Toronto Emergency Medical Services releases findings on Alexander Street call
and confirms actions taken on recommendations. City Manager to oversee
implementation of recommendations.
The investigation found that there was a preventable delay in the ambulance response time to the call. The delay was caused primarily by a series of decisions that were made by
Prior to releasing the findings at the press conference, Chief Farr met with
The investigator made 13 recommendations. The recommendations range from providing staff with remedial training to reinforcement and review of current EMS policy and procedure.
Key actions taken to date include:
- Preparation of remedial training programs for staff, including those
involved in the call.
- Directive to all Toronto EMS managers to review and reinforce the
existing staging policy.
- Improved supervision and management oversight of the staging process
with the implementation of an "alarm" system in the Communication
Center.
- A comprehensive review process of the existing staging policy and
procedure is underway.
In addition, the Mayor has asked the City Manager to convene a working group with representation from EMS, the Ministries of Health and Long-Term Care and Labour, the union and the City to review the current policy regarding paramedic staging. The staging policy is used when a paramedic is in doubt about their safety and may request that police or other appropriate agency attend the scene. This policy was put in place in 2005 as a result of an order by the Ministry of Labour.
The Ministry of Health and Long Term Care Report can be found at: http://www.toronto.ca/your_health/ems.htm.
October 8, 2009
Summary of Sequence of Events Leading to Toronto Emergency Medical
------------------------------------------------------------------
Services' Response to Alexander Street on June 25, 2009
-------------------------------------------------------
-------------------------------------------------------------------------
Time Elapsed Cumulative
Event Time Toronto EMS Actions Between Actions Response
HH:MM:SS MM:SS MM:SS
-------------------------------------------------------------------------
1. 23:04:53 Toronto Central Ambulance 00:00
(11:04:53 p.m.) Communications Centre (CACC)
received a 9-1-1 call from
Alexander St.
-------------------------------------------------------------------------
2. 23:06:18 Emergency Medical Dispatcher 01:25 01:25
(11:06:18 p.m.) (EMD) No.1 commits call to
the Computer Aided Dispatch
(CAD) system
-------------------------------------------------------------------------
3. 23:06:31 Toronto Police Services (TPS) 00:13 01:38
(11:06:31 p.m.) create a call to attend with
ambulance on a "priority 2"
basis
-------------------------------------------------------------------------
4. 23:06:48 Toronto EMS ambulance with 2 00:17 01:45
(11:06:48 p.m.) Primary Care Paramedics
(PCP's) is assigned to call.
-------------------------------------------------------------------------
5. 23:14:00 Paramedics advise dispatch 07:12 08:57
(11:14:00 p.m.) they are staging at
Alexander St. and Yonge St.
-------------------------------------------------------------------------
6. 23:14:13 An EMD contacts the police 00:13 09:10
(11:14:13 p.m.) and is advised that there are
no police available to attend
the call with the Paramedics
at 40 Alexander St.
-------------------------------------------------------------------------
7. 23:19:16 An EMD notifies the Paramedic 05:03 14:13
(11:19:16 p.m.) crews Supervisor that the
crew are staging, awaiting
the police re: 40 Alexander St.
-------------------------------------------------------------------------
8. 23:19:36 EMD No.5 is reached by the 00:20 14:37
(11:19:36 p.m.) Security Guard with the
patient at Alexander St. and
says the patient is conscious
and breathing with what may
be bruising.
-------------------------------------------------------------------------
9. 23:35:26 Toronto Police are assigned 15:50 30:27
(11:35:26 p.m.) to the call.
-------------------------------------------------------------------------
10. 23:36:48 An EMD receives a 2nd call 01:22 31:49
(11:36:48 p.m.) from the Security Company and
is advised the patient is not
breathing and CPR is in
progress.
-------------------------------------------------------------------------
11. 23:38:20 The EMD in point 10 upgrades 01:32 33:21
(11:38:20 p.m.) the call from Bravo (unknown)
to Echo (not breathing patient)
and the call urgency triggers
Toronto Fire Services to
respond.
-------------------------------------------------------------------------
12. 23:38:46 Toronto Fire pumper unit is 00:26 33:47
(11:38:46 p.m.) notified of call.
------------------------------------------------------------------------
13. 23:38:46 2 staged Paramedics 0:00:00
(11:38:46 p.m.) acknowledge the call upgrade
and ask for Fire assistance.
An Advanced Care Paramedic
unit to assigned as well by
EMS Communications
-------------------------------------------------------------------------
14. 23:42:00 Toronto Fire arrives 03:14 37:01
(11:42:00 p.m.) on scene.
-------------------------------------------------------------------------
15. 23:43:16 Advanced Care paramedic unit 01:16 38:17
(11:43:16 p.m.) arrives at the scene.
-------------------------------------------------------------------------
16. 23:43:20 Staged Primary Care 00:04 38:21
(11:43:20 p.m.) Paramedics on scene
-------------------------------------------------------------------------
17. 23:48:30 Toronto Police arrive at 00:10 38:41
(11:38:30 p.m.) the scene
-------------------------------------------------------------------------
18. 00: 01:46 Advanced Care Paramedics
(12:01:46 a.m.) contact base hospital
physician and they advise a
patient with no vital signs
who has not responded to
treatment.
-------------------------------------------------------------------------
19. 00:07:00 Base hospital physician
(12:07:00a.m.) declares the patient deceased.
-------------------------------------------------------------------------
October 8, 2009
Summary recommendations & Toronto Emergency Medical Services (EMS)
action plan in response to Alexander Street investigation and report
The following outlines the 13 recommendations from the Ministry of Health
and Long-Term Care (MOHLTC) report on the above investigation and the
corresponding actions that have been taken, or will be taken by Toronto EMS,
in response to the recommendations. A glossary of short forms is provided at
the end of this document.
-------------------------------------------------------------------------
Recommendation Toronto EMS Action
-------------------------------------------------------------------------
1. That the management of Toronto - EMD No.1 has been retrained on
Central Ambulance Communication the CACC policy and has been
Center (CACC) provides remedial scheduled to receive remedial
training to Emergency Medical training on return to work.
Dispatcher No.1 (EMD) in the roles
and responsibilities of a call - Toronto CACC management staff
receiver and the requirements to will monitor EMD No.1
process requests for emergency performance to ensure
medical services as required by compliance for six (6) months
Toronto CACC policy and procedure which exceeds the MOHLTC
and upon successful completion of recommendation.
this training that performance be
monitored for a minimum of three - All EMS CACC staff have been
(3) months to ensure compliance. reissued the CACC policy.
- In addition all EMD's and their
Supervisors have been told to
review and reinforce existing
policy and procedure.
-------------------------------------------------------------------------
2. That the management of Toronto - EMD No.1 has been retrained on
CACC provide remedial training to the CACC SOP (Standard
EMD No.1 in the requirement to Operating Procedure) with
document all pertinent patient and respect to documenting
scene condition information pertinent patient and scene
learned while receiving requests condition information and
for ambulance service, including has been scheduled to receive
any information that there are remedial training on return to
individuals with a patient, and work. Toronto CACC management
that such documentation be staff will monitor performance
accurate as provided by the call to ensure compliance for six
and that upon successful (6) months which exceeds the
completion of this training that MOHLTC recommendation.
performance be monitored for three
(3) months to ensure compliance. - In addition, all CACC, EMD's
and Supervisors have been told
to review and enforce existing
policy and procedure.
-------------------------------------------------------------------------
3. That the management of Toronto - EMD No. 1 has been retrained
CACC provide remedial training to on the CACC SOP with respect to
EMD No.1 in the appropriate method the appropriate method of
to request police assistance on requesting police assistance
scene as stipulated by CACC policy and has been scheduled to
and procedure and that performance receive remedial training on
be monitored for a minimum of return to work.
thirty (30) days to ensure
compliance. - All CACC EMDs and their
Supervisors have been told to
review and enforce existing
policy and procedures.
-------------------------------------------------------------------------
4. That the management of Toronto - EMD No.5 has been retrained on
CACC provide remedial training to the CACC policy and has been
EMD No.2 in the roles and scheduled to receive remedial
responsibilities of a call training on return to work.
receiver and the requirements to
process requests for emergency - Toronto CACC management staff
medical services as required by will monitor performance to
Toronto CACC policy and procedure ensure compliance for six (6)
and upon successful completion of months which exceeds the
this training monitor performance MOHLTC recommendation.
for a minimum of 3 months.
(90 days)
-------------------------------------------------------------------------
5. That the management of Toronto - EMD No.5 has been retrained on
CACC provide remedial training to the CACC SOP with respect to
EMD No.2 in the requirement to documenting pertinent patient
document all pertinent patient and and scene condition information
scene condition information and has been scheduled to
learned while receiving requests receive remedial training on
for ambulance service, including return to work.
any information that there are
individuals with a patient, and - Upon successful completion of
that such documentation be remedial training, Toronto CACC
accurate as provided by the call management staff will monitor
and that upon successful his performance to ensure
completion of this training that compliance for six (6) months
performance be monitored for which exceeds the MOHLTC
3 months. (90 days) recommendation.
- All CACC EMDs and their
Supervisors have been told to
review and reinforce existing
policy and procedure.
-------------------------------------------------------------------------
6. That the management of Toronto - As an Accredited Centre of
CACC review current policy and Excellence with the
procedure regarding call International Academy of
processing and documentation Emergency Dispatch (IAED),
requirements and to update and or Toronto EMS CACC maintains a
modify such policy to ensure that CQI (continuous quality
all EMD's document action improvement) process and is
requirements pertaining to patient required to perform call
scene conditions. receiving audits daily, and to
provide counsel to EMDs who
fall below a 95% compliance
level with the protocol. This
process exceeds the
requirements of the MOHLTC.
- The current policy and existing
Continuous Quality Improvement
processes will be reviewed by
an EMS management working
group.
-------------------------------------------------------------------------
7. That the management of Toronto - Toronto EMS has reviewed this
CACC and Toronto EMS review the policy.
police notification polices and
amend as required to ensure that - Recommended changes will be
police assistance at the scene of tabled with the City of
a medical emergency is necessary Toronto's 9-1-1 Emergency
for the protection of paramedics, Response Committee to consider
patients and bystanders health and impacts to all allied emergency
safety. services.
-------------------------------------------------------------------------
8. That the management of Toronto EMS - PCP No.1 will be retrained and
provide remedial training to will receive remedial training.
Primary Care Paramedic (PCP) No.1 upon his return to work.
in the requirements of the Basic
Life support Patient Care - Upon successful completion of
Standards as well as Toronto EMS remedial training, Toronto EMS
Standard Operating Procedures management staff will monitor
regarding the decision making performance to ensure
process to withhold patient care compliance for six (6) months.
(stage) and that upon successful
completion of this training - All Primary Care Paramedics and
performance by monitored for a their Supervisors have been
minimum of 6 months. advised to review and enforce
this existing policy and
procedure.
-------------------------------------------------------------------------
9. That the management of Toronto EMS - PCP No.2 will be retrained and
provide remedial training to PCP will receive remedial training
No.2 in the requirements of Basic upon return to work.
Life support Patient Care
Standards as well as Toronto EMS - Upon successful completion of
Standard Operating Procedures remedial training, Toronto EMS
regarding decision making process management staff will monitor
to withhold patient care (stage) performance to ensure
and that upon successful compliance for six (6) months.
completion of this training that
performance be monitored for 6
months to ensure compliance.
-------------------------------------------------------------------------
10. That the management of Toronto EMS - Supervisor No.1 has been
provide remedial training to reinstructed and will receive
Supervisor No.1 in the roles and remedial training upon return
responsibilities of a Supervisor to work.
when notified that a paramedic
crew is withholding patient care - Upon successful completion of
(staging) and upon successful remedial training, Toronto EMS
completion of this training management staff will monitor
performance be monitored for a performance to ensure
minimum of thirty (30) days to compliance for six (6) months
ensure compliance. which exceeds the MOHLTC
recommendation.
-------------------------------------------------------------------------
11. That the management of Toronto EMS - Toronto EMS is currently
provide direction to all staff, reviewing the 3 possible
either by memorandum, directive or recommended options to provide
policy, that in any situation this direction to staff.
where the paramedic does not
believe they have sufficient
information regarding scene safety
that they will request the
dispatcher to provide additional
information.
-------------------------------------------------------------------------
12. That the management of Toronto - Toronto EMS CACC is currently
CACC provide direction to all providing direction to all EMD
staff, either by memorandum, staff through a Continuing
directive or policy that in any Education program reinforcing
situation where it is unclear as the situational interrogation
to what is occurring on scene to inherent in the protocol and
ask pertinent questions of the the need for documentation of
caller in order to obtain as much all pertinent information.
information as possible and all
such information will be
documented in the call details and
provided to the responding
paramedics.
-------------------------------------------------------------------------
13. That the management of Toronto EMS
review the current policies
regarding paramedic withholding
service (staging) to ensure it is
compliant with the Basic Life
Support Patient Care Standards as
well as relevant health and safety
legislation and that consideration
is given to amending these
policies to include;
- immediate notification of TEMS - Toronto EMS has implemented an
management of any and all "Alert Line" in the CACC to
paramedic withholding service provide immediate notification
(staging) events to TEMS management of any EMS
crew who delay patient contact
as a result of a scene safety
concern. This application will
be applied to all delayed
responses immediately. The
notification will provide the
CACC Management Staff and the
Operations Duty Officer with
the location of the delay in
order to deploy the closest
available Operations Supervisor
to respond.
- the immediate response of an - July 17, 2009, Toronto EMS
individual from TEMS management reissued a Management directive
to the scene to perform a scene to all operations management
and safety assessment staff to establish direct
communications with a paramedic
withholding service (staging)
to ensure the safety of the
crew and provide any necessary
assistance or direction. If the
crew remains staged, the
Operations Supervisor is to
respond to the staged crew.
- that Incident Reports will be - A revised documentation process
completed by the paramedics and is being developed using
TEMS manager involved with a existing CAD (Computer Aided
paramedic staging event Dispatch) data and reporting
tools to provide real time
access to information and
updated incident status
comments. This will support the
Professional Standards Unit
(PSU) in collating all required
documentation as CACC
management staff can initiate
the audit process
electronically.
- that all such incident reports - PSU will continue to review and
will be traced and reviewed in a match Operations and CACC
timely manner to ensure that all documentation and forward for
paramedic staging events are review to Operations
reasonable and necessary. management.
- In addition, TEMS has
implemented working group to
review and make recommendations
to policy, the SOP and
paramedic education, for calls
where ambulance service is
withheld.
- TEMS will participate in the
proposed City Manager's working
group with the Union, the
Ministry of Labour and Ministry
of Health to review and make
recommendations to improve the
current withholding service or
"staging" policy. In 2005,
"staging" was put in place by a
joint group of union and TEMS
management in response to a
Ministry of Labour order to
protect the health and safety
of its staff.
-------------------------------------------------------------------------
GLOSSARY OF TERMS
-----------------
1. CACC - Central Ambulance Communication Center - where 9-1-1 calls are
received, caller questioned, situation assessed over the phone, calls
recorded and ambulances dispatched
2. EMD - Emergency Medical Dispatcher - the person who works in the CACC
who takes the 9-1-1 call, questions caller, performs questioning
according to established protocols, determines the priority of the
call, provides the information to the paramedics and dispatches the
ambulance
3. MOHLTC - Ministry of Health and Long Term Care - provincial Ministry
provides the City funds to run the CACC and legislates provision of
ambulance services through the Ambulance Act
http://www.e-laws.gov.on.ca/html/regs/english/elaws_regs_000257_e.htm
4. PCP - Primary Care Paramedic - a health care provider who is a first
responder to patients at a 9-1-1 call
5. ACP - Advanced Care Paramedic - a health care provider who is a first
responder to patients at a 9-1-1 call who has achieved the highest
level certification as a paramedic is able to perform advanced care
such as intubation.
6. CAD - Computer Aided Device - the system that records the calls at
the CACC and transmits the information to the paramedics dispatched
to a call.
7. MOL - Ministry of Labour - the Provincial Ministry that inspects
Toronto EMS adherence to the Occupational Health and Safety Act and
responds to employee concerns about working conditions.
http://www.labour.gov.on.ca/english/hs/
Ministry of Health and Ministère de la Santé et des
Long-Term Care Soins de longue durée
Emergency Health Direction des services de
Services Branch santé d'urgence
Investigation Unit Centre D'Investigation
5700 Yonge Street, 6th Floor 5700 rue Yonge, 6e étage
Toronto ON M2M 4K5 Toronto ON M2M 4K5
Tel.: 416-327-7068 Tél.: 416-327-7068
Fax: 416-327-7912 Téléc.: 416-327-7912
Toll Free: 800-461-6431 Appels sans frais: 800-461-6431
Investigation Unit file: 09IU-03-141
September 24, 2009
Bruce Farr
Chief and General Manager
Toronto Emergency Medical Services
4330 Dufferin Street
Toronto ON M3H 5R9
Dear Chief Farr,
At your request I have completed the investigation of the emergency
ambulance response on June 25, 2009 to 40 Alexander Street in Toronto. I have
enclosed my Summary Report for your information.
The evidence obtained during my investigation substantiated that there was
a preventable delay in the provision of emergency ambulance service for Mr.
James Hearst.
As a result of the investigation it is requested that consideration be
given to the following:
- That the management of Toronto CACC provides remedial training to EMD
No.1 in the roles and responsibilities of a call receiver and the
requirements to process requests for emergency medical services as
required by Toronto CACC policy and procedure and upon successful
completion of this training his performance be monitored for a
minimum of three (3) months to ensure compliance.
- That the management of Toronto CACC provides remedial training to EMD
No.1 in the requirement to document all pertinent patient and scene
condition information learned while receiving requests for ambulance
service, including any information that there are individuals with a
patient, and that such documentation be accurate as provided by the
caller and that upon successful completion of this training that his
performance be monitored for a minimum of three (3) months to ensure
compliance.
- That the management of Toronto CACC provides remedial training to EMD
No.1 in the appropriate method to request police assistance on scene
as stipulated by CACC policy and procedure and that his performance
be monitored for a minimum of thirty (30) days to ensure compliance.
- That the management of Toronto CACC provides remedial training to EMD
No.5 in the roles and responsibilities of a call receiver and the
requirements to process requests for emergency medical services as
required by Toronto CACC policy and procedure and upon successful
completion of this training his performance be monitored for a
minimum of three (3) months to ensure compliance.
- That the management of Toronto CACC provides remedial training to EMD
No.5 in the requirement to document all pertinent patient and scene
condition information learned while receiving requests for ambulance
service, including any information that there are individuals with a
patient, and that such documentation be accurate as provided by the
caller and that upon successful completion of this training that his
performance be monitored for a minimum of three (3) months to ensure
compliance.
- That the management of Toronto CACC reviews current policy and
procedure regarding call processing and documentation requirements
and to upgrade and or modify such policy to ensure that all EMDs
document pertinent information pertaining to patient and scene
conditions.
- That the management of Toronto CACC and Toronto EMS reviews the
police notification policies and amend as required to ensure that
police assistance at the scene of a medical emergency is necessary
for the protection of paramedics, patients and bystanders health and
safety.
- That the management of Toronto EMS provides remedial training to PCP
No.1 in the requirements of the Basic Life Support Patient Care
Standards as well as Toronto EMS Standard Operating Procedures
regarding the decision making process to withhold patient care
(stage) and that upon successful completion of this training his
performance be monitored for a minimum of six (6) months to ensure
compliance.
- That the management of Toronto EMS provides remedial training to PCP
No.2 in the requirements of the Basic Life Support Patient Care
Standards as well as Toronto EMS Standard Operating Procedures
regarding the decision making process to withhold patient care
(stage) and that upon successful completion of this training her
performance be monitored for a minimum of six (6) months to ensure
compliance.
- That the management of Toronto EMS provides remedial training to
Operations Supervisor No.1 in the roles and responsibilities of a
Supervisor when notified that a paramedic crew is staging and upon
successful completion of this training his performance be monitored
for a minimum of thirty (30) days to ensure compliance.
- That the management of Toronto EMS provides direction to all staff,
either by memorandum, directive or policy, that in any situation
where the paramedic does not believe they have sufficient information
regarding scene safety that they will request the dispatcher to
provide additional information.
- That the management of Toronto CACC provides direction to all staff,
either by memorandum, directive of policy that in any situation where
it is unclear as to what is occurring on scene to ask pertinent
questions of the caller in order to obtain as much information as
possible and all such information will be documented in the call
details and provided to the responding paramedics.
- That the management of Toronto EMS reviews the current policies
regarding paramedic staging to ensure it is compliant with the Basic
Life Support Patient Care Standards as well as relevant health and
safety legislation and that consideration is given to amending these
policies to include:
- immediate notification of TEMS management of any and all
paramedic staging events
- the immediate response of an individual from TEMS
management to the scene to perform a scene and safety
assessment
- that Incident Reports will be completed by the paramedics
and TEMS manager involved with a paramedic staging event
- that all such Incident Reports will be tracked and
reviewed in a timely manner to ensure that all paramedic
staging events are reasonable and necessary.
If you have any questions or require any further assistance, please do not
hesitate to contact me.
Sincerely,
(signed)
Rick Brady
Manager - Investigation Unit
c: M. Bates, Director - EHS Branch
D. Brown, Sr. Manager Performance & Quality Management - EHS Branch
G. Bragagnolo, Sr. Field Manager GTA Field Office - EHS Branch
For further information: Media contact: Kim McKinnon, Coordinator Public Information and Media, Toronto Emergency Medical Services, (416) 392-2255, [email protected]
Share this article