In emergency

On the road and on the phone:

Identifying hazards and developing solutions for the paramedic service

By Henrietta Van hulle

Acareer in paramedic service is, with no question, a job that has high risk of psychological harm for its workforce. Ontario’s 11,000 paramedics, 1,200 ambulance communication officers and more than 2,000 support staff are among these workers who face potential occupational mental health injury.

Seeing the risk of psychological harm to the paramedic service, the Public Services Health & Safety Association (PSHSA) dove into the highest risk and the “why” behind the risk and start looking at impactful solutions to minimize those risk factors. In 2021-2022, the process began with a meeting of stakeholders, to try to understand the associated risks and root causes, and develop solutions to mitigate, control or eliminate these risks.

A TWO-PART INVESTIGATIVE PROCESS

The two-part process required the perspective of stakeholders including, worker and management representatives from Ontario’s land and air ambulance services, representatives serving First Nations, urban, rural and remote communities, individuals with lived experience, clinicians, health and safety professionals and representatives from academia and provincial government. This group came together with the common goal to identify the occupational health and safety hazards that workers in paramedic services are most exposed to, and uncover recommendations that represent a balance of perspectives.

PART ONE: RISK ASSESSMENT – WHAT KEEPS YOU UP AT NIGHT?

In Fall 2021, the project participants were asked the question, “What keeps you up at night?” And the group answered with 105 hazards paramedics face in the workplace.

The group then rated each hazard according to its likelihood and consequence to determine the overall risk rating for all hazards. Of the 105 hazards, 48 were found to be high-risk, 54 medium-risk and 3 low-risk. Post-traumatic stress disorder injuries were identified as the top hazard. Risks involving ambulance design, equipment concerns, workplace violence, traffic protection and fatigue rounded out the top ten.

PART TWO: ROOT CAUSE ANALYSIS – PSYCHOLOGICAL HARM

Following the risk assessment, a report was provided to Ontario’s EMS Section 21 Sub-Committee to review the top ten hazards from the first phase of the project. The committee selected the top identified hazard – psychological harm – to be explored in the second project phase beginning in Winter 2022.

Part two of the project had participants come together for a two-day deep dive look at psychological harm risk factors, focusing on front line paramedics and ambulance communication officers. The group looked for hazard factors that have the potential for causing psychological harm and looked for the root cause of those hazards. Thirty-six causes fundamental to the elimination and control of exposures that could lead to psychological harm for paramedic service workers were identified. Project participants then used a scale rating system, to determine the top 11 causal factors.

On the second day, the group looked at those identified 11 factors and brainstormed 150 unique solutions and controls and identified possible interventions to reduce the risk of psychological harm to workers.

The following themes emerged from the proposed solutions. • Updating training (i.e., materials, facilitation, time allotted, methods) for workplace violence, psychological health and safety, fatigue, handling traumatic events, stigma,

self-care, stay-at-work and returnto-work, and resiliency • Providing trauma-informed and paramedic-specific mental health support • Increasing collaboration between educational institutions, base hospital programs and service providers on training, mentorship and program development • Allowing for protected or dedicated time for training and continuing education, breaks and operational pause time to reset and re-energize • Highlighting the need for paramedic-specific health and safety legislation in addition to increased participation from, and consultation with, paramedic service workers when there are system or legislative changes. • Continuing forums and workshops where various workplace parties and decision makers can focus on issues and brainstorm solutions; and

encouraging self-care at the service level by enhancing facilities (e.g., gyms, break rooms, quiet spaces), and spreading awareness. • Engaging family support systems, looking at how family members can be part of the solution, bringing awareness of risk factors, signs and symptoms their paramedic worker might face, and feeling empowered to know where to look for supports for the worker and themselves.

NEXT STEPS

The participants at the table presented cogent, thoughtful and well-reasoned solutions to the hazards faced by Ontario’s paramedic service. Some of the recommended solutions or controls represented quick wins that are relatively simple to implement in a short period of time, while others are system-level changes that require support and coordination from multiple stakeholders, and some may not be feasible. Each recommendation identified those (i.e., ministries, organizations, associations) with the potential to implement solutions.

I would encourage system change makers to review these proposed solutions and control measures and consider collaborating with others identified to determine the viability of, and best practices for, implementing these recommendations. This project will inform PSHSA’s work within the sector for years to come.

The final reports for both project phases, including detailed additional background, methodology, and findings can be accessed at www.pshsa.ca/ paramedicproject. ■ H

1. Post-traumatic stress disorder (PTSD) injuries (Psychosocial Hazards) 2. Inability to use seat belts during patient care while the vehicle is in motion (Ambulance Design) 3. Usage of portable radios, communications, central ambulance communications centre and cell phone use (Equipment Concerns) 4. Support in exigent circumstances when responding to calls for service (Workplace Violence) 5. Violence and abuse in the workplace (Workplace Violence) 6. Reliability of central ambulance communications centre, radio system (Equipment Concerns) 7. Vehicle collisions (Traffic Protection) 8. General design of the ambulance (Ambulance Design) 9. Lack of sleep (Fatigue) 10. Use of traffic protection plans while paramedics are working on the roadway (Traffic Protection)

Henrietta Van hulle is Vice President, Public Services Health & Safety Association

SPONSORED CONTENT

Standardized atrial fibrillation treatment guidelines that reduce emergency room visits

ACANet-funded project is creating Canada’s first set of guidelines for emergency room (ER) physicians that standardize acute atrial fibrillation and flutter (AAFF) treatment across the country, reducing the length of patients’ stay by 21 per cent.

The project has successfully implemented its AAF Best Practices Guidelines into 11 large emergency rooms in five provinces, with plans to be adopted over 1000 sites across Canada.

Most ERs in Canada treat AAFF – abnormally rapid heart rates that have been present for less than seven days and are often disabling to most patients – by using drugs or electricity to help return the heart to its normal ‘sinus’ rhythm. The procedure is known as cardioversion. Patients are usually discharged soon after that.

CANet Investigator Ian Stiell is an ER physician at The Ottawa Hospital Research Institute. His ER group has maintained a low admission rate of less than five per cent for many years with an excellent safety record.

Stiell created the treatment guidelines by combining his ER experience and conversations with patients, ER physicians, and cardiologists from rural, community, and academic centres.

“We have seen more and more Canadian ER physicians willing to cardiovert AAFF patients and then discharge them directly home from the ER,” Stiell says. “We want to encourage ER physicians working in small, medium, and large hospitals across Canada to adopt the guidelines.”

By funding his work to help decrease ER admissions for AAFF cases, CANet is helping Stiell take the success story Canada-wide.

His CANet-funded project is currently on a two-year trial to evaluate the effectiveness of the guidelines in 11 Canadian ERs across Nova Scotia, New Brunswick, Quebec, and Ontario.

The hope is to ease the pressure from an already over-burdened Canadian healthcare system and reduce ER visits by 30 per cent.

Already endorsed by the Canadian Association of Emergency Physicians, the hope is the guidelines will ease the pressure from an already over-burdened Canadian healthcare system and reduce ER visits by 30 per cent.

Dr. Ian Stiell

ABOUT CANet

Our Network brings together health care professionals, academia, government, industry, not-for-profit, and patients to support new ideas and ground-breaking cardiac research.

CANet is developing and promoting effective practical solutions for personal, healthcare, and business applications. Our approach is to put the right tools in the right hands at the right time. We want to empower: at the bedside and in the community effective, and efficient services www.canetinc.ca/impact H

IN EMERGENCY Powder could stop bleeding earlier for trauma patients

By Ana Gajic

Currently, a patient who is suffering from a large amount of bleeding due to trauma receives red blood cell and plasma transfusions. Plasma is challenging to deliver quickly to the patient and unavailable in remote areas: it must be stored at -20 degrees Celsius in special freezers, expires in one year, and takes at least 20 minutes to thaw. As determining a patient’s blood group also takes time, universal donor plasma is commonly used but only 4 per cent of donors are from this group, making it a scarce resource. It can also cause transfusion reactions.

Dr. Pavenski, Dr. Beckett and Dr. Petrosoniak, with the research teams in transfusion, trauma and the emergency department, are leading the St. Michael’s Hospital, a site of Unity Health Toronto, portion of a trial to understand whether an alternative to plasma could provide a more accessible, more efficient and safer option. The trial is co-led by Kingston Health Sciences Centre and Sunnybrook Health Sciences Centre.

In this study, trauma patients with massive bleeding still receive a transfusion of red blood cells. But instead of plasma, they receive products called fibrinogen concentrate and prothrombin complex concentrate. Manufactured from human plasma, the processed products treat and prevent bleeding.

“This could change the way we deliver care to massively bleeding trauma patients,” Dr. Pavenski said. As a white powder that is diluted in water at the patient’s bedside, the products can be stored at room temperature for years and quickly administered at the scene of the trauma. They can be administered faster, stopping bleeding

ED shows ‘Epic’ ability to rise to the challenge

Moments after Hamilton Health Sciences (HHS)’ new digital records system went live on June 4, an air ambulance helicopter landed on the roof of HHS’ Hamilton General Hospital carrying a trauma patient, and then a stroke patient needing immediate intervention arrived by ambulance.

It was trial by fire for the emergency department (ED) team, who had just gained access to the new Epic hospital information system for the first time when these two patients came through their doors.

With the flip of a switch, at around 5:30 a.m., Epic replaced dozens of electronic and paper systems, making every patient’s medical information available in one secure place online. Instantly, long-established medical and administrative workflows changed dramatically.

Epic’s many benefits include improved communication between HHS doctors, nurses and other health care providers, faster access to patient information including test results, and improved patient safety.

ADVANCE PRACTICE PAYS OFF

The ED team was well-prepared for the transition thanks to months of advance practice using Epic’s training tools. But there was a learning curve once the new system went live.

“We didn’t expect perfection at Epic’s launch but our team was welltrained and ready,” says Dr. David Quinlan, an ED physician and trauma team leader at HHS’ Hamilton General Hospital.

Training included practising nine simulations in the weeks leading up to the launch – three code blues meaning vital signs were absent; one stroke simulation where the patient needed clot-busting therapy; and five trauma simulations including an air ambulance scenario.

“The stroke and air ambulance simulations were very similar to what the ED team experienced on launch day,” says Quinlan. “As a result of all of their practice and preparation, including these simulations, our patient-centred goals and treatment weren’t delayed. At the end of the day, that’s what counts.”

Simulations were prepared by a focus group that included Quinlan and ED clinical educator Sarah Hayhow. They were run in the trauma bays during quiet times, with mannequins posing as patients. Everyone involved in ED care participated, including doctors and staff from radiology, surgery, transfusion medicine, and allied health care such as the pharmacy team.

“We ran these simulations as if these emergencies were happening in real time,” says Quinlan.

“For example, when simulating our response to an ED patient needing a blood transfusion we used dummy blood products to represent real blood. This included ordering blood products through the Epic system’s practice tools. These dummy blood products were put in a cooler and retrieved by a porter who delivered them to the trauma bay. Units of blood where then checked and hung above the mannequin for the transfusion.”

RISING TO THE CHALLENGE

Hayhow was instrumental in co-implementing the simulations along with Quinlan. “Our team really had the opportunity to practice,” says Hayhow, who was working the morning that Epic went live to help with trouble shooting.

“We had just turned on the Epic system when the air ambulance arrived, followed about five minutes later by the stroke patient,” recalls Hayhow. “Every nurse was trying to log onto Epic for the first time and access the equipment needed to work in the new system. But our team members stayed calm, dug in and quickly got our patients the help they needed because that’s the emergency way.”

While there were some glitches on launch day, the team was able to work through them efficiently.

“For example, there was difficulty printing blood labels, but we were prepared with a back-up plan,” says Hayhow.

Since the launch, ED team members continue to work through smaller challenges, like adjusting to the new workflows and processes.

“Everything has changed, from the way we document, to the way we draw bloodwork, to the way we administer medications,” says Hayhow. “Every day we’re learning more through hands-on experience about how it all works and looks in an ED environment. And every week, it gets easier.”

CHANGE FOR THE BETTER

While change is never easy, in Epic’s case it’s welcome.

Epic is considered among the best systems in the world and is used internationally by many top-ranked hospitals. Hamilton Health Sciences is among the first hospitals in Canada to implement Epic’s cutting edge and fully electronic system.

“Epic’s clinical applications and tools are unparalleled, and will enable our staff and physicians to continue providing the best care possible for our patients,” says Dr. Barry Lumb, executive lead for the system’s implementation at HHS.

Michelle Leafloor, vice-president of health information and technology services and chief information officer for HHS, calls Epic the future of health care.

“With Epic, not only will we will be able to do even more to improve the health outcomes of our patients,” says Leafloor, “we will also be able to contribute to research that will be life-changing for countless patients beyond our own community.” ■ H

earlier and potentially decreasing mortality. The added bonus, she says, is these products are also safer.

“We are bringing resuscitation straight to the patients at the site of injury. You can do this in an ambulance, you can do this at the side of the highway.”

While the signals in preliminary studies have been positive, this large trial is needed to show whether the factors could replace plasma as a standard of care in Canada and beyond. This study is part supported by the Department of National Defence, as the therapy could be used to treat casualties on the battlefield.

Although traumas decreased during the pandemic due to less travel, commuting and entertainment opportunities, the trial was permitted to continue and is well on its way to recruiting the trauma centres it requires. The plan is for 11 trauma centres across Canada with about 350 patients enrolled.

So far, trauma centres in Toronto, London, Hamilton and Kingston are up and running. On the horizon, Dr. Pavenski hopes to participate in a similar trial in cardiovascular surgery at St. Michael’s and is excited to reopen some of the studies that paused during the pandemic.

“It’s the teams on the ground that have made this happen,” Dr. Pavenski said. “I could not wish for better teams: the transfusion lab, the emergency department, the trauma team, our clinical research coordinators. And of course, patients and their families. Without their understanding none of this is possible.” ■ H

Ana Gajic is the senior communications advisor at Unity Health Toronto

SPONSORED CONTENT Emergency room physicians can accurately predict serious outcomes for syncope (fainting) patients with a validated risk score

Projected to save the Canadian healthcare system approximately $70M per year, the CANet-funded Canadian Syncope Risk Score (CSRS) is helping doctors improve syncope care in the emergency room (ER), reducing the burden on hospitals throughout Canada.

Syncope is the temporary loss of consciousness due to the incomplete delivery of oxygen to the brain. A complete recovery immediately follows it. In some high-risk cases, syncope eventually leads to potentially fatal conditions like arrhythmias.

Syncope accounts for one to three percent of all emergency department visits.

Before creating the CSRS tool, doctors did not have standardized guidelines on evaluating syncope patients, Dr. Venkatesh Thiruganasambandamoorthy

differentiating between low- and highrisk cases, which patients to send back home, and whom to assess further.

The CSRS tool will result in 71 per cent of all syncope patients being discharged quickly from the ER (within 2 hours).

Developed by CANet Investigator, the University of Ottawa Epidemiology and Community Medicine professor, Ottawa Hospital Research Institute scientist, and Ottawa Hospital doctor Venkatesh Thiruganasambandamoorthy, the CSRS helps physicians better identify which ER syncope patients need to be admitted, and which ones can be safely followed up in an outpatient clinic.

CSRS was successfully validated in a recent trial held in nine emergency departments across Canada.

It found that the Score helped ER physicians accurately predict 30-day serious outcomes for syncope patients after being released from the ER. They could determine if a patient was at risk for ventricular arrhythmia and whether they should be admitted. Verylow-risk and low-risk patients could generally be discharged, while brief hospitalization could be considered for high-risk patients.

“We believe CSRS implementation has the potential to improve patient safety and health care efficiency,” Thiruganasambandamoorthy says.

ABOUT CANet

Our Network brings together health care professionals, academia, government, industry, not-for-profit, and patients to support new ideas and ground-breaking cardiac research.

CANet is developing and promoting effective practical solutions for personal, healthcare, and business applications. Our approach is to put the right tools in the right hands at the right time. We want to empower: care at the bedside and in the community effective, and efficient services www.canetinc.ca/impact H