval.

Other regions that implemented Fit2Sit since 2019, include Peel and Guelph Wellington.

Riches says regional council is supportive of investments in paramedic services and his experience with the province demonstrates an eagerness to approve solutions like Fit2Sit as governments struggle to get ahead of the impacts of population growth and age-related illness.

If there's a silver lining in the pandemic, he says, it was exposing deficiencies in the system and getting healthcare teams thinking about ways to improve it.

Those improvements have looked at the impact on staff as well. 

In some cases offload delays have led to what Riches calls "moral injuries." When healthcare workers can't effectively do their jobs and people suffer, those feelings of guilt can accumulate and can affect mental health. 

When the work is non stop, and they have to miss meals or work overtime, burnout can be the end result.

"When they're waiting with a patient, that is not down time," Riches says.

And just like we've seen in nursing, many paramedics have left the profession due to the stresses they've experienced over the last few years. 

Programs to help them cope now include peer support groups and the use of a therapy dog at headquarters.

Fit2Sit could eventually complement another program to divert patients from the often overburdened emergency department at Cambridge Memorial.

Tested last spring in a six-week pilot, the Community Mental Health and Addictions Clinic (C-MAC) diverted patients needing mental health supports to more appropriate care within the hospital.

With over 5,600 calls to Waterloo region's 911 dispatch centre related to mental health in 2022, Riches thinks permanent solutions like C-MAC will be critical to eliminating offload delays.

Even if 50 per cent of those patients can be diverted, that's nearly 3,000 people who would be able to access the care they need and not end up sitting in a chair in the ER, he told CambridgeToday before the program was implemented in April.

The director of the organization that coordinated the clinic with staff from community partners Kristina Eliashevsky says the Cambridge North Dumfries Ontario Health Team expects to release key findings on the pilot this week that shows "a demonstratable need for this service in Cambridge."

Eliashevsky says it was such a success they are in the process of reviving advocacy efforts to seek funding to re-launch the clinic.

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