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Nova Scotia’s ambulance system is trying something new to make sure ambulances staffed by two paramedics are available for the most urgent calls.
Emergency Health Services (EHS) is testing a new model where a single paramedic responds to the least urgent 911 calls. It’s called a SPEAR unit – that stands for Single Paramedic Emergency Advanced Life Support and Basic Life Support.
“We run the wheels off these things when they are on duty because a significant proportion of the requests for service are on the lower acuity end of the scale,” said Derek LeBlanc, Senior Manager of Operations for EHS. “There is lots and lots of work, especially in urban areas, for these units.”
The SPEAR program is one of the initiatives to improve access to care under Nova Scotia’s Action for Health plan. It was born out of necessity. “In the past our system had the capacity to have ambulances with two paramedics do all the work. They did the patient transfers that went to and from and between hospitals, they did all the emergency calls whether they were high acuity or low acuity, and we had enough resources, enough capacity in the system to do all that work in a timely fashion,” said LeBlanc.
That changed with the pressures of staff shortages in health care combined with a pandemic. More calls to 911 and backups in emergency departments were tying up paramedics, making it tough for ambulances to respond to calls within an acceptable time.
LeBlanc said, “We really needed to look inside ourselves and figure out how we could service all the clients of our system better. Just trying to out muscle it and send the same resource all the time and get everywhere on time was becoming increasingly difficult so we knew we had to make changes to the model.”
The SPEAR units, combined with the hiring of more than 100 Transport Operators to transfer patients between hospitals, helps ensure fully staffed ambulances respond quickly to urgent calls while single paramedics take on some of the least urgent cases.
“Any type of call that we would not typically respond with lights and sirens is the type of call that is suitable for a SPEAR unit response,” said LeBlanc. That could include people with chronic conditions, abdominal pain, minor injuries, and falls.
Working on the SPEAR unit is currently voluntary and on an overtime basis, and only paramedics with specialty training are able to fulfil the role. Sean Collins is now support supervisor for Integrated Health Programs for EHS but spent time in the SPEAR unit. “I loved it. The increased challenge requires you to step up and demand more of yourself,” said Collins. “I think it brings with it an additional critical thinking challenge and a degree of independence which some people thrive on. As a ground ambulance paramedic, we definitely get to practice a greater variety of our skills on a more frequent basis as we’re not stuck in situations like offload delay (at hospitals).”
SPEAR unit vehicles are SUVs, not ambulances, and are not equipped to transport patients to hospitals. The paramedic treats the patient on site with the support of an advanced care paramedic, a nurse, and a physician at the EHS Medical Communications Centre. If the team decides a hospital visit is necessary, transportation is arranged.
The fact that SPEAR units have no lights, sirens, or stretchers sometimes raises questions. “There are always those questions – where is your stretcher, where is your partner? It takes some explaining but people are very appreciative,” said LeBlanc. “Most of our patients understand when it’s explained to them why this unit has responded and are quite grateful for the care that is provided.”
Every patient who can be treated outside the hospital is one less patient in the emergency department, and one less ambulance tied up at the hospital, waiting for their patient to be seen. LeBlanc said, “It’s important that the right resource go and assess the need for transport versus just taking everyone to hospital all the time. Often the default is an emergency department and that may not be the right place for that patient to go.”
When there is high demand, ambulance response time to less urgent calls can be prolonged. LeBlanc says introducing the SPEAR unit means more timely care for patients with less pressing needs.
Working alone adds an additional layer of risk. Paramedics working in SPEAR units have extra training to assess safety. “We want to make sure people doing these roles are aware of their surroundings and are prepared for some of the risk associated with responding in a single capacity, so that’s more what we focus their preparation on,” said LeBlanc.
Collins felt prepared. “There is front end education. If you don’t feel safe, let it be known, back out immediately,” said Collins. “If calls have any indication that they would be unsafe for an individual clinician, we don’t respond to those calls. So, if there is police involvement the goal is to send an ambulance.”
LeBlanc says that’s one more factor when it comes to matching the right resource for the right patient at the right time. “This is really where the rubber meets the road. We needed to make sure we had something designed for responding to the needs of less urgent patients who would otherwise wait and potentially deteriorate. Keeping them out of the emergency department stream is sometimes the most important aspect of care.”