Emergency medical services in Canada are the responsibility of each Canadian province or territory. The services, including both ambulance and paramedic services, may be provided directly by the province, contracted to a private provider, or delegated to local governments, which may in turn create service delivery arrangements with municipal departments, hospitals or private providers. The approach, and the standards, vary considerably between provinces and territories.
A rail ambulance is a vehicle used for medical transportation services on railway lines. [1] The first rail ambulance was set up in 1920, in order to enable injured people to be transported to the nearest hospital, was set up in the coalmining community of Cape Breton, Nova Scotia. The car ran between #3 and #7 mines and Town of Sydney Mines. It was discontinued in 1922. [2]
Responsibility for emergency medical services (EMS), as a part of health care in general, lies with the provinces and territories of Canada. With the exceptions of British Columbia and Alberta, which operate their EMS services directly, the method used for service delivery varies between jurisdictions. Typically, the provincial/territorial government provides enabling legislation, technical standards, accreditation or licensing, [3] and oversight to a variety of operators, including municipalities, hospitals, and private companies. Municipalities or hospitals may also, in turn, elect to provide EMS service directly, as a branch of another municipal department, such as the fire department [4] or health department, [5] or may contract out this responsibility to a private company. The approaches used for service delivery are governed by what is permitted under the legislation of the individual province or territory, or under the by-laws of a municipality that has accepted responsibility for EMS service. [6] Provincial governments may also, as in the case of the provinces of New Brunswick, [7] Nova Scotia, [8] and Prince Edward Island, [9] contract directly with a single private company, in these cases Medavie Health Services, [10] to provide province-wide services.
Canadian provinces are also served by air ambulance services. These arrangements may come in a variety of forms, including direct service provision, contracts between private companies and the provincial government, or "subcontract" arrangements in which one private company takes the lead on service provision, perhaps even operating some of their own aircraft and providing dispatch services, but subcontracting many of the operations to smaller air charter services. In some cases, the inter-facility transport of high-acuity patients may be a mix of air-based and ground-based resources. [11] Canada is a vast country, and its sheer size dictates that in many cases a helicopter-based air ambulance service is impractical as the distances required exceed the flight range of the aircraft. For this reason, the use of fixed wing aircraft is commonplace. In some jurisdictions not all air ambulance calls are emergencies, since distances to tertiary care centres mean that some patients with lower-acuity medical conditions are also flown.
Individual provinces and territories typically specify, generally through legislation and regulations, [12] the specifications and types of vehicles to be used in EMS. These vehicles include ambulances, but may also include rapid response vehicles (sometimes called "fly-cars"), and specialized emergency support units, such as equipment vehicles and mass-casualty transport vehicles. Each province or territory, and also the Canadian military, has its own unique ambulance specifications. Individual provinces or territories may also specify types of mandatory equipment in those vehicles, including medical equipment.
Ambulances type in Canada are based on United States federal KKK-1822 Standards requirements:
Bus-based and air ambulances are not based on these standards. Buses are mostly for ambulatory transfer only and offer less advanced care services.
Individual provinces and territories also typically specify required levels of mandatory staff training. [13] British Columbia, Alberta, Saskatchewan, Nova Scotia, Ontario, Prince Edward Island, and Yukon are served by highly educated paramedics with advanced skills. Other jurisdictions have not yet reached these levels, and some jurisdictions have introduced, or are considering introducing, critical care paramedics. [14] Progress varies, driven primarily by public demand, acceptance by the medical community, and funding. A great deal of the recent advancement in standards of care and procedures has been driven by formal outcome-based research [15] and clinical trials, such as the groundbreaking research work on the management of S-T segment elevation myocardial infarctions (STEMI), undertaken in cooperation with the Ottawa Paramedic Service. [16] Some paramedics undertake their own formal research projects or collaborate with other researchers in the medical community, leading to publication (as with the preceding two references, both of which had paramedics in lead investigator roles).
In Ontario, paramedics are certified to administer symptom relief medications under a base hospital physician's license. The Ministry of Health and Long Term Care has established a minimum standard of care for the province, [17] but base hospitals can add medications at their discretion. The number and type of medications beyond the minimum standard also varies with the paramedic scope of practice (primary, advanced or critical care).
Urban areas such as Toronto set standards according to percentiles. In Toronto, the standard is 8 minutes and 59 seconds or less 90 percent of the time on AMPDS triaged Delta and Echo calls. [18] There is no jurisdiction in Canada that is currently reporting successful achievement of this response time standard, [19] and services cite a variety of reasons for this failure, but continue to aspire to the standard. [20] This approach to response time monitoring is accepted in most urban areas of the country, but there are some jurisdictions that set a second standard for rural areas (the majority of the country). Such standards vary from one jurisdiction to the next. Additionally, there are jurisdictions that do not set specific response time objectives, instead simply reporting average response times for emergency calls. [21]
There are currently major initiatives for improved standardization of staff training underway in Canadian EMS. The Paramedic Association of Canada has produced the National Occupational Competency Profile (NOCP), [22] and several provinces are working toward meeting these standards. Provinces and territories are also responsible for standards with respect to the dispatching of EMS resources, and some jurisdictions are measuring performance, benchmarking and setting standards. In addition, initiatives by the Paramedic Chiefs of Canada [23] organization are working towards improved interoperability and a best practice approach to the overall management of EMS systems. Several provinces have started testing using the COPR (Canadian Organization of Paramedic Regulators) licensing exam for both PCP and ACP levels. As of March 2018, these include British Columbia, Saskatchewan, Manitoba, Nova Scotia, P.E.I., and Newfoundland and Labrador.
EMS services in Canada are generally funded, at least in part, and to varying degrees, by the Ministry of Health or Health Department of the province or territory in which they operate. Paramedics and ambulance services are not mentioned in the Canada Health Act, and are therefore not an insured service. Provinces may choose to subsidize some of the cost, usually just for patients with valid provincial health cards. Health insurance in Canada is universal and publicly funded, so the cost of emergency ambulance services is covered to some degree. The degree to which individual use of EMS is subsidized by provincial health insurance varies by province, and may be supplemented either by partial fees for service, or by the property tax revenues of municipalities operating such services. In some jurisdictions, funding is at 100 per cent, [24] and occurs without the patient being aware of its existence. Other jurisdictions fund at varying levels, but may require payment up front. In most cases this is later reimbursed. [25] This may be particularly true of out of jurisdiction services, with an individual from one province who requires EMS service in another province being required to pay for that service and then submit the receipt to their own provincial health insurance scheme for reimbursement. In some jurisdictions, such as Ontario, a deterrent fee scheme is used to discourage the medically unnecessary use of EMS by the public. In such cases, the provincial health insurance scheme pays the majority of the cost of EMS service (around 80 per cent) for medically necessary EMS service, but when a physician decides that the service was not medically necessary, they can cause the patient to pay the full, uninsured amount of the charge, [26] with the patient receiving a bill for the additional deterrent fee at some point after the emergency is over. Within Ontario, for example, such deterrent billing occurs through the receiving hospital, despite the fact that the hospital neither provides nor oversees EMS in most cases.
In addition to regular EMS, many jurisdictions also operate non-emergency patient transport services. In many jurisdictions, there are also companies who specialize in non-emergency patient transfers. Such companies have their own vehicles, which are similar to ambulances and carry some similar patient care equipment. These services can relieve the workload on public EMS through the elimination of some, or most, of the non-emergency transfer volume, [27] and some provide service to the public that is of the highest standard. In many cases, such services are small private businesses, using second-hand ambulances which have been retired from public EMS service, while others use vehicles expressly built for their purposes. [28] There has, however, been some controversy, in some jurisdictions, with respect to the operating procedures of some (but not all) of these services. In some cases, the vehicles are often made to look as much like EMS ambulances as possible, [29] even retaining emergency lights and sirens (which they are forbidden by law to use), and incorporating the word "paramedic" (this term is not protected in Canada yet), variations on "EMS" (in some cases, "event medical services") or spelling variations of "ambulance", such as "ambu-lans", or using the Star of Life logo on their vehicle markings. These services are not generally licensed, or required to meet any recognized standard. These services generally attempt to recruit staff who meet provincial EMS qualification standards, but are under no legal obligation to do so. Such services are not covered by provincial health insurance, operate on a fee-for-service basis, and are not considered to be a legitimate part of mainstream EMS. [30]
EMS services are publicly operated, and many by the provincial ministry of health (mostly since the 1970s). In Ontario services were devolved to local municipalities in the 1990s.
Emergency medical services (EMS), also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care. They may also be known as a first aid squad, FAST squad, emergency squad, ambulance squad, ambulance corps, life squad or by other initialisms such as EMAS or EMARS.
An emergency medical technician is a medical professional that provides emergency medical services. EMTs are most commonly found serving on ambulances and in fire departments in the US and Canada, as full-time and some part-time departments require their firefighters to be EMT certified.
A paramedic is a healthcare professional trained in the medical model, whose main role has historically been to respond to emergency calls for medical help outside of a hospital. Paramedics work as part of the emergency medical services (EMS), most often in ambulances. They also have roles in emergency medicine, primary care, transfer medicine and remote/offshore medicine. The scope of practice of a paramedic varies between countries, but generally includes autonomous decision making around the emergency care of patients.
An ambulance is a medically equipped vehicle which transports patients to treatment facilities, such as hospitals. Typically, out-of-hospital medical care is provided to the patient during the transport.
A certified first responder is a person who has completed a course and received certification in providing pre-hospital care for medical emergencies. Certified individuals should have received much more instruction than someone who is trained in basic first aid and cardiopulmonary resuscitation (CPR) but they are not necessarily a substitute for more advanced emergency medical care rendered by emergency medical technicians and paramedics. First responders typically provide advanced first aid level care, CPR, and automated external defibrillator (AED) usage. The term "certified first responder" is not to be confused with "first responder", which is a generic term referring to the first medically trained responder to arrive on scene and medically trained telecommunication operators who provide pre-arrival medical instructions as trained Emergency Medical Dispatchers (EMD). Many police officers and firefighters are required to receive training as certified first responders. Advanced medical care is typically provided by EMS, although some police officers and firefighters also train to become emergency medical technicians or paramedics.
A medical director is a physician who provides guidance and leadership on the use of medicine in a healthcare organization. These include the emergency medical services, hospital departments, blood banks, clinical teaching services and others. A medical director devises the protocols and guidelines for the clinical staff and evaluates them while they are in use.
The City of Toronto Paramedic Services, is the statutory emergency medical services provider in Toronto, Ontario, Canada. The service is operated as a division of the City of Toronto, under the Community & Social Services cluster. The service is funded by the municipal tax base, and operates similarly to other municipal divisions, such as the Toronto Parks, Forestry & Recreation division, or the Toronto Water division, but retains operational independence from other divisions. While under municipal government control, it is subject to provincial legislation and licensing. It is not the only service provider in its area; private-for-profit medical transport services also provide routine, non-emergency transports and coverage for special events, but the statutory emergency medical system is the only provider permitted to service emergency calls.
A paramedic is a healthcare professional, providing pre-hospital assessment and medical care to people with acute illnesses or injuries. In Canada, the title paramedic generally refers to those who work on land ambulances or air ambulances providing paramedic services. Paramedics are increasingly being utilized in hospitals, emergency rooms, clinics and community health care services by providing care in collaboration with registered nurses, registered/licensed practical nurses and registered respiratory therapists.
In the United States, the paramedic is a allied health professional whose primary focus is to provide advanced emergency medical care for patients who access Emergency Medical Services (EMS). This individual possesses the complex knowledge and skills necessary to provide patient care and transportation. Paramedics function as part of a comprehensive EMS response under physician medical direction. Paramedics often serve in a prehospital role, responding to Public safety answering point (9-1-1) calls in an ambulance. The paramedic serves as the initial entry point into the health care system. A standard requirement for state licensure involves successful completion of a nationally accredited Paramedic program at the certificate or associate degree level.
The British Columbia Ambulance Service (BCAS) is an ambulance service that provides emergency medical response for the province of British Columbia, Canada. BCAS is one of the largest providers of emergency medical services in North America. The fleet consists of more than 500 ground ambulances operating from 183 stations across the province along with 80 support vehicles. Additionally, BCAS provides inter-facility patient transfer services in circumstances where a patient needs to be moved between health care facilities for treatment. BCAS also operates a medical evacuation program that utilizes both fixed-wing and rotary aircraft.
York Region Paramedic Services provides legislated land ambulance services and paramedic care for the local municipalities within York Region. Paramedic Services is a division of the Region's Paramedic and Seniors Service Branch. Prior to 2000, ambulance services were provided by 2 private operators, York County Hospital, Nobleton Volunteer Ambulance and Ontario's Ministry of Health. The patchwork of service also had York Region dispatched by 3 different Ministry of Health Communication Centres. Georgian CACC now dispatches the whole region on the Ontario Government leased Bell Mobility Fleetnet VHF trunked radio system. There are approximately 480 full-time paramedics serving the region. Paramedic Operations are based in East Gwillimbury, Ontario.
Hamilton Paramedic Service is the designated service provider for emergency medical services (ambulance) in the City of Hamilton, Ontario.
Emergency Health Services (EHS) is a branch of the Nova Scotia Department of Health tasked with providing emergency medical services. It is also responsible for transportation of patients between hospitals and medical facilities. At present, all ground ambulance and air ambulance service in Nova Scotia is contracted by EHS to Emergency Medical Care (EMC), a subsidiary of Medavie Health Services.
Ottawa Paramedic Service is a uniformed municipal public safety agency providing emergency and non-emergency paramedic care to residents and visitors of city of Ottawa, Ontario. It is the sole, licensed, statutory provider and is operated directly by the city. The Service is an independent third service provider. This means that it is part of the Emergency and Protective Services department of the city but functions as an independent and separate agency from other services. The Ottawa Paramedic Service operates in compliance with legislation and licensing standards overseen by the government of Ontario. It also provides routine, non-emergency transports and emergency paramedic coverage for special events. It is the only service provider permitted to service medical emergency calls in the City of Ottawa.
In the United States, emergency medical services (EMS) provide out-of-hospital acute medical care and/or transport to definitive care for those in need. They are regulated at the most basic level by the National Highway Traffic Safety Administration, which sets the minimum standards that all states' EMS providers must meet, and regulated more strictly by individual state governments, which often require higher standards from the services they oversee.
Emergency Medical Service in Germany is a service of public pre-hospital emergency healthcare, including ambulance service, provided by individual German cities and counties. It is primarily financed by the German public health insurance system.
Emergency medical services in the Netherlands is a system of pre hospital care provided by the government in partnership with private companies.
Air medical services are the use of aircraft, including both fixed-wing aircraft and helicopters to provide various kinds of medical care, especially prehospital, emergency and critical care to patients during aeromedical evacuation and rescue operations.
The Ambulance Operators Association of Nova Scotia (AOANS) was the provincial association representing ambulance company owners in Nova Scotia. The association's focus was negotiating with the Government of Nova Scotia over funding and private ownership of ambulance services. The AOANS was also contracted by the Government of Nova Scotia to provide a training program for ambulance personnel and an ambulance inspection program. Between 1994 and 1999, after the publication of the Murphy Report, Nova Scotia transitioned to a single ambulance service provider. This resulted in the AOANS members being bought–out and their ambulance services merged into the new system. The AOANS was formally dissolved in 2002.
Middlesex-London Paramedic Service is the statutory Emergency medical services provider for Middlesex County, and London, Ontario. The service provides Paramedic Services to the City of London, the Townships of Adelaide Metcalfe, Lucan Biddulph, Middlesex Centre, North Middlesex, Southwest Middlesex, Strathroy-Caradoc, Thames Centre, Newbury. Middlesex London Paramedic Service delivers ambulance service to Middlesex and London in accordance with service and patient care standards set by the County of Middlesex, City of London, and Ministry of Health and Long Term Care. Medical oversight for controlled medical acts is provided under the direction of the Southwestern Ontario Regional Base Hospital Program.
