Imagine you’re in medical distress and need an ambulance. You call 911 and, within 15 minutes, paramedics arrive. They put you on a stretcher, load you in, and take you to a hospital. Then you wait. And wait. And wait.
Known as an offload delay, this has become an increasingly common situation in Niagara Region and throughout Ontario, according to experts. “It has become a crisis,” says Kevin Smith, chief of Niagara Emergency Medical Services.
Since 2007, the provincial standard for offloading — the process by which hospitals assess, register, and assume care of patients from paramedics — has been 30 minutes; anything longer is considered a delay.
Patients caught in offload delay wait an average of 90 minutes in Niagara before hospital care takes over. Over the past four weeks, 77 per cent of Niagara EMS calls have gone into offload delay. In the past seven months, 349 people stayed on EMS stretchers for four to six hours, and 10 remained under paramedic care in hospital for more than eight.
What causes offloading delays?
“It all comes back to one thing,” says Darryl Wilton, president of the Ontario Paramedic Association, “and that’s a bed shortage.” People stay in hospitals longer than necessary because other options — such as long-term care — aren’t available, he explains.
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Hospital capacity has been driving delays since before the pandemic, says Michael Sanderson, chief of Hamilton Paramedic Services: “Our offload delays are kind of the canary in the coal mine.” As public-health restrictions have eased and more operations have resumed, he says, there’s been greater demand — and need — for emergency health care.
In a November 4 update to city council, Sanderson noted that, since July, “ambulance time consumed at hospitals beyond the first 30 minutes averaged 108 hours per day, and as high as 186 hours in a single 24-hour period.”
Both Hamilton and Niagara have logged increases in 911 calls, too, but Niagara paramedics have not seen a substantial increase in patient transfers to emergency departments. This, Smith wrote to Niagara's regional council, means the problem is not the volume of arrivals but how patients are processed.
Smith also noted that recent Ontario Health data indicates that St. Catharines’ hospital had the worst delays of 74 sites surveyed over the past 11 months. (The Ministry of Health did not respond to TVO.org’s repeated requests for the full survey data.) A spokesperson for Niagara Health tells TVO.org via email that the St. Catharines emergency department is the region’s largest: “Patient volumes are higher than our other two EDs, patients have … more complex needs.”
What are the consequences?
Sanderson says life-threatening emergencies are typically looked after quickly and make up fewer than 10 per cent of EMS hospital transfers in Hamilton. Asked whether patients with life-threatening conditions had experienced offload delays, a spokesperson for the Hamilton Paramedic Service did not respond. In response to the same question, the Niagara EMS spokesperson says, “Our paramedics certainly wait on offload delay with patients who are sick and must continue to monitor them and provide care until they are able to transfer care to the hospital.”
Patients requiring non-urgent care are more likely to have to wait. “While they’re on the ambulance stretcher, the paramedics continue to do the best that they can to care for them — but they’re not receiving hospital care,” says Sanderson. Prolonged time on a stretcher can become uncomfortable for patients, he adds, and even simple food requests require hospital-staff approval.
Offload delays also have ripple effects: EMS call-response times are longer when more first responders are stuck at hospitals. Between August and October, Hamilton paramedics logged 41 “code zeroes,” meaning there were one or no ambulances available to respond. During the same periods in 2020 and 2019, there were four and 13.
Offload delays are also stressful for paramedics. “We can hear all the calls where they’re waiting; we can hear the code-zero alarms going off on their radios,” says Wilton. And since offload delays often mean paramedics don’t have any real down time, Sanderson says, that stress intensifies: “We’ll start to see the next day that they’re tired, they’re burnt out, and tempers become frayed.”
In his report to council, Smith links pandemic exhaustion and offloading stress to increased absences and difficulty filling shifts. Comparing the period of April to August this year with last, paramedic sick time for Niagara EMS was up 33 per cent, an increase of 1,719 hours or $121,000. Offload delays cost $113 per hour in non-overtime wages; this year, Niagara is on pace for 20,000 hours of delays for a total cost of $2.3 million. In 2020, paramedics spent about 12,024 hours in offload delay and in 2019, about 16,266 hours.
What can be done?
To meet the 30-minute offloading standard, Sanderson says, “it’s going to take a lot of work on the part of hospitals and on the part of the provincial government” — but he still considers it “absolutely a realistic number” with the proper resources in place.
Sanderson and Wilton agree that funding for care outside hospitals, including LTC and community-paramedicine programs, is part of the solution. Wilton says that setting up alternative destinations for paramedics to take patients to, such as emergency clinics, could also help, and Smith notes the need for more dispatchers.
In a statement to TVO.org, Johan Viljoen, Niagara Health’s chief of staff, writes that the hospital network works not just with Niagara EMS but also with government and other primary-care providers, such as family doctors, to improve community-care options and “avoid unnecessary hospital visits.”
A spokesperson for St. Joseph’s Healthcare Hamilton tells TVO.org that, while challenged by high demand, it’s also working with partners on solutions. It has reinstated a pilot project to help reduce delays. Through it, the hospital’s in-patient units are asked to take an additional patient each when there are fewer than five ambulances available for call.
The Ministry of Health tells TVO.org via email that it “is leading focused discussions in regions particularly affected by ambulance offload delays, to monitor and assess actions being taken by hospitals.” It highlighted funding for nurses tasked with offloading patients as well as an initiative that gives eligible mental-health, addiction, and palliative-care patients in about 30 municipalities the option to receive care from a paramedic or in the community.
While Sanderson says systemic changes are needed, he adds that existing operations can be improved with smaller adjustments. For example, his service has discussed the possibility of nursing and paramedic students doing offloading instead of nurses, or inter-hospital transport being reorganized so that paramedics aren’t required: “You kind of eat the elephant one bite at a time.”
Correction: An earlier version of this article mistakenly referred to the Niagara Paramedic Association instead of to the Ontario Paramedic Association. TVO.org regrets the error.
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