RED doc is a discussion tool for communities and stakeholders wishing to understand the need for a flexible, coordinated and accountable Rural Emergency Response. The partnership is a growing network of Rural Mayors and Emergency Service providers, with representation of AUMA, AAMDC, Fire Chiefs of Alberta and includes the input of Health Care resources, researchers and concerned citizens. Contact Mayor Barb Sjoquist for information or to connect to a partner near you: Prepared by Dr. NJ Marlett (University of Calgary, Faculty of Medicine) & HR MacLean (Consultant) for RED Committee of the Provincial Partnership to Support Community First Response MAY 2012

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3 Updates: March – April 2012 Meeting with Minister Fred Horne to present the RED doc. This was a very positive meeting and the minister came to understand the complexity of a rural 911 and emergency response. He offered his support in opening a review. Health Quality Council review of EMS announced with reference to RED doc concerns Minister using RED doc in meetings with AUMA, AAMDC and communities Agreement with Fire Chiefs of Alberta to work together to promote rural first response. Representatives chosen

4 Updates: May 2012 New municipalities continue to join the partnership Preliminary meeting with Health Quality Council staff Partnership meetings to plan future meetings and review documents Paramedics and Ambulance providers have been studying RED doc and asked that their roles be included Study of culture of urban fire and ambulance to better understand rural history and culture Meeting with STARS senior management

5 The Trigger Why we are concerned about the provincial approach to EMS

Partnership to support Rural Community First Response Who we are and what we’ve done… 6 The Rural Response March Health Minister declares ‘Hold’ on Ambulance Dispatch Transition July EC911 Risk Management study for the Health Minister Nov. 2010, Wainwright Meeting formed Partnership to Support Rural First Response Aug. 2011, Stettler - Provincial Partnership conference provides data on shared issues Fall, 2011 – AUMA & AAMDC pass resolutions on halting transition & negotiating 911 cell phone fees Nov Research report from Stettler conference distributed Feb – RED doc released as living, action document April AUMA Research being compiled & Heath Quality Council review requested on EMS transition

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Communicate, research, learn about, work together, and become politically active to recognize, protect and advance a Rural EMS Direction (RED) that includes 3 Key Principles: Our Call to Action 8

Why is a Rural EMS Strategy needed? 9 Remote and Rural areas require flexible strategies that reflect their unique and changing strengths and needs. Borderless ambulance dispatch uses rural ambulances to support urban response time targets, increasing rural risk. Many remote and Rural areas do not have adequate telecommunication infrastructure. Rural Health profile is distinct (more catastrophic accidents, older population, fewer health resources, lower income.) Trauma profiles are more severe –farm, hunting, resource industry accidents, road accidents marked by faster speed, more rollovers. Rural EMS could provide a broad range of health supports in rural Alberta if communities are involved in the development. Ambulance ground response is costly and prone to being outside the windows for effective response time.

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‘Rurality’ Definitions for ‘Rural’ and ‘Remote’ rely on population size and density, and the distance to services. In Alberta, there is a belief that most of the population lives in Edmonton and Calgary with a scattering of medium sized cities. Popular belief that 95% of the province claims to be rural and remote. AHS has a ‘Rural’ research division that is working on a comprehensive mapping system of rural factors that could be used to create logical rural EMS divisions within either a provincial or zone model. 12

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Local preparedness to respond to accidents and health crises in Rural Alberta... The length of time for each emergency event is very short but these events change peoples’ lives and community identities. Some of the types of incidents that are involved: four teens roll over while rounding a curve at high speed coming home from ‘after grad’, a senior slips while canning and breaks her hip, a child chokes on a small candy, a man cuts his leg when clearing land, a small plane crashes into a lake in a remote area. All need immediate attention. What generally happens: locate the person in need, dispatch emergency personnel including a fast response to stabilize the situation and the health condition, provide medical assistance on scene, transport to nearest or most appropriate health resource, provide support and follow up to family and community, and learn from experience and data collected. What’s at Stake? 14

Community First Response (CFR) is key to sustainable rural municipalities. Capacity depends on local engagement and collaboration with EMS and Police. Municipalities are competent and willing to work for change but feel disenfranchised. The centralized plan has disregarded municipal expertise and created major risks. Fire based First Response was and is developed and resourced by Rural municipalities. Ensure Community Capacity for First Response in Medical Emergencies Principle 1 15

16 Technology cannot replace Social Capital Everyone needs the security of knowing that there is support close by to assist in an emergency. Local knowledge of locations, family health history and networks, and informal resources are the social capital of health when institutionalized health care is far away. Rural communities exist through informal networks. This is lost in systems that are ‘centrally based and controlled.’ International EMS research supports policy that enables rural and remote areas to create flexible EMS, responsive to local needs and resources. See the Community Health Capacity Study guide

Please consider using this guide in your Municipal councils, schools, community organizations, Fire Departments, Health Centres, Ambulance and Paramedic groups. Share your findings and get engaged in developing Community Engagement in First response and emergency preparedness. Rural Health Capacity Study Guide 17 Refer to notes

Community Health Capacity Study Guide 18 Refer to notes

Community Health Capacity Study Guide 19 Refer to notes

The search for an Alberta Solution: Values 20 The One Health Solution All areas should receive same level of service Assumption of cost savings in economies of scale and unification of practices, equipment and infrastructures. A Coordinated Alternative Build on local strengths and needs to increase local capacity to respond Rational Network of Dispatch Centres acting as one but responding to and accountable for local needs

The search an Alberta Solution: Functions 21 The One Health Solution Getting help fast: Technology will locate and enable seamless ambulance dispatch to get ALS to the health event Quality of Care: Control of all ALS trained staff. Reduce ALS trained staff and emergency equipment from Fire First Response. Transportation: No boundaries, all ambulances the same. Paramedics practice where needed, ambulances interchangeable. Monitoring and accountability: EMS accountable only to AHS. A Coordinated Alternative Coordinated 911 dispatch of best local resource available including fire first response, police and ambulance. Team response with CFR with BLS training augments other health professionals. Ambulance specific to region, purchased to meet local needs (smaller for urban settings, large for long hauls, 4x4 for remote areas). Expand options. Accountable to municipalities, AHS, Public Safety. Data open

Actively encourage community groups, schools, councils to work on the Community capacity study guide and share their results. Cooperate with Health Quality Review to investigate financial and social costs of Transition. Investigate roles and responsibilities for all partners. Based on international research, negotiate EMR training and protocols (UK) Promote incentives for rural options that increase collaboration between services Increase ALS within Rural Fire First Response rather than reduce it. Recognize Rural Health Capacity 22

911 is the first call for emergencies. 911 generally is a public service that connects or dispatches Fire (Municipal Affairs), Police (Solicitor General) and Ambulance (Health) services. It can be provincial, regional or municipal with call transfers to service providers or to local dispatch. A Rural 911 call and dispatch strategy would act as part of a provincial/zone model. Rural 911 would combine seamless call and integrated dispatch of fire and ambulance. The risks of relying on 911 cell phone location information needs to be addressed separately. Ensure coordinated Provincial 911 Network that includes Rural Call and Dispatch Centres Principle 2 23

Roles in Rural Integrated Dispatch 24 Community Resources, Local Businesses, Local Health Care providers, Citizens

Rural Alberta Dispatch 25 Rural areas pioneered coordinated dispatch and by the early 1990s rural 911 dispatch was funded by municipalities working together. When events cross boundaries, mutual agreements are in place to coordinate large scale responses. Rural dispatch hires local people with intimate knowledge of resources, locations and routing. Rural Coordinated Dispatch provides ‘command centre’ functions for local emergency events. Smaller rural centres are quick to adapt to change. Personalization of service protocols

All Fire Fighters were trained in Basic Life Support. As the need for Advanced Life Support increased Fire Fighters advanced their training to reach an ALS standard. In some centres, entire Fire Departments were ALS trained. Medical oversight was provided by local physicians. ALS trained staff were in demand and many left volunteer positions for full time employment in Cities. Rural Fire was faced with training new recruits to cover ALS needs and this became a serious drain on resources. In Urban centres, Paramedic services aligned with Ambulance. This was not an issue in Rural areas because there were so few ALS trained staff. Innovative cross trained or coordinated situations were created. With consolidated AHS dispatch, First Responders are less frequently dispatched and Fire Fighters with ALS training have been actively discouraged from practice. A growing number of Rural Fire Departments and Municipalities have chosen to continue to provide ALS service as part of their First Response and their normal Emergency and Rescue operations. 26 History of Community First Responders

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28 Fire/Emergency Services departments provide emergency preparedness, response and follow up. Medical first response is a natural part of the existing mandate. Administrative home for First Response: staff call out, emergency vehicles, equipment, organization, record keeping, training and recruitment, accountability. Dispatch protocols are negotiated with local Fire departments, municipalities, EMS/AHS – flexible and diverse contracts make maximum use of resources. Please refer to notes: Approved Scope of Practice for Fire based First Responders Current Situation of First Responders

29 Fire Departments have many specialties that require extensive training and support. Because AHS does not understand or support First Response there is a struggle in some municipalities to continue to pay for the First Responder advanced skills training. Training has been informal or contracted through Red Cross, St. Johns Ambulance using their national accreditation. These are affordable and do not require expensive certification. Rural Fire Departments are volunteer and are concerned about the expected costs of standardized training and certification though the College of Paramedics. Research seems conflicted about the need for ALS trained First Response and municipal governments question the economics of advanced training when graduates are lured into cities. Please refer to notes: The need for a specific Rural First Response Protocol Issues related to First Responders

SAIT/NAIT Advanced Life Support Paramedic Program STARS first flight, paramedics central to service March Iris Evans, then Minister of Health, cancels AHS plans to transition EMS due to cost overrun April AHS transitions EMS to province April Cochrane/Airdrie/FREMS transition to AHS April Canmore last town to transition to direct delivery of EMS to AHS

31 With transition, pay grades were increased dramatically but the problems with reduced benefits and infrastructure problems with dispatch have created discontent. Currently paramedics are employed by Fire Departments and Ambulance services. Conflicting directions are emerging. EMS practitioners feel that AHS is moving the profession to a more “technical and less clinical role” to reflect future pay grades. The College of Paramedics began working to become recognized within the Health Professions Act in 2006 but have not yet been accepted. Issues of Alberta Paramedics

Anatomy of a 911 call in Rural Alberta in non-transitioned areas Call received at regional site 1. Secure and verify location 2. Dispatch from regional site Dispatch First Response Dispatch Ambulance Dispatch Fire Department Transfer call to Police/ RCMP Dispatch other community resources 3. Coordinate response though communication Infrastructure, call monitoring. Support linkages and consultation. 4. Collect, Manage Data on Response and Outcomes 32

Anatomy of a Transitioned 911 Call 33 In post transitioned dispatch regions there are serious risks that are being mitigated by the 911 centres. The complexity of the routing and back up systems create many more steps than in an integrated dispatch system and thus more chances for delays and miscommunication. The added work involved in this new system is costly and the costs are being born by the dispatch centre/member municipalities.

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Essential Elements of Rural 911 Linked PSAP (Public Safety Answering Point) can create a unified provincial 911 service Trained dispatcher to answer call, dispatch service and coordinate response. In UK, dispatch is part of treatment. Negotiated dispatch protocols with municipalities, Fire departments, designated First Responders, local resources. Need to tailor protocols to ensure maximum participation. Unified tracking of call, response and outcome measures throughout the provincial or zone system Accountability systems for costs for all services 35

Cell phone / 911: DISCONNECT! Cell phone use in Rural areas is rapidly increasing. Encourage citizens to pay attention to where you are, because cell phones are not as reliable as land lines in locating calls. Six provinces have legislation related to 911 and collection of 911 monthly fees to pay for 911 centres: Quebec (40 cents), Saskatchewan (62 cents), Nova Scotia (43 cents), New Brunswick (53 cents), PEI (50 cents) and Manitoba (in process). Regulations governing Cell phone accuracy rest with the CRTC. VOIP: disconnect between service or billing address and the actual location. Minister Service Alberta/ Municipal Affairs to take the lead on 911 legislation and administration; cannot be done by one of the emergency services. Please refer to notes on Cell phone issues from the Stettler conference 36

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Rural 911 Strategy 38 Research, Negotiate and Introduce 911 legislation with Provision for Rural Strategy: mandate, resourcing, standards cf. provincial summaries of 911. Negotiate and research a Provincial 911 Network that includes Rural 911 call and dispatch centers. Ensure protocols for ‘default’ First Response dispatch in Rural Settings. Research and negotiate shared equipment, reporting, accountability and review process.

For spending and contracting For quality of care – tracking calls and outcomes For a shared and transparent set of criteria for positive and negative outcomes For complaints and concerns Access to Health Quality Council for disputes Please see notes for description of above issues Principle 3 Accountability of Costs, Services and Outcomes 39

Uncovering the Hidden Financial Costs of Transition Before transition, reciprocal agreement were in place between the various services to balance costs. AHS is assuming authority over EMS Medical Services without negotiating or financing the services that they now expect. Municipalities are expected to assume rising costs that result from recent service fragmentation. AHS expects communities to provide Community First Responders who will work for AHS. Who is keeping track of the direct and indirect costs of transition? 40

Uncovering the Hidden Social Costs of Transition Before transition, most medical emergencies were handled by a consistent local team of Fire First Response, local ambulance and RCMP. This is breaking down. In many towns a divide has been created as municipalities consider removing ALS fire first response to qualify for AHS payment of Ambulance/ALS There is a strong impression among seniors that the degradation of fire first response compromises the rural safety net. Many now feel that they are only safe in a large urban setting. Loss of Identity for Community First Responders 41

Accountability 42 Investigate Social and Financial costs of Transition (Health Quality Council) Introduce common system for tracking health related costs in First Response Shared and transparent outcome criteria among Dispatch and Emergency Medical Response, e.g. UK criteria

We respectfully submit that it is possible to achieve a RED Strategy It would meet the expectations for a system that is provincial in principles, standards and function, that: coordinates technology, dispatch and response protocols, ensures upgrade and support for the training of First Response personnel at the community level, is capable of common data systems and accountability, rebuilds the Rural emergency medical team that has been the pride of Alberta. It would be based on three principles of Rural Health sustainability: Emergency Health capacity of individuals, families and communities, Collaboration at call, dispatch and service, Accountability and monitoring. 43

Appendix Review of Research & Policy: Review of international literature using filters: Rural Emergency Medical Response and First Responders. EMS is a new and evolving field of practice that bridges health and public safety and is affected by the legislation of many different ministries. EMS is becoming more integrated into the Health Care continuum but supports local initiatives and partners. EMS is a site of incubation of ideas, reform and communitization of Health. Provincial models are living labs of centralized and coordinated systems. Please view notes: an international set of research and policy websites 44 First Response and Coordinated 911

Bibliography of Research and Policy related to Community First Response and Coordinated 911 Dispatch Introduction and context of research related to this emerging topic 45 Refer to notes

Bibliography of Research and Policy related to Community First Response and Coordinated 911 Dispatch Canadian References Refer to notes 46

47 United Kingdom References Refer to notes Bibliography of Research and Policy related to Community First Response and Coordinated 911 Dispatch

48 European Union References Refer to notes Bibliography of Research and Policy related to Community First Response and Coordinated 911 Dispatch

49 United States References Refer to notes Bibliography of Research and Policy related to Community First Response and Coordinated 911 Dispatch

50 Introduction to the Review Refer to notes Provincial 911 Dispatch

51 Provincial 911 Dispatch Nova Scotia, New Brunswick and Prince Edward Island Refer to notes

52 Provincial 911 Dispatch Newfoundland and Quebec Refer to notes

53 Provincial 911 Dispatch Ontario and Manitoba Refer to notes

54 Provincial 911 Dispatch Saskatchewan and Alberta Refer to notes

55 Provincial 911 Dispatch British Columbia Refer to notes