An EMS Transfer Authorization Centre in Response to SARS in Toronto, Canada

1. An EMS Transfer Authorization Centre in Response to SARS in Toronto, Canada Russell D. MacDonald, MD MPH FRCPC Medical Director, Central Region Ontario Air Ambulance Base Hospital Program Assistant Professor, Faculty of Medicine University of Toronto Toronto, Ontario, Canada

2. Thank you • National Disaster Medical System • Chesapeake Health Education Program • Ministry of Health and Long-Term Care, Government of Ontario • Ontario Air Ambulance Base Hospital Program • Toronto EMS • EMS agencies in Ontario

3. Outline • Introduction to City of Toronto and Province of Ontario • SARS outbreaks in Greater Toronto Area • EMS response to mitigate risk of SARS • Lessons Learned • Future Prospects • Summary

4. Welcome to Province of Ontario

5. Welcome to Province of Ontario Toronto

6. Welcome to Province of Ontario Minneapolis Toronto Detroit Chicago Syracuse

7. Welcome to Province of Ontario 1000 km / 600 miles 1600 km / 1000 miles Minneapolis Toronto Detroit Chicago Syracuse

8. Welcome to City of Toronto • Ontario’s capital city • Canada’s largest and most populous city • 641 square kilometers • 2.5 million people • CN Tower, SkyDome • Greater Toronto Area • city and 4 neighbouring cities • 5.1 million people

9. Healthcare in Toronto • Canada’s largest hospital network • 15 acute care hospitals • Canada’s largest pediatric hospital • >100 other health care facilities • long-term care, alternate level of care • largest medical school in Canada

10. EMS in Toronto • Canada’s largest EMS provider • 400,000+ calls per year • 800+ paramedics and 200+ support staff • headquarters for North America’s largest air ambulance program • 20,000 calls per year • ~250 flight paramedics • 8 rotor and 18 fixed wing aircraft

11. SARS in Toronto • Feb 23: woman returns from Hong Kong • March 5: woman dies at home • EMS respond and attempt resuscitation • others in family also ill • March 7: son admitted to hospital • ill family members visit him in hospital • March 12: WHO issues first alert • March 13: son dies in hospital • March 16: Toronto case cluster identified

12. SARS in Toronto • March 25: second wave of cases peaks • March 26: Provincial Government declares Health Care Emergency • Provincial Operations Centre activated • “code orange” at GTA hospitals

13. SARS in Toronto

14. SARS in Toronto

15. SARS in Toronto

16. SARS in Toronto

17. SARS in Toronto

18. SARS in Toronto

19. SARS in Toronto

20. SARS in Toronto • March 27: interfacility patient transfers halted to prevent spread of SARS • March 30: Government identifies urgent need to resume transfers yet mitigate risk of spread of SARS

21. SARS in Toronto

22. EMS Response to SARS • stakeholders meet • command and control of all transfers • appropriate medical oversight • develop and implement solution in 72 hrs • 3 phases: • needs assessment • design and implementation • expansion and ongoing operations

23. EMS Response: “The PTAC” • Provincial Transfer Authorization Centre • single centre with medical oversight • oversee all interfacility patient transfers • implement directives • retrospective epidemiologic tracking if needed • paramedic based decision-making • on-site physician backup

24. Needs Assessment • estimated 1300 requests / day • peak volume 8am – 4pm • locate at Toronto EMS HQ • expand existing dispatch infrastructure • algorithms for decision-making • no existing industry model • must “go live” within 72 hour timeline

25. PTAC Proposal Fast-tracked • March 30: proposal developed • March 31: proposal approved • April 1: proposal implemented • regionalized health care delivery = urgent need for patient transfers

26. Design and Implementation • PTAC “activated” on April 1 at 14:30 • space, equipment, and personnel not in place • algorithms not fully developed • process flow not developed • temporary phone and fax being installed • dispatch and support personnel reassigned • Toronto’s existing EMS dispatch centre carried initial load while temporary PTAC set up

27. Design and Implementation • By 17:00 • temporary PTAC operational and meeting demand • EMS command staff develop job positions • physician “trains” paramedic screeners • physician and paramedic supervisors refine algorithms • By 23:00 • demand decreased • meet to further develop decision algorithms and process flow • Within 36 hours • handling > 500 request per day • infection control measures implemented

28. Design and Implementation

29. Decision Algorithm • Sending and receiving physicians agree to transfer. • Infection control at both facilities agree to transfer. • Healthcare facility categories match. • Emergent transfer is medically necessary. • Bed available and held for patient.

30. Decision Algorithm • Sending and receiving physicians agree to transfer. • Infection control at both facilities agree to transfer. • Healthcare facility categories match. • Emergent transfer is medically necessary. • Bed available and held for patient. PTAC will not authorize transfer unless all criteria are met or there are circumstances that mandate transfer. PTAC physician arbitrates decision with sending and receiving physicians, and infection control personnel.

31. Decision Algorithm • Sending and receiving physicians agree to transfer. • Infection control at both facilities agree to transfer. • Healthcare facility categories match. • Emergent transfer is medically necessary. • Bed available and held for patient. Sending facility faxes transfer request form to PTAC Sending facility advised to follow up fax with phone call if necessary

32. Decision Algorithm • Sending and receiving physicians agree to transfer. • Infection control at both facilities agree to transfer. • Healthcare facility categories match. • Emergent transfer is medically necessary. • Bed available and held for patient. Sending facility faxes transfer request form to PTAC Patient passes SARS screening tool If patient does not pass SARS screening tool, PTAC physician reviews call, and arbitrates with sending and receiving physicians

33. Decision Algorithm • Sending and receiving physicians agree to transfer. • Infection control at both facilities agree to transfer. • Healthcare facility categories match. • Emergent transfer is medically necessary. • Bed available and held for patient. Sending facility faxes transfer request form to PTAC Patient passes SARS screening tool PTAC approves transfer and issues authorization number Authorization number not issued unless transfer is authorized

34. Decision Algorithm • Sending and receiving physicians agree to transfer. • Infection control at both facilities agree to transfer. • Healthcare facility categories match. • Emergent transfer is medically necessary. • Bed available and held for patient. Sending facility faxes transfer request form to PTAC Patient passes SARS screening tool PTAC approves transfer and issues authorization number Toronto EMS CACC dispatches call OR transfers request to local ambulance service

35. SARS Screening Tool • unprotected contact with person with SARS in past 10 days? • fail screen if answer is yes • in a health facility closed due to SARS in past 10 days? • quarantine or under investigation for SARS? • in southeast Asia in past 10 days? • symptoms of viral illness? • temperature checked: >38oC? • fail screen if yes to any two of the above

36. Process Flow Sending facility faxes request to PTAC

37. Process Flow Sending facility faxes request to PTAC Requests logged, time-stamped, given request number

38. Process Flow Sending facility faxes request to PTAC Requests logged, time-stamped, given request number Requests collated and checked; sending facility contacted for missing information

39. Process Flow Sending facility faxes request to PTAC Requests logged, time-stamped, given request number Requests collated and checked; sending facility contacted for missing information Completed requests forwarded for medical clearance; algorithm used to determine authorization

40. Process Flow Sending facility faxes request to PTAC Requests logged, time-stamped, given request number Requests collated and checked; sending facility contacted for missing information Completed requests forwarded for medical clearance; algorithm used to determine authorization If criteria met, authorization number assigned and forwarded to sending facility

41. Process Flow Sending facility faxes request to PTAC Requests logged, time-stamped, given request number Requests collated and checked; sending facility contacted for missing information Completed requests forwarded for medical clearance; algorithm used to determine authorization If criteria met, authorization number assigned and forwarded to sending facility Request forwarded to data entry to complete record

42. Process Flow Sending facility faxes request to PTAC Life-threatening? Requests logged, time-stamped, given request number Requests collated and checked; sending facility contacted for missing information Immediate attention and clearance Completed requests forwarded for medical clearance; algorithm used to determine authorization If criteria met, authorization number assigned and forwarded to sending facility Request forwarded to data entry to complete record

43. Expansion & Ongoing Operations • April 7: permanent location • 280 m2 in Toronto EMS HQ • accommodate 40 staff and up to 1500 requests/day • permanent telephone and fax installations • computer network with database • 50 new staff recruited • total staff now 80

44. April 14: government relaxes transfer restrictions >1000 request / day emergent processed immediately non-emergent processed within 45-60 minutes peak demand requires 20 clerical staff 5 paramedic supervisors 1 manager 1 physician Expansion & Ongoing Operations

45. Expansion & Ongoing Operations • early May: outbreak over? • only sporadic cases in health care workers • no new community cases in >20 days • health care system shifts to “new normal” • sustained level of infection control practices • high index of suspicion • PTAC maintained as tracking system • >1300 requests / weekdays

46. SARS 2 • May 20: • patients from a rehabilitation hospital transferred to 2 hospitals for ongoing care • patients pass screening tool prior to transfer • May 22: • respiratory illness outbreak in rehab hospital • public health investigation • PTAC prevents further transfers • facility continued to make requests despite outbreak

47. SARS 2 • May 23-24: • 9 patients from rehab under investigation for SARS • 2 hospitals fully or partially closed • health care staff become ill with respiratory illness • PTAC records used to identify and locate transfers between affected institutions • public health issue new quarantine orders • some hospitals close to new patients

48. SARS 2 • Toronto in its second outbreak • government creates “SARS hospital alliance” • June 12: • last new case of SARS • August 18: • hospitals return to “new normal”

50. PTAC Requests