emergency medical services emergency service planning · 2014 service profile, enabling a model of...
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This document has been produced by ORH Ltd for British Columbia Emergency Health Services (BCEHS) on 10th November 2015. This document can be reproduced by BCEHS, subject to it being used accurately and not in a misleading context. When the document is reproduced in whole or in part within another publication or service, the full title, date and accreditation to ORH Ltd must be included.
This document is intended to be printed double-sided. As a result, some of the pages in the document are intentionally left blank.
Disclaimer
The information in this report is presented in good faith using the information available to ORH Ltd at the time of preparation. It is provided on the basis that the authors of the report are not liable to any person or organisation for any damage or loss which may occur in relation to taking, or not taking, action in respect of any information or advice within the document.
ORH Limited is the trading name of Operational Research in Health Limited, a company registered in England with company number 2676859.
Accreditations
Other than data provided by BCEHS, this report also contains data from the following sources:
© HERE All rights reserved.
Her Majesty the Queen in Right of Canada, © Queen's Printer for Ontario
Contents Page
Executive Summary i
1 Introduction ...................................................................................... 1
1.1 Report Context .................................................................................. 1 1.2 BCEHS ............................................................................................. 1 1.3 Report Structure ............................................................................... 2
2 Terms of Reference ............................................................................ 3
2.1 Overview of Requirement ................................................................... 3 2.2 Detailed Specification ......................................................................... 3
3 Methodology ...................................................................................... 5
3.1 Overview of Approach ........................................................................ 5 3.2 Project Timetable, Activities and Consultation ....................................... 6 3.3 Data and Analysis .............................................................................. 6 3.4 Modelling and Appraisal ...................................................................... 7
4 Current Service .................................................................................. 8
4.1 Demand ........................................................................................... 8 4.2 Resources ......................................................................................... 9 4.3 Response Standards .......................................................................... 9 4.4 First Responders.............................................................................. 10
5 Service Appraisal ............................................................................. 12
5.1 Resource Use .................................................................................. 12 5.2 Improving Efficiency ........................................................................ 13 5.3 Improving Effectiveness ................................................................... 16
6 Demand Projection .......................................................................... 19
6.1 Overview of Methodology ................................................................. 19 6.2 Metro-wide Projections ..................................................................... 20 6.3 LHA-level Projections ....................................................................... 21
7 Modelling Preparation and Validation ............................................... 22
7.1 Introduction .................................................................................... 22 7.2 Model Preparation ............................................................................ 22 7.3 Model Validation .............................................................................. 23
8 Modelling for 2015 ........................................................................... 24
8.1 Introduction .................................................................................... 24 8.2 Creating the Base Model ................................................................... 24 8.3 Modelling Options ............................................................................ 24 8.4 Achieving the Shadow Targets in 2015 ............................................... 29
9 Modelling 2017 and 2020 ................................................................. 30
9.1 Modelling for 2020 ........................................................................... 30 9.2 Modelling for 2017 ........................................................................... 32 9.3 Alternative Scenarios ....................................................................... 33
10 Station Configuration Modelling ....................................................... 35
10.1 Station Database ............................................................................. 35 10.2 Configuration Modelling Results ......................................................... 38
11 Sensitivity Modelling ........................................................................ 40
11.1 Introduction .................................................................................... 40 11.2 Sensitivity Modelling Results ............................................................. 40
12 Summary ......................................................................................... 42
12.1 Overview of Review ......................................................................... 42 12.2 Current Service Profile ..................................................................... 43 12.3 Future Service Development Options ................................................. 45 12.4 Meeting the Shadow Targets ............................................................. 48
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ORH Modelling Approach
Review Timetable
Modelling Scenarios
Demand Profile Summaries
Resourcing Summary
Performance Profile Summaries
Participating Fire Services – Records Received (2014)
Participating Fire Services – Time Fields Supplied
Resource Use – Key Statistics
Proposed Improvement in Activation and Mobilization Times
Shift Timings
Shadow Targets Proposed for Response Times
Delta/Echo Response Time Percentiles
Comparing Categories and Targets
Forecast Annual Patients by Age Band
Population-based Demand Projections
Modelled Life Cycle of an Incident
Top 25 Additional 24/7 Ambulance Deployment Locations
Adding ALS-skilled PRUs
Summary of ALS PRU Results
Response Performance Gap to Shadow Targets
New Locations Required by 2017
2017 and 2020 Response Performance Standards
Average and 95th Percentile Response Times
First Responder Waiting Times by Scenario
Potential Hub and Spoke Locations and Vehicle Additions for
2020 Targets
Comparing Future Scenarios
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Appendices
A Current Service Profile
B Service Appraisal Summaries
C Demand Projection
D Model Validation
E Modelling 2014 and 2015
F Modelling 2017 and 2020
G Station Configuration Modelling
H Sensitivity Modelling Summaries
I Glossary
i
EXECUTIVE SUMMARY
1. This review of Metro Ambulance Operations has involved detailed analysis of the 2014 service profile, enabling a model of emergency cover to be prepared, validated and used to assess a range of options for change. Progress Reports
throughout the 20-week review were presented to a BCEHS Steering Committee and discussed in detail with a Working Group.
2. An appraisal of current service provision was undertaken, highlighting where efficiency and effectiveness needed to improve. This was supported with some benchmarking comparisons. This appraisal informed the identification of options
for modelling.
3. In 2014 Metro Ambulance responded to an average of 827 incidents per day: 714 emergency response and 113 transfers. Mainland Metro accounts for 86%
of this demand, and Metro Island 14%. The highest acuity Delta/Echo incidents make up a quarter of emergency responses, with Bravo/Charlie 43% and Alpha/Omega, the least acute category, 31%. Red and Yellow transfers account
for about 30% of transfer workload, with 70% categorized as Green or Blue (the least urgent).
4. There are 37 ambulance stations, most at or close to capacity, and 36 ‘cross-
over points’ used for standby. Six ‘annexes’ are also used for unit deployments. ALS units are deployed to 13 stations (2,520 unit hours deployed per week), BLS units to all stations (11,251 unit hours per week), and Transfer units to 11
stations (560 unit hours per week).
5. The utilization of ALS units is 30.5%, which is relatively low for a metropolitan area, and BLS units are 52.1% utilized (broadly average). This tiering structure
between ALS and BLS does not give good ALS cover to the Metro area. For example, 21% of incidents require an HLA response but, of these, only 25% receive a first response from an ALS unit. ALS respond to only 45.7% of
Delta/Echo incidents, usually arriving after the BLS unit.
6. Fire Service First Responders (FRs) are used extensively, responding to 243 Metro incidents per day (across 17 Fire Services covering Metro Vancouver); the
RAP identifies 29% of incidents as ‘FR appropriate’ (87% of Delta/Echo).
7. It takes over two minutes on average for BCEHS to notify the First Responder. Their response is very quick (93% within 9 minutes from time notified), and
they most often (75.5% of the time) have to wait for the first BCEHS unit to arrive (eg, average waiting time when an FR responds to a Bravo/Charlie call is 9:29). It was agreed between BCEHS and Municipality representatives that
reducing this waiting time should be an area of focus.
8. Analysis has highlighted very long activation times (the assignment time from Call Answer to Vehicle Assign) and mobilization times (the chute time from
Vehicle Assign to Vehicle Mobile). For example, a Delta/Echo incident takes 4:13 to assign and mobilize. These times are definite outliers when benchmarked. Significant improvements are required in this time to allow unit
resources to be used more efficiently. A phased programme of improvement in
Figure A: Shadow Targets Proposed for Response Times
Category 9 minutes 15 minutes 30 minutes 60 minutes
Delta/Echo 75% (51%) 95% (86%)
Bravo/Charlie 75% (64%) 95% (90%)
Alpha/Omega 75% (81%) 95% (95%)
(Current achievement at these time thresholds in brackets)
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these average times for Delta/Echo incidents of 80 seconds by 2020 has been set and agreed, with expected improvements for all calls.
9. This review has excluded the Control function. It is recommended that a Control review is undertaken with a scope that includes: call handling; dispatching practices; staff levels; dispatch desk jurisdictions; systems used; protocols
followed; and the use of the RAP. Such a review would need to be set in the context of increasing demand and resource levels.
10. Response times are measured from the time the call is answered to the first
vehicle on scene. A nominal target of 90% within 9 minutes has been set for Delta/Echo calls (currently 51.2%), and a more formal target of 75% in 9 minutes for ‘Red Flag’ incidents (currently at 65%). Realistic targets need to be
set based on best practice to allow resource plans to be developed.
11. There is significant variation in response performance between districts (eg, from 41.1% to 67.1% on the 9-minute Delta/Echo standard), and there is a
requirement within the review objectives to set appropriate minimum levels.
12. Whereas the first on scene 9-minute response percentile from Call Answer to Delta/Echo incidents is 51.2%, for ALS response to Delta/Echo it is only 39.9%,
and just 27.8% when they respond to HLA incidents. ALS units respond to 75% of ‘Red Flag’ incidents (the highest acuity needing their skills) but with a 9-
minute response percentile of just 37%. As well as an overall improvement in response times it is also necessary to raise the ALS response standard to higher acuity calls, ie, Delta/Echo, HLA and Red Flag.
13. In consideration of these issues and the need to give a basis for the modelling of options, ORH proposed a set of ‘shadow targets’ for emergency response based on best practice elsewhere and some comparative benchmarking. For
Delta/Echo incidents the 9-minute response target is set at 75% – between the 51.2% currently being achieved and the 90% nominal target set. These targets, with current achievement, are shown in Figure A.
14. Emergency demand levels were projected forward to 2020 based on demand rate trends coupled with forecast population growth by age/sex group and by LHA. Transfer demand was assumed to reflect recent trends and the overall
Metro population growth. This gave a 6.1% per annum increase in emergency demand and a 2.0% per annum increase in transfer demand distributed by LHA. This demand profile was used for modelling the future.
15. Once the model was validated against the 2014 service profile it was used to test a range of operational measures to test their impact on the efficiency and effectiveness of cover. The projected improvement in activation and
mobilization times gave significant response time improvements. It was found that there was only marginal benefit in changing shift patterns (some were identified for the weekend). It was assumed that the average time at hospital
would be held at current levels and that there would be no change in the conveyance rate (80%), nor in the time crews spend on scene.
Figure B: Average and 95th Percentile Response Times
YearActivation
Time Reduction
Additional Resources
Average Timefor BCAS 1st Response
(D/E Calls)
95th Percentilefor BCAS 1st Response
(D/E Calls)
2015 No Change No Change 10:17 19:54
No Change No Change 11:27 22:13
30 seconds No Change 11:03 21:54
30 seconds ALS PRUs Only 09:12 19:39
No Change No Change 15:07 30:05
80 seconds No Change 13:54 29:10
80 seconds ALS PRUs Only 10:41 25:02
80 secondsFull Resources For Shadow
Targets07:09 14:44
All times in minutes : seconds
Note: Core emergency demand projection of 6.1% per annum assumed here
2020
2017
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16. Resourcing options were assessed. Increasing the size of the Transfer fleet is not an efficient measure. Introducing ‘mixed crewing’, ie, crewing units with an
ALS and a BLS crew member, gave good outcomes in terms of extending the coverage of ALS skills, but this would be very challenging to implement given commitments made to the union. Also it would not improve ‘first on scene’
response times. The most positive outcomes for improving cover cost-effectively is to deploy single-staffed ALS PRUs which would extend ALS coverage and improve first on scene response times.
17. The combination of improved activation/mobilization times and deploying ALS PRUs makes a significant impact on Delta/Echo response times, but to meet the extra demand projected and to improve response standards towards the
shadow targets proposed will involve additional BLS units.
18. To meet the targets set by 2020 will involve achieving the reductions in activation/mobilization time by that year and deploying 1,344 ALS PRU hours
per week (42 ALS FTEs and a peak deployment of 12 cars) and 3,792 additional BLS unit hours per week (235 FTEs with an increase in peak BLS unit deployments of 29). Seven of the existing ‘cross-cover’ points will need to be
upgraded to station locations with facilities, and there is significant potential to develop ‘hub and spoke’ systems of cover in five areas, and this would be an
efficient measure for ensuring sufficient capacity.
19. The benefits of investing in these resources and station configuration changes alongside the efficiencies identified are considerable:
First on scene response standards will be in line with best practice, and the minimum district response standard raised (eg, Fraser Valley Delta/Echo – from 42% within 9 minutes to 60%).
ALS coverage will be extended to most of the Metro area, allowing these skills to reach 83% of HLA cases (currently 58%) with a 9-minute response time percentile of 50% (currently 28%).
The First Responder waiting times will be reduced (eg, for Delta/Echo incidents from an average of 4:37 to 3:11).
The reconfigured deployment locations will allow staff and vehicle
resources to be accommodated appropriately and used efficiently.
20. A phased programme of change has been proposed aiming for a 30-second improvement in activation/mobilization times by mid-2017 and completing the
introduction of ALS PRUs (42 FTEs) and some BLS units (35 FTEs).
21. Figure B illustrates the impact on the average and 95th percentile Delta/Echo response times for alternative scenarios to the development path summarized
above. If no changes were made by 2020, the average Delta/Echo response time would rise from the 2015 level of 10:17 (minutes:seconds) to 15:07, and the 95th percentile response time would rise from 20 to 30 minutes. The First
Responder average wait time on Delta/Echo incidents would rise from 4:37 to 5:53 in 2017 and 8:08 in 2020.
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22. Alpha/Omega standards would fall very significantly by 2020 for options involving no new resources as the higher acuity calls take priority and there will
often be insufficient units available to service these calls as the demand increases. Whilst the ALS PRU only option shown improves Delta/Echo response by 2017 and minimizes the response fall by 2020, Bravo/Charlie and
Alpha/Omega response standards decline progressively.
23. Sensitivity modelling looked at testing a few of the assumptions made. If time at hospital were to reduce to 30 minutes this would lower the staffing
requirement in 2020 by 47 staff. If the demand projection were to be lowered - 4.2% per year rather than the 6.1% used – then this would reduce the staffing requirement in 2020 by 57 staff.
1
1 INTRODUCTION
1.1 Report Context
1.1.1 Operational Research in Health Limited (ORH) was commissioned to undertake a demand analysis and modelling review for British Columbia Emergency
Health Services (BCEHS) in February 2015, and review work began in mid-March. The scope covers service delivery for both Metro Ambulance and Air Ambulance Operations.
1.1.2 This is the Final Report for the demand analysis and modelling review for Metro Ambulance. A succession of Progress Reports were produced and discussed with BCEHS over a 20-week review period, and this report now
focuses on the results and conclusions reached, supported by quantitative evidence.
1.1.3 A brief overview of BCEHS is given below before describing the report
structure in sub-section 1.3.
1.2 BCEHS
Organization Overview
1.2.1 British Columbia Emergency Health Services (BCEHS) is supported by the Provincial Health Services Authority (PHSA). BCEHS is mandated to provide provincial ambulance and emergency health services under the Emergency and
Health Services Amendment Act, S.B.C. 2013.
1.2.2 BCEHS is currently responsible for two (2) operating entities. BC Ambulance
Service (BCAS) provides emergency health services and ambulance services throughout the province of British Columbia. The BC Patient Transfer Network (PTN) is responsible for planning and coordination of all inter-facility patient
transfers.
BCAS Overview
1.2.3 Created in 1974 the BCAS is tasked with the provision of public ambulance
services across the province. BCAS is the largest provider of emergency medical services in Canada and one of the largest in North America. BCAS serves over 4.4 million British Columbians and responds to calls for emergency
911 and inter-hospital transfer services across six health authorities covering 944,700 square kilometres.
1.2.4 In 2013/14, BCAS responded to more than 515,000 events throughout the
province – 425,000 pre-hospital (911) events, and 90,000 inter-facility transfers. BCAS also transported an additional 6,600 patients by air ambulance. BCAS employs 4,486 staff – 3,881 paramedics and dispatchers
and 605 physicians, nurses, management and support personnel. BCAS operates from 184 ambulance stations, five administration offices, and three dispatch centres. BCAS has a fleet of 577 vehicles, including 510 ambulances
and 67 support vehicles and dedicated ambulance aircraft.
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1.3 Report Structure
1.3.1 The terms of reference as taken from the original tender document are
reproduced in Section 2, and the approach taken by ORH in undertaking the work is described in Section 3.
1.3.2 The current service profile is exemplified in Section 4, covering the demand
met, resources used and standards achieved (including a description of the contribution made by First Responders). Section 5 then provides an appraisal of this quantified profile, highlighting potential efficiency measures and
identifying target response standards.
1.3.3 The time horizons taken for the projections in this review are to 2017 and 2020. Section 6 sets out the methodology and results for projecting demand
to these years.
1.3.4 The simulation model of Metro Operations was built and validated using activity data from the 2014 calendar year, and this process is explained in
Section 7, along with providing modelling results from the 2015 ‘base year’. The main deployment results for the two forward years are then set out in Section 8.
1.3.5 Section 9 focuses on modelling results related to the station configuration, and Section 10 shows the impact of changing some of the key assumptions made in the main modelling.
1.3.6 Finally, the results and conclusions reached are summarized in Section 11.
1.3.7 A glossary of terms provided throughout the report is provided in Appendix I.
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2 TERMS OF REFERENCE
2.1 Overview of Requirement
2.1.1 BCEHS would like to see forecasted impacts on service delivery, response times and patient care as a result of:
call patterns;
station locations;
staff deployment;
skills mix methodology; and
population growth and/or changes to demographics.
2.1.2 BCEHS, at the end of this project would like to have information to move
forward with effective and efficient service delivery to meet changing demands. Initially, BCEHS is looking for specific evaluations and recommendations in Metro operations and/or Air Ambulance operations with
options to conduct further detailed analysis in other service delivery areas. BCEHS has no preference as to whether this is achieved by utilizing a commercial off the shelf (COTS) software and/or through a consulting service
contract. The solution needs to provide the analysis, service delivery planning recommendations and implementation plans. BCEHS may award one or more contracts at its discretion that best meets current and future needs.
2.1.3 The expectation is that the service or software solution will enable BCEHS to:
a) gain an in-depth knowledge and understanding of current BCEHS service delivery resources;
b) identify any inefficiencies within the current BCEHS service delivery;
c) identify any inconsistencies in resources and demand matching;
d) identify potential to optimize current BCEHS resources; and
e) determine response times that could be achieved with optimization of the current system taken as a whole and the incremental cost to improve appropriate response times.
2.2 Detailed Specification
Business Requirements
2.2.1 From this project, BCEHS will require the ability to:
a) Determine the most appropriate service delivery response model that achieves the proposed emergency response time standards.
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b) Determine the most appropriate service delivery response model including but not limited to:
i. Location of vehicles, air ambulance aircraft and stations.
ii. Type and number of shift schedules.
iii. Paramedic staffing by type and number and optimal configurations.
iv. Recommended best practices and deployment methodologies from other jurisdictions.
c) Determine reasonable system costs to achieve the service delivery
standards.
d) Determine the reasonable considerations that should be accounted for
in setting service delivery standards (for example – specific to the Downtown and the Fraser Valley areas of Metro Operations).
e) Revisit analysis in subsequent year(s), after implementing some or all
recommendations.
Outcomes
2.2.2 BCEHS should, from this project, be able to:
a) Determine and recommend the most appropriate service delivery model (considering the appropriate model of care based on call demand, location and patient acuity) that achieves the desired emergency
response time standards, including:
i. inventory of resources (ALS/BLS, CCP, Ambulance, aircraft);
ii. location and deployment of resources (appropriate type, mix and number, priority lists, staffing pattern & levels);
iii. unit hours for both Ambulances and 1st response
resources; and
iv. phased 12- to 24-month implementation plan.
b) Determine and recommend resource thresholds for proposed
deployment model with parameters for adding resources.
c) Identify how any approach is consistent with the current RAP and flexibility for RAP changes in subsequent reassessment.
d) Suggestions on Management/Performance Information requirements to implement and measure impact of changes.
e) Estimate capital and operating cost impact of each recommendation
proposed.
Figure 1: ORH Modelling Approach
ValidationEnsuring the model
accurately reflects the current situation
OptimizationIdentifying the “best” solutions given known
constraints
SimulationModelling future
scenarios and answering ‘what if’ questions
SensitivityModelling to check that identified solutions are robust and future-proof
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3 METHODOLOGY
3.1 Overview of Approach
3.1.1 The ORH consultancy approach to supporting service development and tackling complicated resource planning problems related to emergency ambulance
cover involves a combination of analysis and modelling:
analysis of demand, performance and resource use to allow the model of the service area to be populated and validated, and to inform an
appraisal of potential options for change; and
identifying and modelling options that aim to improve the effectiveness, efficiency and equity of service provision.
3.1.2 Analysis for operations is based upon inputs from CAD-derived workload and emergency ambulance vehicle resourcing data, including both the resource plan and the actual deployments made. External data are also analyzed where
appropriate; for example, census data is used to support demand projections.
3.1.3 The relationship between the demand profile, the resources deployed and the performance achieved for an emergency ambulance service is complex. This is
particularly the case with multiple call categories, different vehicle types and staff skills, and various response time targets. Given this complexity, a modelling approach is required to inform resource planning decisions.
3.1.4 Figure 1 opposite illustrates the overall modelling approach taken. The two key types of modelling used by ORH are:
Simulation modelling – the process of creating and analyzing a digital
version of a physical model to predict performance in the real world.
Optimization modelling – finding the best possible choice from a set of alternatives, by using a mathematical expression of a problem to
maximize or minimize some target function or goal.
3.1.5 ORH uses information specific to the Service to populate the models. This requires analysis of CAD data to provide information about such factors as
demand, call locations and job cycle times. Service data are also used to determine resource numbers, types, deployment locations and dispatch times.
In addition to these data, ORH develops a detailed travel time model of the service area using commercially available software calibrated against information on journey times measured from the CAD data.
3.1.6 The model is validated by comparing the model outputs with actual Service performance data. A fully validated simulation model will accurately produce outputs which correspond to the actual performance, utilization and vehicle
workload experienced by the Service.
3.1.7 Once populated and validated, the models can be used to answer a wide variety of ‘what if’ questions. Sensitivity modelling helps to provide confidence
in the results by illustrating the degree to which performance changes as the value of input parameters alters.
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3.1.8 ORH uses its optimization model (OGRE – ‘Optimization by Genetic Resource Evolution’) to identify optimum deployment locations. OGRE is set up with parameters taken from the simulation modelling inputs, and additional
constraints are established in consultation with the Ambulance Service (eg, sites which will always be used). The locations found using OGRE are then input to the simulation model in order to quantify the performance and
workload implications.
3.2 Project Timetable, Activities and Consultation
3.2.1 Figure 2 opposite shows how the generic approach described above was translated into a 20-week review timetable for undertaking the Metro Ambulance analysis and modelling work.
3.2.2 The review was overseen by a BCEHS Steering Committee, and a Working Group was also established to discuss the analysis and modelling results as these emerged during the review process.
3.2.3 The main data collection and analysis activities were undertaken in the earlier phases of the review, supported by internal BCEHS stakeholder consultation. This analysis, including the demand projection work, enabled simulation and
optimization models to be established midway through the review period. The models were then used to examine a range of options, the results of which were set out in a series of Progress Reports to allow informed feedback from
BCEHS representatives.
3.2.4 In parallel with the analysis of Metro Ambulance data, analysis was also undertaken of First Responder activity across Metro Vancouver, and a series of
meetings, supported by separate Progress Reports, took place with Municipality and Fire Service representatives.
3.3 Data and Analysis
3.3.1 The calendar year 2014 was chosen as an appropriate sample period to represent the current service profile. A detailed call-by-call sample of workload, timings and unit activity was specified and supplied as an extract
from the CAD.
3.3.2 BCEHS also supplied month-by-month reported levels of demand and response performance for the agreed sample period. This enabled ORH to validate its
own analysis of the CAD workload for that period.
3.3.3 The establishment levels of staff by type/skill level (funded, actual and vacancies) were provided by BCEHS, together with representative planned and
actual deployed levels.
3.3.4 Operational data were then subject to a detailed analysis to draw out the
current relationship between demand, performance and resources. This provided a quantitative description of the current operational profile, drawing out factors relevant to the terms of reference. In particular the current
relationship between resource utilization and response performance was exemplified, and the current matching between resource deployments and the daily/hourly demand profile assessed.
Base Position
Identify Efficiencies
Current Demand
New Locations
Requirements to meet targets with current
demand
Requirements to meet targets to
agreed future date
Comprehensive Deployment Plan to Agreed Future Date
Simulation
Optimization
Service Advice
Service Constraints
Demand Projections
Service Data
Optimization
Simulation
Simulation
Simulation
Model Runs
Figure 3: Modelling Scenarios
Phasing Resources by
Location and Type
Options for Targets
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3.3.5 The analysis distinguished between the different types of response in terms of vehicles (ambulance, single response, etc) and skill type. It examined the catchment areas of each station, taking account of the different mobilization
times for types of vehicle and time of day.
3.3.6 A station database was also compiled listing all facilities currently available to Metro Ambulance. Some of the key items on this list were the size, tenure and
capacity of current response locations.
3.4 Modelling and Appraisal
Model Set-up and Validation
3.4.1 ORH’s ambulance simulation was populated using parameters derived from the data analysis work. Analysis of the CAD data provided information about such
factors as demand, call locations and job cycle times. Service data were also used to determine resource numbers, types, deployment locations, and dispatch times for model input.
3.4.2 ORH also developed a detailed travel time model of the Metro operational area using commercially available software calibrated against information on journey times from CAD data. To achieve this, the area was ‘noded’ with key
points in relation to the road network and incident distribution.
3.4.3 Travel times between nodes are a key model input and were assigned initially based on road classifications that differentiate achievable speeds in ‘average’
traffic conditions. A careful calibration process was then undertaken that gave ambulance vehicle travel times reflecting lights-and-sirens and normal speeds, different speeds for different periods of the day, and distinguishing speeds by
vehicle type.
3.4.4 The model was validated, by day and hour, by comparing model outputs, such as response performance (for the main dispatch codes), vehicle workload and
hospital workload, to actual parameter values measured in the sample period data. Once validated, the model could then be used with confidence to explore the effects of changes in such factors as demand, deployment numbers and
deployment locations.
Modelling Scenarios
3.4.5 Figure 3 illustrates the modelling steps taken and agreed with the Steering
Committee for the review.
3.4.6 The model was validated to reflect the 2014 service profile, and initially this validated model was used to assess the impact of a range of operational
measures aimed at improving the efficiency and effectiveness of provision.
3.4.7 Some further modelling was then undertaken using the 2015 base position (as there were a few deployment changes in moving from 2014 to 2015).
3.4.8 An iterative series of simulation and optimization modelling runs were then undertaken, focusing first on the 2020 year, and then back to 2017. These modelling runs were geared to the ‘shadow targets’ agreed with BCEHS and
incorporated agreed efficiency measures.
Figure 4: Demand Profile SummariesReported Incidents /Day
Transfer
Transfer
603.70
101.90
Mainland
Emergency Transfers
109.40
7.93
Island
Emergency Transfers
178.24
308.45
217.94
9.20
Emergency
DELTA/ECHO
BRAVO/CHARLIE
ALPHA/OMEGA
OTHER
10.79
20.93
22.55
37.06
Transfers
RED YELLOW GREEN BLUE
124.0
190.8
128.1
160.8
109.4
Emergency
FRVAL SNDTC SDRB VANNS GRVIC
28.5
30.420.3
22.6
7.9
Transfers
FRVAL SNDTC SDRB VANNS GRVIC
8
4 CURRENT SERVICE
4.1 Demand
4.1.1 The CAD sample for 2014 was analysed and a validation check made on the demand level measured for pre-hospital events. As Appendix A1a shows,
there is close agreement between ORH’s and the Service’s measurement of demand levels by month and by main determinant, in both the Mainland and Island Metro districts.
4.1.2 An ‘assigned incident’ is one in which a least one vehicle has been assigned; a ‘responded incident’ is one in which at least one vehicle has arrived on scene. Appendix A1 focuses on responded incidents.
4.1.3 Appendix A1b summarizes demand in terms of responded incidents, separating emergency incidents (pre-hospital events) from transfers. The following can be noted:
The categorization system for transfers moved completely from AMPDS to the 4-colour system from April 2014 onwards.
On the Mainland, transfers account for 14% of demand, whereas for
the Island this is just 7%.
Overall monthly demand levels are fairly stable across Metro as a whole.
Less than 0.5% of demand met by Metro resources originates in the Rural areas.
4.1.4 The average daily demand by district is summarized in Appendices A1c - A1c-
i for emergency demand and A1c-ii for transfers.
4.1.5 Appendix A1d illustrates the geographical distribution of Delta/Echo emergency demand by category over 2014. Incidents have been located on
the nodes assigned across the area. The geographical pattern of other emergency categories is similar to that shown here for Delta/Echo.
4.1.6 Appendix A1e tabulates the distribution of transfer demand by origin hospital
by category – Red/Yellow/Green/Blue – for the nine-month period April to December 2014.
4.1.7 The overall hourly profile across Metro for emergency and transfer incidents that receive a response is shown at Appendix A1f. The demand rate ranges from 16 per hour in the early morning hours (between 04.00 and 06.00) to
about 50 per hour in the middle of the day (between 11.00 and 15.00).
4.1.8 A summary of the salient factors of the demand profile is given opposite in Figure 4.
Figure 5: Resourcing Summary
Metro Operations
Stations 37
Cross Cover Points 36
Annexes 6
Total 79
Ambulances 121
Regular FT Staff 599
Irregular FT Staff 173
PT Staff 381
ALS Units 2,520
BLS Units 11,521
Tranfer Units 560
Total Units 14,601
ALS Units 30.5%
BLS Units 52.1%
Sites
Establishments
Deployed Hours per Week
Average Utilization
9
4.2 Resources
4.2.1 There were 37 ambulance stations across Metro in 2014, together with one
proposed station site at Waltham Burnaby. These are illustrated in Appendix A2a. In addition to station sites, there are 36 ‘cross cover points’ (that are not stations) and 6 ‘annex’ sites – see Appendix A2b.
4.2.2 Appendix A2c shows that the following weekly deployment hours are planned:
ALS units – 2,520 vehicle hours;
BLS units – 11,521 vehicle hours; and
Transfer units – 560 vehicle hours.
4.2.3 A comparison between the hourly demand and resource deployment profiles is shown at Appendices A2d to A2d-i for weekdays, and A2d-ii for weekends
(the weekend is defined here as Friday 18.00 to Sunday 17.59).
4.2.4 The vehicle mobilization geographical profile for emergency incidents is illustrated in Appendix A2e. In overall terms, vehicles are mobilized in the
following proportions by location type:
station – 40%;
cross cover point/standby – 3%;
annex – 4%;
hospital – 4%;
other (typically on the road) – 49%.
4.2.5 Staff and vehicle establishments by station are summarized in Appendix A2f.
4.2.6 The average ALS unit utilization rate is 30.5% and for BLS units it is 52.1%. Utilized time here is measured from Time Mobile to Time Clear in response to
incidents. It excludes time spent undertaking standby movements. The utilization rate takes this time as a percentage of time on shift.
4.2.7 A summary of the overall resourcing position is given in Figure 5 opposite.
4.3 Response Standards
4.3.1 A validation check was made on ORH’s calculation of response times (Call Answer to Arrive on Scene) to emergency incidents by comparing average
achievement levels with BCEHS-produced statistics. This was done by month for Mainland and Island, and for grouping incidents into three categories – Alpha/Omega, Bravo/Charlie and Delta/Echo. The results are shown in
Appendix A3a. As can be seen, there is good agreement, although with ORH’s measurements in general giving slightly higher values. The overall agreement for each paired category is within 10 seconds, but with Mainland Alpha/Omega
differing by 17 seconds.
Figure 6: Performance Profile Summary
ORH Calculation - 2014
Emergency Incidents:
Alpha/Omega Bravo/Charlie Delta/Echo
Metro Mainland 23:03 16:34 10:41
Metro Island 13:36 11:11 08:34
Metro Overall 21:28 15:48 10:24
Delta/Echo Incidents:
9 minutes 15 minutes
41.1% 79.2%
45.8% 85.9%
41.1% 83.7%
67.1% 91.7%
66.2% 93.5%
51.3% 86.4%
Transfer Performance (Metro-wide)
Percentage arriving at destination hospital more than 30 minutesafter 'appointment time'
Red Transfers 12%
Yellow Transfers 34%
Vancouver/North Shore
Greater Victoria
Overall
Average Response Time (mins:secs)
Fraser Valley
South Delta/Richmond/Burnaby
Surrey/North Delta/Tricities
Percentile Performance
10
4.3.2 BCEHS produces regular reports on Delta/Echo emergency response times. A breakdown of 9-minute and 15-minute percentile response performance for these calls is given at Appendix A3b. Metro-wide, the 9-minute response
percentage for 2014 was 51.3%, and the 15-minute percentile 86.4%. Achievement levels are higher on the Island (13% of incidents) than on the Mainland. Delta/Echo response performance varies by district (A3c), with
Vancouver/North Shore and Greater Victoria returning far better percentile achievements than the other three districts.
4.3.3 Appendix A3d sets out the response performance by the three paired AMPDS
determinant categories, showing the cumulative distributions as well as a range of percentile points. Bravo/Charlie response performance is similar to
‘all emergency’ response performance, with Delta/Echo better and Alpha/Omega worse.
4.3.4 Appendix A3e repeats the A3d profile for each of the five districts. Response
performance is best in Greater Victoria and Vancouver/ North Shore.
4.3.5 Appendix A3f shows the hourly emergency response performance achievement by paired AMPDS category. It is notable that response
performance does not vary significantly by hour of the day, though there is some evidence of a dip in response performance at shift change times (early morning and early evening).
4.3.6 Appendix A3g illustrates the geographical profile of Delta/Echo incidents that received a response outside of the 9-minute threshold in Metro Mainland (A3g-i) and in Metro Island (A3g-ii).
4.3.7 Transfer ‘performance’ is analysed at Appendix A3h. Appendix A3h-i calculates the difference between time arrive at scene and time of actual pickup. In general, performance improves from Blue through to Red. The
difference between time arrive at hospital and pickup time is shown at A3h-ii for Red and Yellow transfers; for Red transfers the 50th percentile is between 10 and 20 minutes early, and for Yellow up to 10 minutes after the
appointment time.
4.3.8 A summary of the response performance profile is given opposite in Figure 6.
4.4 First Responders
Introduction
4.4.1 It was agreed that ORH should undertake an analysis of First Responder (FR) activity across the same 2014 sample period as for Metro Ambulance.
Seventeen Fire Services participated and returned activity data amounting to 90,486 records (see Figure 7 overleaf) across the varying time fields, as shown in Figure 8. A total of 88,690 of these records were linked to a BCEHS
event number, giving an average of 243 FR responses per day.
4.4.2 A detailed report discussing the analysis of these data has been provided separately, so only a broad summary of the findings is given here.
Figure 7: Participating Fire Services - Records Received (2014)
Fire Service Number of RecordsNumber of Fire
Halls
City of Vancouver 35,309 19
Surrey 20,234 17
Richmond 6,067 7
Burnaby 5,644 7
Coquitlam 4,088 4
Delta 3,999 7
New Westminster 3,453 3
District of North Vancouver 2,383 7
Township of Langley 2,084 7
Port Coquitlam 1,986 2
Langley City 1,747 1
Maple Ridge 1,697 3
White Rock 867 1
Port Moody 757 2
City of Pitt Meadows 146 1
Sechelt 24 1
Scotch Creek/Lee Creek 1 1
Total 90,486 90
Figure 8: Participating Fire Services - Time Fields Supplied
Field NameCity of
VancouverCoquitlam Langley
Misc. Municipalities
Port Moody Sechelt BurnabyNew
WestminsterRichmond Delta
IncidentBeginTime P P P P P P P P
DispatchTime P P P P P P P
OnRouteTime P P P P P P P
OnSceneTime P P P P P P P
ReturnToServiceTime P P P P P P P
Incident Date P P
Commit Time P P
First On Scene Time P P
Incident End P P
Dispatched P
First Unit Enroute Time P
First Unit Arrival Time P
Incident Close Time P
Misc.Municipalities include City of Pitt Meadows, District of North Vancouver, Langley City, Maple Ridge, Port Coquitlam, Surrey and White Rock
11
First Responder Profile
4.4.3 The average time occupied per day on FR activity was measured from the time of call contact to the time the unit left the scene. Across all the participating
Fire Services this totaled 85 hours per day on average. This ranges from 0.16 hours for the City of Pitt Meadows Fire Service to 26.32 hours for the City of Vancouver Fire Service.
4.4.4 FRs mobilize very quickly from the time notified by BCEHS – an average of just 18 seconds across all incident types.
4.4.5 The overall average FR response time from time notified is 5:33
(minutes:seconds) with little variation between categories, although the responses to Delta/Echo incidents are almost always faster than for
Bravo/Charlie (the exceptions are for Burnaby, North Vancouver and Richmond). There is significant variation between Fire Services in these average response times, although for the most acute Delta/Echo calls, the
range is about 1.5 minutes – between 4:14 and 5:48 – if Langley and Pitt Meadows are excluded at 7:33 and 8:25 respectively.
4.4.6 FRs respond to scene from time notified within 9 minutes on 93.4% of
occasions.
FR and BCEHS Profile
4.4.7 It takes an average of 2:30 (minutes:seconds) from BCEHS receiving a call to
notifying the Fire Service (2:12 if times greater than 10 minutes are excluded).
4.4.8 The FR arrives on scene before the BCAS ambulance on the vast majority of
occasions – 75.5% overall and by category:
72% for Delta/Echo (FRs respond to 83% of these incidents); 80% for Bravo/Charlie (FRs respond to 43%); and
87% for Alpha/Omega (FRs respond to only between 1% and 2%).
4.4.9 The average time period (‘backup’) for the BCAS unit to arrive after the FR on these occasions also varies by incident acuity:
4:37 for Delta/Echo; 9:23 for Bravo/Charlie; and 13:23 for Alpha/Omega.
4.4.10 The 9-minute FR response percentiles from BCAS Call Answer are:
80.3% for Delta/Echo; 72.8% for Bravo/Charlie; and
74.2% for Alpha/Omega.
4.4.11 In modelling options for Metro Ambulance Operations, there is naturally interest in how the FR waiting times can be reduced. If their response
continues to be quick, this waiting time could only be reduced if BCEHS response times improve. If BCEHS were to notify FRs more quickly, this would tend to increase the FR waiting time.
Figure 9: Resource Use - Key Statistics
ALS alone 2.5%
BLS alone 81.0%
ALS then BLS 5.6%
BLS then ALS 8.2%
Other 2.7%
Delta/Echo 1.44
Bravo/Charlie 1.11
Alpha/Omega 1.02
Overall 1.17
Delta/Echo 83.1%
Bravo/Charlie 79.5%
Alpha/Omega 81.8%
Overall 80.5%
Hot Response 41.7%
Cold Response 52.1%
Appropriate for FR Response 28.7%
HLA Response Required 20.6%
Response Order
Multiple Attendance Rates
Conveyance Rates
RAP: Percentage of Incidents with Specified
Response
12
5 SERVICE APPRAISAL
5.1 Resource Use
5.1.1 Vehicle workload summaries are presented at B1. Ninety-five percent of responses are made by BLS (82.2%) and ALS (12.9%) units – see B1a-i.
Transfer units are not used for emergency response and undertake 30% of transfers; BLS units do 66% of transfers (B1a-ii and B1a-iii).
5.1.2 Multiple attendance ratios have been calculated by category of call – see B1b.
For emergency incidents the overall ratio is 1.17 (1.44 for Delta/Echo incidents), and for transfers 1.04 (1.05 for Delta/Echo and Red). The frequency of vehicle combination responses by category of emergency incident
is shown at Appendix B1c. ALS units respond to 43% of Delta/Echo incidents, most often following a first response by a BLS unit (23%).
5.1.3 Non-conveyance rates are summarized in Appendix B1d-i; for emergency
incidents, 16.9% of Delta/Echo are not conveyed, 20.5% of Bravo/Charlie and 18.2% of Alpha/Omega. The overall non-conveyance rate for emergency incidents is 19.5%, and for transfers 4.2%. Some 8% of incidents are
cancelled before a unit reaches the scene (see B1d-ii).
5.1.4 Appendix B1e then breaks down the average time for all the different components of a response for the first vehicle on scene (B1e-i) and then
separately for BLS (B1e-ii) and ALS (B1e-iii).
5.1.5 An analysis of average time at scene is given in Appendix B1f. ALS units spend longer on the scene of an emergency incident than BLS units (18.5
minutes compared to 17 minutes) – see B1f-i. Time at scene for transfers is longer than for emergency incidents (B1f-ii).
5.1.6 Appendix B1g-i lists the receiving hospitals in Metro in order of volume. The
average time at hospital is also shown in the last column. Appendices B1g-ii and B1g-iii tabulate the number and proportion of offload delays by hospital.
5.1.7 Appendix B1h examines some aspects of the Resource Allocation Plan (RAP).
Just over half of emergency incidents require a ‘cold response’ with 42% ‘hot’ (see B1h-i), and 29% of emergency incidents assigned as being appropriate
for a First Responder response (B1h-ii). One-fifth of incidents require higher skills (‘HLA’).
5.1.8 Appendix B1h-iii shows that 20.6% of responded emergency incidents require
an HLA response and, of these, 24.6% receive a first response from an ALS unit. Also, 73.2% of emergency incidents require a BLS response and, of these, 95.4% receive a BLS unit as a first response.
5.1.9 The hourly utilization profile is shown by vehicle type in Appendix B1i: B1i-i – BLS units 52.1% utilized; and B1i-ii – ALS units 30.5% utilized. Utilization is calculated as the time occupied from Time Mobile to Time Arrive on Scene for
responses (excluding standby moves), divided by total shift time.
5.1.10 A summary of some key resource use indicators is given in Figure 9 opposite.
13
5.2 Improving Efficiency
Introduction
5.2.1 The description of resource use above, together with the analysis of the current service profile in Section 4, suggests areas where operational efficiency can be improved. This assessment was also supported by benchmarking
analysis of key service factors (not shown in detail in this report) to inform discussion with the BCEHS Steering Committee on potential efficiencies.
5.2.2 Candidates for potential efficiencies can then be taken forward in the
modelling.
5.2.3 This sub-section considers the following aspects of operational provision in turn:
assignment and chute times;
time at scene and non-conveyance rates;
time at hospital and offload delays;
resource utilization and tiering; and
resource/demand matching and shifts.
Assignment and Chute Times
5.2.4 The Assignment Time (or Activation Time) is the Time from Call Answer to Vehicle Assign; the Chute Time (or Mobilization Time) is the time from Vehicle Assign to Vehicle Mobile. Times currently achieved are shown in Appendix
B1e as part of the overall call cycle time.
5.2.5 This review does not cover the control and dispatch function, but the activation time is a critical consideration in an operational review where the response
time clock starts at Call Answer. ORH UK benchmarking for Ambulance Red calls (similar to D/E here) gives average activation times (from Call Answer) of between 01:15 and 02:00 (minutes:seconds). The average for D/E in Metro is
2:41. An improvement to these long activation times in Metro would improve the efficiency and effectiveness of cover.
5.2.6 Long activation times are likely to be due to a combination of pressures on
operational resource availability and processing issues within Control. It is not possible without a quantitative understanding of the call handling and dispatch processes within Control to determine to what extent each of these is
contributing to the long allocation times. However, there is evidence that even during the quietest hours of the night, when operational unit utilization is low, Control processing times are longer than they should be. There is therefore
definitely potential for a systematic review of Control being able to identify both efficiency and effectiveness improvements. Such a review in the near future would be timely given the projected increase in demand (see Section 6)
and the associated need to ensure that there is sufficient capacity in Control in future years.
Figure 10:
Proposed Improvements in Activation and Mobilization Times
Proposed Targets for Delta/Echo (*)
Year Mins:secs Seconds Mins:secs Seconds Mins:secs Seconds
2014 2:41 161 1:32 92 4:13 253
2015 2:40 160 1:30 90 4:10 250
2016 2:35 155 1:20 80 3:55 235
2017 2:25 145 1:10 75 3:40 220
2018 2:10 130 1:10 70 3:20 200
2019 1:55 115 1:10 70 3:05 185
2020 1:40 100 1:10 70 2:50 170
Proposed Improvements (by mid-year) in seconds for Delta/Echo (*)
Year Year Cumulative Year Cumulative Year Cumulative
2014 - - - - - -
2015 - - - - - -
2016 5 5 10 10 15 15
2017 10 15 5 15 15 30
2018 15 30 5 20 15 50
2019 15 45 - 20 15 65
2020 15 60 - 20 15 80
CA-VA: Call Answer to Vehicle Assign = 'Activation Time'
VA-VM: Vehicle Assign to Vehicle Mobile = 'Mobilization Time'
(*) Commensurate improvements in all incident categories would be expected
Current times are shown in the emboldened 2014 line
CA-VA VA-VM CA-VM
CA-VA VA-VM CA-VM
14
5.2.7 The overall average ‘chute time’ – the time from Vehicle Assign to Vehicle Mobile is 01:44 in Metro operations, and for D/E this is 1:32. Appendix B1j-i shows how the overall chute time is broken down by mobilization type and
suggests how this time could potentially be reduced by 20 seconds. Benchmarking with UK and Ontario Ambulance Services shows the BCEHS Metro chute time to be of the order of double the longest elsewhere.
5.2.8 A combination of improved activation and mobilization time would have a significant positive impact on response times (see Section 7) and targets for improvement need to be set for subsequent years (see Section 8).
5.2.9 Options here were discussed with the BCEHS Steering Committee and a phased improvement was agreed as shown in Figure 10 opposite.
Time at Scene and Non-conveyance Rates
5.2.10 The average time spent at scene (see B1f) of just over 16 minutes is relatively low compared to other Services. This is associated with a relatively high
conveyance rate (80.5%).
5.2.11 If BCEHS were to move towards a more formal ‘see and treat/assess’ regime, then for certain categories of call (identified through an enhanced triaging
system), the time at scene would increase and the conveyance rate fall. This in turn would reduce hospital attendance rates. However, there are no plans to introduce such an operational change in the near future.
5.2.12 The conclusion therefore, for modelling future scenarios, is to assume that the current time at scene for ALS and BLS units at emergency incidents will not change, nor will the associated conveyance rate.
5.2.13 The equivalent profile for Transfer units – a 95.8% conveyance rate and a 30-minute time at scene – will also be assumed to not change.
Time at Hospital and Offload Delays
5.2.14 Time at hospital averages just over 37 minutes for emergency incidents. This includes the impact of ‘offload’ delays. There is wide variation around this average with, for example, at least 10% involving more than one hour at
hospital.
5.2.15 This average time is low compared to Ontario Services and high compared to UK Services.
5.2.16 It was agreed with the BCEHS Steering Committee that the base assumption for the future should be that this time, and the variation by hospital and by day/hour, should stay the same in the future modelling. However, it was also
agreed that sensitivity modelling would examine the impact of this average time reducing to no more than 30 minutes at each hospital. The main underlying assumption, though, is that this time will not lengthen in the future.
Resource Utilization and Tiering
5.2.17 BLS units are more utilized than ALS units. The average BLS utilization is 51%, varying from 26% to 65% across the hours of the week (see B1i-i), with
ALS at an average of 30.5%, varying from 15% to 45% (see Bli-ii).
0
20
40
60
80
100
120
140
160
180
200
Num
ber
Shift Start Time
Figure 11: Shift Timings
BLS ALS
15
5.2.18 The ‘vehicle combination analysis’ at B1c shows how BLS and ALS units respond. BLS units respond to 95.9% of incidents, whereas ALS respond to 16.4% of incidents. For Delta/Echo incidents, the most common response –
53.2% - is for just a BLS unit to respond.
5.2.19 For a busy metropolitan area, the ALS utilization is low and the BLS utilization around average. The tiering structure, separating ALS from BLS, with
restricted ALS coverage (deployed to 13 out of the 37 stations), does not give an efficient operational regime in respect of ensuring that higher skilled ambulance responses are made in a timely manner to higher acuity incidents.
Options for change need to be examined here.
Resource/Demand Matching and Shifts
5.2.20 Resource/demand matching graphs are shown at Appendix A2d. Currently ALS and BLS units in the mainland mostly work 11- or 12-hour shifts with changeover times around 06:00 and 18:00, working 4 days on and 4 off
(Alpha, Bravo and Charlie shifts). Echo shifts are worked in CRS Victoria around a 10-hour work day (4 days on and 3 off). There is some potential to improve deployment times in relation to the demand profile but no clear
indication that the shift system itself needs to change as it embraces these four different types of shift working.
5.2.21 Appendix B1j-ii illustrates peaks in call activation times (ie, allocation times)
around the shift change times, with a commensurate fall in response performance. Shift change times are already partially staggered (see Figure 11). Enforcing a policy of posting clear even though near the end of a shift
would help minimize this performance fall which may also be related to Control shift changes. Eliminating the two performance falls shown (around 06:00 and 18:00) would raise Delta/Echo 9-minute response performance by at least 1%.
5.2.22 There is also evidence that the BLS unit cover at weekend evenings and nights should differ from weekdays (compare the demand patterns at A2d). This only happens currently in a few stations (eg, CRS). BLS unit cover needs to be
better at weekends between 18:00 and 02:00 (ie, Friday night into Saturday morning, and Saturday night into Sunday morning). This could potentially be achieved by moving some early BLS Bravo shifts from an early start to starting
at between 13:00 and 15:00 on Fridays and Saturdays (see Figure 11).
Summary
5.2.23 The commentary above on potential efficiency measures, based on analysis
outcomes, was discussed with the BCEHS Steering Committee at the interim stage of the review.
5.2.24 It was agreed that future scenario modelling should take account of:
planned improvements in assignment and chute times (Figure 10);
sensitivity modelling around reduced hospital times; and
changes in the ALS/BLS unit tiering structure.
Figure 12: Shadow Targets Proposed for Response Times
Category 9 minutes 15 minutes 30 minutes 60 minutes
Delta/Echo 75% (51%) 95% (86%)
Bravo/Charlie 75% (64%) 95% (90%)
Alpha/Omega 75% (81%) 95% (95%)
(Current achievement at these time thresholds in brackets)
Figure 13: Delta/Echo Response Time Percentiles
Response Type Minutes (**) 9 15 First FR Response (*) 80.3% 95.9% First BCAS Response 51.2% 86.4% First BCAS ALS Response 39.9% 78.4% First FR + BCAS Response (*) 85.5% 96.9%
(*) only calculated for where First Responder responds which is on 87% of occasions for Delta/Echo
(**) all measured from BCAS clock start time
16
5.3 Improving Effectiveness
Emergency Response
5.3.1 BCEHS currently monitors emergency response standards from 911 Call Answer to first BCEHS Vehicle on Scene. Other jurisdictions that allow for some initial triage of an incoming call may choose to ‘start the response clock’
further into the initial call (eg, when the Chief Complaint or AMPDS determinant is identified). No such triage process is being developed in BCEHS, so it was agreed to continue with monitoring emergency response
times from Call Answer.
5.3.2 Starting the response clock at Call Answer gives an accurate reflection of the patient experience, and it also allows for future response time measurements
to be accurately compared with historical ones. However, this represents a challenging performance measure, encompassing both control processing time (call handling and dispatching) as well as operational mobilization (the ‘chute
time’) and the time taken to then reach the scene.
5.3.3 It was also agreed, at least for the purposes of this review, to not take account of the associated timings of the First Responder response when this was made.
There are no systems in place at present to share data to allow this, and no plans for this to happen.
5.3.4 There is a current response target set at 90% within 9 minutes of Call Answer
for Delta/Echo incidents across Metro Ambulance. The current first on scene response performance from Call Answer is far short of this at 51.3% within 9 minutes for these high acuity incidents. In order to structure the modelling, a
set of ‘shadow targets’ was proposed by ORH, based on experience elsewhere, and was agreed by the Steering Committee. These ‘shadow targets’ are summarized in Figure 12 opposite.
5.3.5 There is significant variation in response standards by district (see A3c and A3e); for example, with the Delta/Echo 9-minute response time percentile varying from 41.1% in Fraser Valley and Surrey/North Delta/Tricities to 67.1%
in Greater Victoria. In setting out to achieve the Figure 11 response targets Metro-wide, there will also be an underlying objective to reduce this district performance variation and raise the minimum standard achieved (eg, 60% for
the above standard) – this will need to be taken into account in the modelling.
5.3.6 There is concern, however, at the length of the waiting time between a First Responder response (usually first on scene) and the BCEHS response (see
sub-section 4.4). Any modelling results for an improved BCEHS response to such incidents will need to be translated into the impact on this waiting time. This calculation will also need to take account of planned improvements in
control processes and practices that are likely to reduce the time to notify Fire Services that a response is required (currently an average of over 2 minutes); this in itself would tend to increase the FR waiting time.
5.3.7 Figure 13 summarizes the key response time statistics for BCEHS and First Responders (FRs). If the FR response were to be taken into account, the 9-
minute Delta/Echo response percentile would not be far off the 90% target currently set for Delta/Echo incidents that FRs attend (FRs currently respond to 83% of Delta/Echo incidents).
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17
5.3.8 Practically all Echo incidents and two-thirds of Delta incidents are identified as ‘HLA’, requiring the highest available skill level. Currently ALS units respond to 58.2% of such incidents (ie, ALS units do not respond at all to 41.8% of
HLA incidents). When they do make HLA responses they do so with a 9-minute response percentage of 27.8% (39.9% for the Delta/Echo HLA incidents). Modelling should examine ways in which this standard can be
improved.
5.3.9 A selection of 12 MPDS determinants are identified as ‘Red Flag’ incidents, covering cardiac, breathing problems, etc. There is a planned response target
of 75% within 9 minutes associated with these incidents (currently a 70% target), and a current performance level of around 65%. These incidents
would clearly benefit from a timely ALS response, but the current operational regime does not give this: ALS units respond to 75% of such incidents (usually after the BLS unit) with a 9-minute response percentile of 37%.
5.3.10 It is difficult to benchmark emergency response standards and targets with other jurisdictions because of the different contexts in which emergency ambulance services are provided. The main areas of variation which make
such comparisons difficult are as follows:
the extent of control-based triage varies (‘hear and treat’);
the extent of targeted on-scene triage varies (‘see and treat’);
the incident categorization schemes vary;
the proportion of (ALS) paramedics varies; and
the response ‘clock start’ time varies.
5.3.11 Figure 14 opposite gives some examples of categories and standards set in a few other jurisdictions that are largely urban in nature. A few general
conclusions can be drawn:
The current Delta/Echo target of 90 per cent within 9 minutes from Call Answer is far more stringent than any target set amongst these
services.
Monitoring response standards for high acuity calls from Call Answer is
undertaken in other jurisdictions, but many have a time between Call Answer and Vehicle Assign (these often in conjunction with a triaging system that allows the category of call to be identified before Vehicle
Assign).
Targets at the 50th and 95th percentile levels are more common than a
single target at the 90th percentile.
Although some jurisdictions just set targets for their high acuity calls,
the practice of also setting targets for the lower acuity calls is also common to allow system-wide planning.
18
5.3.12 The ‘shadow targets’ proposed, and accepted by the Steering Committee, were put forward based on ORH’s experience in working with a range of Services, but more importantly were set in the context of the issues facing the Service:
The current Delta/Echo target of 90 per cent within 9 minutes from Call Answer is far from being met (and is unlikely to be feasible).
Keeping a Call Answer clock start for the response clock to allow standards in the developing Service to be accurately compared with the past, and to ensure a focus on Control processing efficiency.
There are relatively long waiting times for First Responders until the
first BCEHS resource arrives, and they arrive first on 75% of occasions.
There are relatively poor response times for ALS units to arrive on
scene to HLA, Delta/Echo and Red Flag incidents.
Transfer Performance
5.3.13 Current transfer performance is set out in Appendix A3h, covering planned
pickup time (in relation to time at scene – see A3h-i) for all categories, and appointment time (in relation to time arrive at hospital – see A3h-ii) for Red and Yellow transfers.
5.3.14 It was agreed with BCEHS that, for Red transfers, maximizing the arrivals within a 10- or 15-minute window around the appointment time would be a suitable aspiration, and for Yellow, Green and Blue transfers, windows of 15
and 30 minutes should apply.
5.3.15 Currently just a quarter of Red transfers arrive within 10 minutes of their appointment time, and 55% of Yellow transfers within a 30-minute window.
Modelling undertaken therefore noted the impact on this standard without being specific about a target percentage achievement.
19
6 DEMAND PROJECTION
6.1 Overview of Methodology
Emergency Demand
6.1.1 The approach taken in this review for projecting demand takes account of the
increasing population in British Columbia, the change in the population profile (ie, the ageing population), and the changing propensity for calling an ambulance.
6.1.2 The demand projections are based on previous historic demand responded to by Metro ambulances (data supplied by BCEHS), and historic and projected population data (obtained from the website for BC Stats, an organization
within the Service BC division of the Ministry of Technology, Innovations and Citizens’ Services, and who operate under the authority of the British Columbia Statistics Act, R.S.C.V. 1996, C. 439).
6.1.3 The approach taken here is based on the methodology presented in the La Trobe report ‘Factors in Ambulance Demand: Options for Funding and Forecasting’ (Livingstone 2007). Several forecasting models were investigated
as part of the La Trobe study. Their ‘Method 4’, which used age:demand distribution trends to forecast future growth, was considered by the authors to produce the best results. The underlying hypothesis is that demand is strongly
related to the population age profile. Also, there is an underlying trend for increased demand at all age groups due to unquantifiable factors such as the overall level of health provision, public expectation, etc, which, it is assumed,
will continue into the foreseeable future.
6.1.4 In summary, the approach taken here is to calculate demand rates over the last five years by age and gender, and to understand how these have
increased for each age/gender combination. These rates can then be projected to the year 2020 and then combined with population forecasts to predict the overall demand level in 2020.
6.1.5 To illustrate the changes in the population profile in the Metro region, ‘population pyramids’ are shown for 2014 and 2020 in Appendices C1a and
C1b respectively. The overall population level in Metro is forecast to increase from 4.6 million in 2014 to 5.0 million in 2020, an annual rate of increase of about 1.3%.
Transfer Demand
6.1.6 Projecting future transfer demand is not so straightforward, partly as comparable historical trend data for transfer demand does not exist, and also
because future levels and patterns are likely to be a reflection of required flows within the health system and projecting these changes is uncertain. In 2014 the transfer demand met by BCAS was 2.7% above the 2013 level. The
population is growing at 1.3% per annum. Given these rates, it was agreed to use a projected growth rate for transfers in Metro of 2.0% per annum, retaining the same profile of origin/destination hospitals and category
proportions as in 2014.
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
<101
‐04
05‐09
10‐14
15‐19
20‐24
25‐29
30‐34
35‐39
40‐44
45‐49
50‐54
55‐59
60‐64
65‐69
70‐74
75‐79
80‐84
85‐89
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Total Annual Demand
Age Ba
nd
Fig
ure
15
: F
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In 201
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20
6.2 Metro-wide Projections
Calculating Historic Demand Rates
6.2.1 Historic data were supplied to ORH by BCEHS detailing the age and gender of emergency patients responded to by Metro ambulance for the period 2009 to 2014. A summary of the patient age and gender profile of Metro ambulance
demand is shown in Appendix C2a.
6.2.2 The profile of the Metro area population is shown in Appendix C2b, and is presented in the same format as Appendix C2a.
6.2.3 The demand rates for each age, gender, and year combination are shown in Appendix C2c. These are calculated by dividing the patient data by the population data. The demand rates are shown as average demand per 1000
population for clarity.
Calculating Future Demand Rates
6.2.4 From Appendix C2c, the overall trend of increasing demand rates can be seen.
In 2009, across all ages and genders, the demand rate was around 43 per 1000 people; in 2014, the demand rate was 54. The results of projecting the trend in demand rates for each gender and age combination are presented in
Appendix C3.
6.2.5 In Appendix C3a, the historic demand rates for males across the age groups are summarized and projected forward to the year 2020 using a simple linear
trend for each age group. The same calculation has been carried out for females, and is shown in Appendix C3b.
6.2.6 A graph comparing the forecast demand rate for males and females by age in
the year 2020 is provided in Appendix C3c.
Calculating Future Demand Levels
6.2.7 A table of the 2014 and projected 2020 population levels are shown in
Appendix C4a.
6.2.8 The 2020 population figures are then combined with the forecast demand rates for 2020 (Appendices C3a and C3b) to create forecast demand levels for
2020. These are shown in the table in Appendix C4b and graphed in Figure 15 opposite.
6.2.9 Over the six years from 2014 to 2020, demand is projected to increase by
42.5%, which equates to an average of 6.1% per year (taking into account compound growth, etc). In 2014, there were 54 incidents per 1000 people on average, and by 2020 this is expected to rise to an average of 74 incidents per
1000 people.
6.2.10 BCEHS has recently compared the demand to date in 2015 with the demand seen in the same period in 2014. In the first twenty weeks of 2015, demand
was 6.4% higher than in the same period in 2014. This provides some confidence in the demand level projections produced by ORH.
Figure 16: Population-Based Demand Projections by LHA
Sorted by forecast change (highest to lowest)
LHA 2014 Demand2020 Forecast
Demand6-Year Change
Avg Change
per Year
Sooke LHA 3,695 5,576 50.9% 7.1%
Richmond LHA 10,646 15,811 48.5% 6.8%
South Surrey/White Rock LHA 6,093 9,038 48.3% 6.8%
Maple Ridge LHA 4,930 7,308 48.2% 6.8%
Surrey LHA 20,334 29,901 47.1% 6.6%
Coquitlam LHA 11,527 16,860 46.3% 6.5%
Chilliwack LHA 4,977 7,269 46.0% 6.5%
Langley LHA 7,403 10,787 45.7% 6.5%
North East LHA 5,817 8,338 43.3% 6.2%
Agassiz - Harrison LHA 551 785 42.5% 6.1%
Mission LHA 2,072 2,952 42.5% 6.1%
South Vancouver LHA 7,870 11,159 41.8% 6.0%
North Vancouver LHA 7,574 10,722 41.6% 6.0%
Burnaby LHA 12,559 17,736 41.2% 5.9%
New Westminster LHA 3,675 5,172 40.7% 5.9%
Delta LHA 5,504 7,706 40.0% 5.8%
Midtown LHA 4,708 6,564 39.4% 5.7%
Abbotsford LHA 7,383 10,289 39.4% 5.7%
West Side LHA 7,447 10,315 38.5% 5.6%
Downtown Eastside LHA 3,207 4,421 37.9% 5.5%
W. Vancouver-Bowen Island LHA 3,383 4,662 37.8% 5.5%
Saanich LHA 4,470 6,129 37.1% 5.4%
Greater Victoria LHA 13,558 18,241 34.5% 5.1%
City Centre LHA 6,392 8,495 32.9% 4.9%
All Metro Area LHAs 165,774 236,238 42.5% 6.1%
21
6.3 LHA-level Projections
Overview
6.3.1 Population data is available from BC Stats at a Local Health Authority (LHA) level, which give smaller sub-divisions of the Metro Area.
6.3.2 In this section the population forecast is re-calculated at an LHA level, allowing
different areas in the region to receive different levels of growth within the model (although the overall growth across the whole region will remain at 6.1% per year, as presented in sub-section 6.2 above).
Selecting the LHAs
6.3.3 LHA boundaries are not coterminous with the regional boundaries used by Metro Ambulance. A map of LHA boundaries is provided in Appendix C5a-i.
6.3.4 The approach here is to calculate the demand growth for each LHA shown in Appendix C5a-i, and then apply the resulting percentage growth to the geographical incident distribution within the LHA (shown in Appendix C5a-ii).
Forecasting by LHA
6.3.5 Forecasts have been undertaken for each age and gender combination for each individual LHA. Examples for two LHAs are shown in Appendix C5b. In
Appendix C5b-i, the projection forecast for Richmond LHA gives a pattern of growth which is relatively typical compared to the Metro-wide profile shown in Figure 15. In Appendix C5b-ii, the projection forecast for City Centre LHA is
shown. This pattern is less typical, with a greater ‘spike’ in demand in the 30-34 age group, and a projected fall in demand in the 20-24 age group.
6.3.6 The overall demand uplift (ie, across all age groups) for each LHA is shown in
the table opposite in Figure 16. A map of the LHAs with the demand increases is provided in Appendix C5c.
6.3.7 The greatest demand uplift is expected in Sooke LHA, with an expected growth
of 7.1% per year, and the smallest rate of change occurs in City Centre LHA, where the demand forecast is a growth of 4.9% per year. The average rate of growth across all LHAs is 6.1% per year.
6.3.8 These LHA demand projections were applied in the main modelling runs for 2017 and 2020 (see Section 8). They give emergency demand increases from a 2014 base of 19.4% by 2017 and 42.5% by 2020.
6.3.9 An alternative projection, assuming a halving of the projected increase in demand rate by age/gender but still reflecting the changing population levels by age/gender, was applied in sensitivity modelling (see Section 10). This
gives emergency demand increases of 13.1% by 2017 and 28.0% by 2020 (from a 2014 base).
Vehic
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ure 1
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22
7 MODELLING PREPARATION AND VALIDATION
7.1 Introduction
7.1.1 This section gives an overview of the model developed to undertake the review and the validation process performed to ensure confidence in the model
outputs.
7.2 Model Preparation
7.2.1 A summary of the life-cycle of an incident within the model is shown opposite
in Figure 17. In broad terms, incidents are generated and then the response is determined. The response is then ‘acted out’ within the model – the vehicle or vehicles travel to the incident, possibly transport the patient to hospital, and
then come available to respond to future incidents. A variety of outputs can then be reported by the model, including response performance, vehicle utilization, etc, based on what occurred during the simulation.
Incident Generation
7.2.2 Incidents are generated at random within the model in accordance with the analysis of the CAD workload data. This is done separately for each category
of call. This includes the frequency of calls that occur, which varies by hour of the day and day of week, and the geographical distribution of incidents.
Determining the Response
7.2.3 Once an incident is generated, the model determines how to respond. This is based on the category of the call and the dispatch protocols. The closest
appropriate vehicle or vehicles are identified (ie, the vehicle that can arrive the quickest), based on the current location of all vehicles, the availability or unavailability of vehicles, and the road network.
7.2.4 It may also be that due to the high level of calls (and thus low availability of vehicles), the assignment of a vehicle to a low priority call may be delayed to preserve the ability to respond to any subsequent high priority calls that may
occur.
Carrying out the Response
7.2.5 Once the response is determined, the vehicle then travels to the scene. There
is a chance that the vehicle may not arrive at scene, due to being stood down, or because the vehicle is re-directed to a higher priority call (in which case a new response needs to be found).
7.2.6 Once the vehicle arrives on scene, the vehicle will spend an amount of time there, depending on the type of response and the category of incident. Once this time is elapsed, the vehicle may then transport the patient to hospital, in
accordance with the analysed transport rates. If this occurs, the nearest appropriate hospital is identified and the patient taken there. Finally, when the vehicle posts clear (either from scene or at hospital), the vehicle may then
travel back to station, or respond to subsequent calls awaiting a response.
23
7.3 Model Validation
7.3.1 The analysis of the 2014 sample year was used to build and validate the
simulation model. Inputs for the model were derived from those actually measured during the year, including: activation time, mobilization time, time at scene, time at hospital, the hot/cold RAP categorization etc.
7.3.2 Model validation is the process of checking that model outputs are in line with those measured in the 2014 sample period. This includes (but is not limited to):
response performance by category for emergency and transfer events, at geographical sub-areas and by hour of the day and day of the week;
unit behaviour, including the percentage of time spent on different categories of call, multiple attendance rates, non-conveyance rates, overall unit utilization; and
workload by station and patient flows to the different receiving hospitals.
7.3.3 Some illustrations of the validated model outputs are provided in Appendix D.
7.3.4 Appendix D1 graphs some example response times, comparing the model outputs with the actual analyzed distribution, and shows the close match between the two:
D1a – Delta/Echo response time distribution;
D1b – Bravo/Charlie response time distribution;
D1c – Alpha/Omega response time distribution.
7.3.5 Further examples are given at Appendix D2 for the Delta/Echo response time distribution in Vancouver/North Shore (D2a) and the Alpha/Omega response time distribution in Fraser Valley (D2b). Again, the agreements are close.
7.3.6 Appendix D3a compares unit workload by category of call and unit type, and at D3b the 24-hour overall modelled ambulance utilization is compared with actual. In this latter case, the model is under-predicting utilization in the
afternoon and evening, but the profile is closely matched, and the overall discrepancy is only 2 percentage points.
7.3.7 Appendix D4 compares the actual distribution of patients by receiving hospital
with that output by the model. As can be seen, the agreement is very good.
7.3.8 These illustrations confirm that the model was validated accurately and that it could therefore be used with confidence to assess options for change.
24
8 MODELLING FOR 2015
8.1 Introduction
8.1.1 Before going on to identify resource requirements in future years, a series of efficiency options were tested in the model to allow decisions regarding which
efficiencies should be built into the future year modelling. For these initial runs, a 2015 base model was created. The creation of the base model is described below, before going on to describe the 2015 model results.
8.2 Creating the Base Model
8.2.1 The model validation was based on the 2014 calendar year, and took account of a certain level of ‘dropped shifts’. In order to prepare a more up-to-date
base position, the 2014 validated model was re-based to 2015. This model assumed one year’s demand increase from 2014 to 2015, that all planned shifts were put out by the Service, and reflected recent station
closures/relocations that had occurred between 2014 and 2015.
8.2.2 The performance at each of the shadow targets Metro-wide and at a district level of the new base 2015 model is shown in Appendix E1, and compared to
the validated model. Overall, there is a 2.3% drop in the Delta/Echo performance Metro-wide. This performance fall is driven by the one-year demand increase. The station relocations and the change to planned shifts
had only small impacts on performance.
8.3 Modelling Options
8.3.1 In the 2015 base model position, modelling identified the impacts of:
reducing activation and mobilization times;
reducing times at hospital;
adding an additional 24/7 ambulance to each station individually;
introducing mixed crewing;
introducing ALS-skilled PRUs;
introducing BLS-skilled PRUs; and
increasing the size of the transfer fleet.
Reducing Activation Times
8.3.2 The first efficiency assessed through modelling was the impact of reducing the combined activation and mobilization time – the time between the call being answered in Control and the vehicle being mobilized that arrives on scene first.
In the 2014 sample, this average time for Delta/Echo incidents was 4:13, and was shown in the benchmarking to be long compared to other jurisdictions.
25
8.3.3 Appendix E2a shows the Metro-wide impacts of reductions in these times for five scenarios ranging from 15 seconds to 75 seconds. The positive impact on performance is fairly linear, with Delta/Echo 9-minute response performance
improving by 2.3% with a 15-second reduction (and thus negating the impact of one-year’s demand increase from 2014 to 2015) to an 11.0% improvement when activation times were reduced by 75 seconds. The impact at the higher
time thresholds (eg, 15 minutes for Delta/Echo calls) is less since longer times are less sensitive to (small) improvements in activation and mobilization times.
8.3.4 Modelling runs were then undertaken to identify the resource equivalent of the
activation time improvements, for 15, 45 and 75 seconds. The results are shown in Appendices E2b, E2c and E2d respectively.
8.3.5 The 15-second reduction in average times is equivalent to an additional 504 weekly Alpha car staff hours deployed (calculated here approximately as 15.6 FTE staff based on a 42-hour working week and an estimated 30% relief
factor). The 45-second improvement is equivalent to 57.2 FTE1, and the 75-second reduction to 114.4 FTEs. In terms of response time impact therefore, management effort directed at improving the control and operational
components of the activation and mobilization time would clearly be well rewarded in terms of service improvement. It would also deliver a more efficient operational base in which to invest further resources as required to
meet improved standards.
Reducing Times at Hospital
8.3.6 The second option modelled was the impact on reduced times at hospitals.
Although not completely within the control of BCEHS, it is of interest to see what performance improvement would result from some reductions in this time. Modelling runs here reduced the average time at hospital by 5, 10 and
15 minutes, across all hospitals and hours of the day, but not going below an average level of 30 minutes at any one hospital. The results are shown at Appendix E3a. Response performance improves by between 1.4% and 6.4%
across the different categories, thresholds and time reductions.
8.3.7 The next step then found the approximate resource equivalent for these three levels of time at hospital reduction – see Appendices E3b to E3d. As with the
activation time reductions, these were derived by finding the minimum number of deployed ambulances required to give the same response performance improvement as shown at Appendix E3a. The results are as follows:
5-minute reduction – 672 weekly staff hours (20.8 FTEs1);
10-minute reduction – 1176 weekly staff hours (36.4 FTEs); and
15-minute reduction – 1344 weekly staff hours (41.6 FTEs).
8.3.8 The reason that the larger reductions produce smaller incremental rises in the FTE-equivalent is that the modelling has imposed a minimum of a 30-minute average time at hospital, and several hospitals reach this level after a 5- or
10-minute reduction.
1.1.1
1 See Appendix I glossary for the calculation of FTEs.
Figure 18: Top 25 Additional 24/7 Ambulance Deployment Locations
Station DistrictImpact on 9-minute
Performance
1 242-Richards/St Pauls Vancouver/North Shore l ALS 1.8%
2 249-Surrey/Memorial Hosp Surrey/North Delta/Tricities l ALS 1.8%
3 261-West 7th Vancouver/North Shore l ALS 1.7%
4 248-Cordova Vancouver/North Shore l ALS 1.6%
5 242-Richards/St Pauls Vancouver/North Shore l BLS 1.5%
6 260-New West (12th Street)South
Delta/Richmond/Burnabyl ALS 1.5%
7 244-Vancouver-PearsonSouth
Delta/Richmond/Burnabyl BLS 1.5%
8 243-Arbutus Vancouver/North Shore l ALS 1.5%
9 261-West 7th Vancouver/North Shore l BLS 1.5%
10 260-New West (12th Street)South
Delta/Richmond/Burnabyl BLS 1.4%
11 244-Vancouver-PearsonSouth
Delta/Richmond/Burnabyl ALS 1.4%
12 249-Surrey/Memorial Hosp Surrey/North Delta/Tricities l BLS 1.4%
13 245-Vancouver-KingswaySouth
Delta/Richmond/Burnabyl BLS 1.4%
14 248-Cordova Vancouver/North Shore l BLS 1.4%
15 243-Arbutus Vancouver/North Shore l BLS 1.4%
16 245-Vancouver-KingswaySouth
Delta/Richmond/Burnabyl ALS 1.4%
17 266-North Delta Surrey/North Delta/Tricities l ALS 1.3%
18 246-Burnaby-OrmidaleSouth
Delta/Richmond/Burnabyl BLS 1.3%
19 247-New West (Rousseau) Surrey/North Delta/Tricities l BLS 1.3%
20 258-Burnaby-DouglasSouth
Delta/Richmond/Burnabyl ALS 1.2%
21 250-Richmond-NorthSouth
Delta/Richmond/Burnabyl BLS 1.2%
22 246-Burnaby-OrmidaleSouth
Delta/Richmond/Burnabyl ALS 1.2%
23 266-North Delta Surrey/North Delta/Tricities l BLS 1.2%
24 250-Richmond-NorthSouth
Delta/Richmond/Burnabyl ALS 1.2%
25 258-Burnaby-DouglasSouth
Delta/Richmond/Burnabyl BLS 1.1%
Skill Level
26
Ranking Additional 24/7 ALS and BLS Units
8.3.9 The next model runs involved a series of individual simulations, adding a 24/7 ALS ambulance and a 24/7 BLS ambulance (separately) to each individual
station in turn. No other changes to operational parameters (such as activation times and mobilization times) were assumed.
8.3.10 The Metro-wide and district impacts of 24/7 ALS unit and BLS unit addition are
shown in Appendices E4a and E4b respectively. The best additional deployments have a 9-minute Metro-wide impact of between 1% and 2% and a district impact of between 3% and 6.3%. These impacts are for ‘first on
scene’ to D/E incidents, and there will be an associated improvement in ALS response times to HLA and Red Flag incidents.
8.3.11 The ‘top 25’ additions with the biggest Delta/Echo 9-minute performance Metro-wide (across the ALS and BLS additions) are summarized opposite in Figure 18 and at E4c. The best three additions of ambulance resource in
terms of improving Delta/Echo 9-minute performance are an ALS ambulance at station 242 (St Paul’s Hospital), station 249 (Memorial Hospital) and Station 261 (West 7th). It should be noted that these performance improvements
cannot be added together.
Mixed Crewing
8.3.12 The impacts of mixed crewing were investigated within the model. The
primary reason for investigating these options was concern over the current ALS coverage (see paragraph 5.2.18). In the base 2015 model, only 27.8% of HLA-required calls receive ALS skills on scene within 9 minutes.
8.3.13 Fully mixed crewing (where every ambulance is crewed with an ALS crew member and a BLS crew member) would mean that 48.5% of HLA-required incidents received a response within 9 minutes, and 81.3% within 15 minutes.
Multiple attendance rates would fall, in turn increasing vehicle availability, which produces a performance boost to Delta/Echo calls of 2.9% in 9 minutes.
8.3.14 Currently, ALS ambulances are crewed with two ALS-skilled crew members.
One option would be to ‘split’ or ‘de-couple’ current ALS crews, in effect doubling the ALS ambulance unit provision.
8.3.15 The impact of this has been modelled, with the ‘extra’ ALS crews generated re-
deployed to highly utilized stations that currently only have BLS ambulances. Doubling the number of ALS ambulances in this way raises the number of HLA-required calls receiving ALS skill on scene in 9 minutes and 15 minutes to
41.8% and 72.1% respectively, and raises Delta/Echo 9-minute performance by 1.1%. Currently 16.8% of deployed unit hours are ALS; under this scenario 33.5% of units deployed would have ALS skills.
8.3.16 Mixed crewing (either full mixed crewing or increased ALS deployment through de-coupling existing ALS ambulances) has clear benefits in terms of getting higher clinical skills to those patients who require them in a more timely
manner, and to response performance in general. It does, however, represent a significant challenge in terms of implementation in the short- to medium-term, as it is not permitted by the current collective agreement with staff.
Figure 19: Adding ALS-skilled PRUs
Dispatch Rules
HLA-Required Calls
Other D/E Calls
Other Parameters
l Mobilize 15-seconds quicker than ambulances
l Travel 2% quicker than ambulances
l Spend same time on scene as ALS ambulance
Deployment
l Added to BLS stations only
Target
l 53% of HLA-required calls receiving ALS-skill on scene in 9 minutes
Pass 1
Use base assumptions, with no changes
Pass 2
Pass 3
As Pass 2, but allow PRUs to be deployed at stations with highly utilized ALS ambulances
Figure 20: Summary of ALS PRU Results
1 1680 52 13.4% 14.7% 26.0%
2 1680 52 20.2% 12.3% 23.1%
3 1848 57 20.1% 13.8% 25.6%
HLA 9-min
Improvement
(ALS)
PassStaff Hours
per week
Approx
FTEs
PRU
Utilization
D/E 9-min
Improvement
The following conservative assumptions were also made:
Base Assumptions For ALS-Skilled PRUs
Modelling Steps for ALS PRUs
As Pass 1, but allow PRUs to respond to 'Hot' Bravo/Charlie calls. PRU sent if closest vehicle, and can respond
within 15 minutes
If closest to an HLA call, respond, and back up with nearest ambulance (BLS or ALS)
If BLS ambulance closest, send BLS. ALS-Skilled PRU will 'backup' the BLS ambulance if it can respond within 15
minutes.
Send PRU if closest vehicle. Operate in 15-minute catchments.
27
Introducing ALS-Skilled PRUs
8.3.17 The introduction of Primary Response Units (PRUs) with ALS-skilled paramedics was then investigated within the 2015 base model as a way of
increasing ALS coverage. Single-crewed ALS-skilled PRUs could be introduced to improve the response to calls requiring a higher clinical skill. The model was used to look at the optimum deployment of these resources.
8.3.18 The initial ‘base assumptions’ for modelling ALS-skilled PRUs are shown opposite in Figure 19. In essence, for HLA-required calls, the PRU would respond if closest, and would automatically be backed up by the closest
ambulance (regardless of whether this was an ALS or BLS ambulance). The PRU would also ‘back up’ a BLS response to an HLA-required call if the PRU
could arrive in 15 minutes. For non-HLA Delta/Echo calls, the PRU would respond only if it was the closest vehicle and if it could arrive in 15 minutes. PRUs did not respond to any other call categories than Delta/Echo calls.
8.3.19 These base assumptions were used for the first pass (‘pass 1’). Analysis of the results led to minor changes to these assumptions in ‘passes 2 and 3’ of the ALS PRU options. These changes are also described in Figure 19. A summary
of the pass 1 results is shown in Appendix E5a. A total of 1,680 PRU hours were added per week (seven 24/7 PRUs and six 12/7 day PRUs).
8.3.20 The introduction of PRUs increased the number of HLA-required calls receiving
an ALS response in 9 minutes by 26%, from 28.1% to 54.1%. The increase in Delta/Echo 9-minute response performance was 14.7%.
8.3.21 However, with these rules of operation, the PRUs had a utilization rate of only
13.4%. In pass 2, the rules were relaxed so that PRUs would also respond to those Bravo/Charlie calls that require a ‘Hot’ response according to the RAP.
8.3.22 The results of pass 2 are shown in Appendix E5b. The improvements to ALS
coverage and Delta/Echo performance is reduced slightly, but still provides large gains over the base position. The 15-minute performance improvement to Bravo/Charlie calls has increased from pass 1 now that PRUs also respond
to some of these calls. PRU utilization has increased from 13.4% to 20.2%.
8.3.23 The stations that the PRUs could be added to was limited to BLS stations, since the primary reason for their introduction was to improve the ability to provide
ALS skills when required. However, it was found that during the busiest hours of the day, some ALS ambulances were so utilized that they were frequently unavailable on another job when an HLA-required call occurred within the
station catchment.
8.3.24 In pass 3, two additional 12-hour day PRUs were added to the stations that already deployed ALS ambulances. The results of pass 3 are shown in
Appendix E5c. The PRU utilization remains at 20%, and the two additional day PRUs restore the number of HLA-required calls receiving ALS skills on scene within 9 minutes back to the pass 1 levels.
8.3.25 These results – see summary in Figure 20 – show that adding ALS PRUs is a viable option for future operational development, providing substantial improvements to ALS coverage and response times to high acuity incidents,
and gives good outcome in comparison to the mixed crewing options – see Appendix E5d. Their ‘ranking order’ is shown at E5e.
28
Adding BLS-skilled PRUs
8.3.26 A series of modelling runs were undertaken to identify the potential for introducing BLS PRUs to meet the 75% Delta/Echo 9-minute target. In this
modelling, BLS PRUs were added at stations either 24/7 or for a 12-hour day shift only. PRUs with the largest impact on Delta/Echo 9-minute response performance were added first. As the number of BLS PRUs increases the
marginal impact on response performance diminishes, and it was found to be infeasible to raise the 9-minute D/E response to 75 percent given the current operational parameters.
8.3.27 The results in Appendix E6 show the ranked order for adding PRUs (best first) and that by adding 1,428 deployment hours per week (equivalent to about 44
FTEs) the 9-minute Delta/Echo (D/E) response time percentile would improve by 10.8% to 62.2% with a 4.1% rise in the 15-minute percentile. The utilization achieved by these PRUs would be 22.5%. Adding a further ten 12-
hour day shifts (roughly another 26 FTEs) would raise these response percentages further by 5% and 2% respectively and give an overall PRU utilization of 19.5%.
8.3.28 This option is less favourable than the option for adding additional ALS PRUs. Although it raises the ‘first on scene’ response performance to Delta/Echo calls, it does not improve ALS response to high acuity calls. The ALS PRU
option does both.
Increasing the Size of the Transfer Fleet
8.3.29 In the base position, 560 Transfer unit hours are deployed per week across 11
stations. Typically, 65% of the transfer work is undertaken by BLS units, and 30% by Transfer units (the other 5% is undertaken by other units, such as ITTs, CTTs and ALS ambulances).
8.3.30 The approach taken here was to first increase the number of transfer units so as to improve the standard of service to transfer patients, and to do this to a point where additional units were only having a small marginal impact. Once
this had been done, the number of BLS units were then reduced to the point where emergency response standards reverted to the base position.
8.3.31 Stations and shifts where BLS units undertook a significant level of transfer
work were chosen as the candidates for adding a Transfer unit. In total an additional 1440 Transfer unit hours were added per week (see E7a-i), across seven locations, mostly Monday to Friday (see E7a-ii). Five units were added
in the evenings/nights and at weekends.
8.3.32 The impacts are shown at Appendix E7b. In this position, Transfer units account for 15% of BLS/Transfer unit deployments and they undertake 74% of
transfer work across Metro (80% of Mainland transfers). The maximum number of transfers undertaken by a BLS station falls from 4.0 to 1.4 per day. The tables at E7b show the performance improvement resulting from this
measure; as well as transfer standards improving for all categories by a few percentage points, there would be an emergency response improvement because of a lower BLS utilization across all categories (see bottom table in
Appendix E7b).
Figure 21: Response Performance Gap to Shadow Targets
Delta/Echo Current Target Difference
9 minutes 51% 75% 24%
15 minutes 86% 95% 9%
Bravo/Charlie Current Target Difference
15 minutes 64% 75% 11%
30 minutes 90% 95% 5%
Alpha/Omega Current Target Difference
30 minutes 81% 75% -
60 minutes 95% 95% -
29
8.3.33 The second pass of the Transfer unit modelling involved reducing BLS units until emergency response standards fell back to the base position. It was found that 644 BLS unit hours per week could be removed per week. The
resulting hourly deployment and the specific BLS removals are shown in Appendices E8a-i and E8a-ii respectively.
8.3.34 The net impacts are shown at Appendix E8b. The response profile for
transfers remains the same. There is now no improvement in Red transfer standards, nor in emergency response standards, but still an improvement in the standard to Yellow, Green and Blue transfers, if only by a few percentage
points.
8.3.35 The conclusion reached is that in the context of emergency response standards
and Red transfer standards needing to improve, it is not a cost-effective strategy to introduce more tiering into the BLS and Transfer unit system. An investment of about 60 staff is not giving sufficient return in terms of an
improvement in transfer standards. Such an improvement is best achieved alongside an improvement in emergency response and Red transfer standards by introducing more BLS units across the Metro Mainland area.
8.4 Achieving the Shadow Targets in 2015
8.4.1 Modelling runs were undertaken to identify the additional resource requirements required to achieve the shadow response targets. The current
gap with the base 2015 position is shown in Figure 21 opposite.
8.4.2 The initial modelling assumed no efficiencies or changes to operational parameters (such as activation times, times at hospital or times on scene).
Given the results of the option modelling discussed in sub-section 8.3, it was decided to meet the targets through deployment of additional BLS ambulances and the introduction of ALS-skilled PRUs.
8.4.3 The performance achieved through additional deployments is shown for all shadow targets Metro-wide and at a district level in Appendix E9a. All shadow targets are being achieved Metro-wide. The resource levels in Surrey, North
Delta and the Tricities were found to be low compared to the requirement to achieve performance efficiently, and so this district received many additional resources and sees the biggest increase in Delta/Echo 9-minute performance
of 42.5%.
8.4.4 Day-by-hour deployment summaries, comparing the base deployment against the deployments required to meet targets, are shown in Appendix E9b. No
ALS ambulances or Transfer units were added. An additional 1,776 BLS ambulances and 2,816 ALS-skilled PRU vehicle hours were added per week. This is roughly equivalent to 110 BLS staff FTEs and 87 ALS staff FTEs – in
total just under 200 additional staff. The peak ALS car deployment would be 26, and the BLS unit peak deployment increases by 14.
8.4.5 The impacts on vehicle utilization and HLA response are shown in Appendix
E9c. Utilization rates fall across all vehicle types, with BLS ambulances seeing the biggest fall (7.8%). The ability to get ALS skills on scene to HLA-required
calls is also much improved. The number of HLA-required calls receiving an ALS response within 9 minutes has increased by 14% to 60%.
30
9 MODELLING 2017 AND 2020
9.1 Modelling for 2020
9.1.1 The base 2020 model was created by:
increasing the demand to the 2020 projected demand level;
implementing expected station changes; and
implementing an 80-second reduction in the combined activation and mobilization time.
9.1.2 The overall increase for emergency demand is expected to be 6.1% per year, although some areas see higher or lower demand increases dependent on the forecast population growth and expected changes to the age profile. Transfer
demand is projected to increase by 2% per annum.
9.1.3 Future station changes implemented within the 2020 model include the relocation of station 246 and 260 in Burnaby in 2017.
9.1.4 In agreement with the Service, an 80-second reduction in activation/ mobilization times was assumed to be in place by 2020. This is to occur in a gradual manner over the following years (see Figure 10 opposite page 14).
9.1.5 The performance output of the base 2020 model is compared to the base 2015 model in Appendix F1a. Metro-wide 9-minute performance is expected to fall by 15.2%, to 33.0%. Performance in South Delta, Richmond and Burnaby has
the lowest predicted Delta/Echo performance of 20.9% within 9 minutes.
9.1.6 The call categories with the biggest falls are the Alpha/Omega standards, which are sacrificed in an attempt to sustain Delta/Echo performance. The
Alpha/Omega response performance is predicted to fall by over 50% in 2020.
9.1.7 Modelling runs were then undertaken to identify the resources required to meet the shadow targets in 2020. It was assumed during this modelling that
ALS PRUs could not be deployed 24/7 and could only be deployed during the hours of 06:00 and 02:00.
9.1.8 The resulting performance achievement with the additional resources for all
shadow targets is shown in Appendix F1b. All targets are met Metro-wide.
9.1.9 The increase in deployment (by day and hour) is shown in Appendix F1c.
Given the results of the option modelling (sub-section 8.3), only BLS ambulances and ALS-skilled PRUs were added to meet targets; the number of ALS ambulances and Transfer vehicles remains the same as the current
deployment levels.
9.1.10 To meet targets in 2020, an additional 3,792 BLS ambulance hours and 1,314 ALS PRU hours are required per week (above current deployment levels) to
ensure that all targets are met. This is a different profile from that found for 2015 (see sub-section 8.4), requiring significantly more BLS ambulances. This is driven by the projected demand increase, which in turn requires more
vehicles to be deployed that are capable of transporting patients to hospital.
31
9.1.11 In overall resource terms, this result indicates the need for the following increase in resource levels by 2020:
an additional 235 BLS FTEs;
an additional 42 ALS FTEs;
12 ALS PRU vehicles (the peak deployment) plus relief; and
an additional 29 BLS unit vehicles (additional peak deployment) plus
relief.
9.1.12 Fewer ALS PRUs are needed than in the 2015 modelling (see paragraph 8.4.4) because of the impact of the improved activation and mobilization times here.
The exact deployments are shown at Appendix F1d.
9.1.13 To meet the targets in 2020, additional locations have been identified to
improve emergency incident coverage. In all bar one case, existing cross-cover points that are particularly well-located in relation to demand have been utilized. It will be necessary to aim to provide facilities at these locations
(either in the form of a station or a facilitated Annex), to allow the sites to be utilized 24/7. One new location, in Fraser Valley, has also been identified. These changes to the station configuration are discussed in more detail in
Section 10, including proposals for introducing hub and spoke arrangements to accommodate the extra resources efficiently whilst giving the deployments at optimal locations to allow the targets to be met efficiently.
9.1.14 It was also found that an additional BLS vehicle was required at station 247 which is already at full vehicle capacity, but where there is potential for the station to be relocated at the Royal Columbian Hospital. This relocation was
built into the 2020 modelled scenario on the assumption that the new site would have capacity for a third vehicle.
9.1.15 With these first on scene ‘shadow targets’ being met in 2020, given the
deployments and assumptions modelled, there will be associated benefits for HLA incident response and Red Flag incident response, together with a reduction in the waiting time for First Responders.
9.1.16 ALS skilled response is currently made to 58% of HLA incidents with a 9-minute response performance of 27.8%. These percentages would rise to 83% and 50% respectively.
9.1.17 Red Flag incidents would have a first on scene 9-minute response percentage of about 78.5%, comfortably within target, and an ALS 9-minute response percentile of 58% (currently 37%).
9.1.18 In terms of the change in the response profile expected for joint responses from BCEHS and First Responders (FRs) the following change is estimated from the modelling:
For Delta/Echo incidents, the FR currently arrives first on 72% of occasions (2015 modelled) and this would fall to 47%, with an associated change in the average waiting time (when arriving first) from
4:37 to 3:11 (minutes:seconds).
Figure 22: New Locations for 2017
Well-Located Cross Cover Points
Code District Nearby Station(s)
XCCLA Fraser Valley 205 (Mt Lehman)
XCFRA Surrey/North Delta/Tricities 249 (Surrey/Memorial Hosp)
XCKING Surrey/North Delta/Tricities266 (North Delta)
253 (Surrey/Cloverdale)
XCMCB Surrey/North Delta/Tricities 247 (New West/Royal Columbian Hosp)
XCNOR Surrey/North Delta/Tricities 247 (New West/Royal Columbian Hosp)
XCSTE South Delta/Richmond/Burnaby
250 (Richmond North)
251 (Delta Ladner)
269 (Richmond/Williams)
XCTUR Surrey/North Delta/Tricities 247 (New West/Royal Columbian Hosp)
New Locations
Name District Nearby Station(s)
Vedder Crossing Fraser Valley 206 (Chilliwack)
32
For Bravo/Charlie incidents, the FR currently arrives first on 80% of occasions (2015 modelled) and this would fall to 52%, with an associated change in the average waiting time from 9:23 to 6:01.
9.2 Modelling for 2017
9.2.1 Modelling runs have been undertaken to illustrate likely response performance
achievement in 2017. Two runs have been undertaken: one assuming that no additional resources are deployed, but that activation time reductions of 30 seconds (in line with Figure 10) have been realized, and one assuming some
increased level of deployment, in line with those required for 2020.
9.2.2 The likely performance achievement in the base 2017 position is compared to the base 2015 position in Appendix F2a. The base 2017 position includes the
2017 demand forecast, a reduction in activation/mobilization time of 30 seconds, and the relocation of the Burnaby station (which is expected to occur at some point in 2017).
9.2.3 In 2017, with no additional resources, Delta/Echo performance at the 9-minute standard is expected to fall by 4.7%, to 43.5%. As before, the Alpha/Omega targets see the biggest reduction, with falls of around 20% to 25%. These
falls in performance are compared with the 2015 base position.
9.2.4 In the second 2017 run, some of the deployments identified as required to meet targets in 2020 were introduced. In this run, all of the ALS-skilled PRUs
were added (as this represents the most cost-effective measure), as well as any BLS units associated with new locations (ie, optimally-located cross-cover points and a new location in Fraser Valley – see Figure 22 opposite).
9.2.5 The response performance achieved through these additional deployment levels are shown in Appendix F2b. None of the shadow targets are met, although the longer standards for Delta/Echo and Bravo/Charlie (15 minutes
and 30 minutes) are very close to target, at 92% to 93%.
9.2.6 The deployment profile by vehicle type, day and hour is shown in Appendix F2c. The deployments modelled here include 564 BLS hours per week above
the current level, and the recommended 1,344 PRU hours per week.
9.2.7 The additional resources required to meet this improved position for 2017 under the assumptions stated are:
35 BLS FTEs;
42 ALS FTEs;
12 ALS PRU vehicles (peak deployment) plus relief; and
4 BLS unit vehicles (additional peak deployment) plus relief.
9.2.8 To meet the standards projected for 2017, additional locations have been identified to improve emergency incident coverage. In all bar one case,
existing cross-cover points that are particularly well-located in relation to demand have been utilized. It will be necessary to aim to provide facilities at these locations (either in the form of a station or a facilitated Annex), to allow
Fig
ure 2
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33
the sites to be utilized 24/7. One new location, in Fraser Valley, has also been identified. These changes to the station configuration are discussed in more detail in Section 10.
9.2.9 With these first on scene standards being met in 2017, given the deployments and assumptions modelled, there will be associated benefits for HLA incident response and Red Flag incident response, together with a reduction in the
waiting time for First Responders which will still arrive first on scene in the majority of cases.
9.2.10 ALS skilled response is currently made to 58% of HLA incidents with a 9-
minute response percentile of 27.8%. These percentages would rise to 70% and 47% respectively.
9.2.11 Red Flag incidents would have a first on scene 9-minute response percentage of about 70% (outside the planned 75% target) and an ALS 9-minute response percentile of 53% (currently 37%).
9.2.12 In terms of the change in the response profile expected for joint responses from BCEHS and First Responders (FRs) the following change is estimated from the modelling:
For Delta/Echo incidents, the FR currently arrives first on 72% of occasions (2015 modelled) and this would fall to 59%, with an associated change in the average waiting time from 4:37 to 3:45
(minutes:seconds);
For Bravo/Charlie incidents, the FR currently arrives first on 80% of
occasions (2015 modelled) and this would fall to 62%, with an associated change in the average waiting time from 9:23 to 6:47.
9.3 Alternative Scenarios
9.3.1 The two sub-sections above give a development path towards achieving the ‘shadow targets’ in 2020, with improved standards by 2017. This identifying and realising efficiency improvements in Control, and requires significant
investment in ALS and BLS resources, both staff and vehicles.
9.3.2 This sub-section describes the results of modelling runs that examine alternative scenarios through 2017 to 2020:
a) What if no improvement in Control activation/mobilization times were achieved, and no new resources invested in?
b) What if no new resources were invested in, but the
activation/mobilization time improvements were achieved?
c) What if only the ALS PRUs identified were added, and the activation/mobilization time improvements still achieved?
9.3.3 The results of these modelling runs are summarized opposite in Figure 23 for both the ‘core’ emergency demand projection (6.1 per cent per annum) and a lower demand projection (4.2 per cent per annum – see paragraph 6.3.9).
Figure 25: First Responder Waiting Times by Scenario
Year Scenario
%age FR first Wait Time %age FR first Wait Time
2015 Current 72% 4:37 80% 9:29
2017 Recommended (i) 59% 3:45 62% 6:47
No New Resources
No AT Reduction
No New Resources
30-second AT Reduction
ALS PRUs
30-second AT Reduction
2020 Recommended (ii) 47% 3:11 52% 6:01
No New Resources
No AT Reduction
No New Resources
80-second AT Reduction
ALS PRUs
80-second AT Reduction
(i) 35 BLS FTEs plus 42 ALS FTEs
(ii) 235 BLS FTEs plus 42 ALS FTEs
AT = combined reduction in activation and mobilization times
Core demand projection assumed
Delta/Echo Bravo/Charlie
2017 87% 5:53 92% 11:46
2017
2017
2020
2020
2020
11:5792%5:3885%
19:1794%
72% 86%4:12 9:41
8:08 98%
89%
97%
6:24 98% 18:12
80% 4:49 16:44
34
9.3.4 Under all scenarios, for all six measures, the standard achieved by 2020 is short of the ‘shadow targets’ in 2020.
9.3.5 Figure 23 shows that Delta/Echo 9-minute standard will fall from its current
value of 51% for Options 1 and 2, but that the addition of just ALS PRUs (Option 3) will maintain or improve the standard under the different assumptions. However, in all scenarios it can be seen that Bravo/Charlie and
Alpha/Omega standards fall to much lower levels, particularly by 2020.
9.3.6 The impact of these options using the core demand projection of 6.1% per year on the average response time and the 95th percentile response time is
summarized below in Figure 24.
9.3.7 The impacts of these different options on First responder waiting times, again
with the core demand projection used, is summarized opposite in Figure 25. The recommended position means that First Responders will be first on scene on about half of occasions by 2020 and their average waiting times will be
reduced by about one third. The other scenarios increase the average waiting time and the percentage of occasions that First Responders have to wait.
Figure 24: Average and 95th Percentile Response Times
Year
Activation
Time
Reduction
Additional
Resources
Average Time
for BCAS 1st Response
(D/E Calls)
95th Percentile
for BCAS 1st Response
(D/E Calls)
2015 No Change No Change 10:17 19:54
No Change No Change 11:27 22:13
30 seconds No Change 11:03 21:54
30 seconds ALS PRUs Only 09:12 19:39
No Change No Change 15:07 30:05
80 seconds No Change 13:54 29:10
80 seconds ALS PRUs Only 10:41 25:02
80 seconds
Full Resources
For Shadow
Targets
07:09 14:44
All times in minutes : seconds
Note: Core emergency demand projection of 6.1% per annum assumed here
2020
2017
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10 STATION CONFIGURATION MODELLING
10.1 Station Database
10.1.1 Details of the stations used by the ambulance service were provided to ORH, including details of ownership, contract termination dates (where appropriate)
and vehicle capacity. These data have been combined with the model results for 2020 (with the deployments required to reach the shadow response targets) to indicate areas where capacity issues may arise.
10.1.2 This combined ‘station database’ is shown in Appendix G1. The fields include (in order):
The station code (typically a 3-digit number)
The station name
The peak (ie, maximum deployed at any one time) deployment by vehicle type in the base position
The peak deployment in the 2020 (in the meeting shadow targets position), by vehicle type
The station code (repeated for reference as the table runs over two
pages)
The ownership of the station
The contract termination date
The total ‘peak’ deployment in the base position (across all vehicle types)
The total ‘peak’ deployment in the 2020 position
The change in the peak deployment between the two positions
The maximum vehicle capacity of the station
The capacity shortage at the site in 2020 (the amount by which the
peak deployment in 2020 exceeds the maximum vehicle capacity)
10.1.3 Commentary on the stations exceeding capacity in the 2020 position is first provided in this sub-section.
10.1.4 To meet performance targets efficiently, improvements to the emergency incident coverage was found to be required. Some of the services current
‘cross cover’ points were found to be well-located in terms of access to emergency incidents. In the 2020 modelling runs, these sites were used for unit deployments (sometimes 24/7). Since these cross-cover points are
typically road-side locations with no facilities, it is proposed that the service should look to provide facilities (either as a station or an annex) to allow vehicles to be deployed from these locations.
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10.1.5 In addition to the cross-cover points, an additional location was identified in Fraser Valley located to the south of Chilliwack near the ‘Vedder Crossing’. This site would also need to be facilitated, although is not used 24/7, so may
be well suited to being an ‘Annex’ location.
10.1.6 The map at Appendix G2a shows the base station locations (small white circles), and shows those locations in 2020 that have additional deployment
compared to the base, differentiating those stations that receive additional BLS deployment, additional PRU deployment, or both, as larger coloured circles.
Stations Exceeding Capacity in 2020
10.1.7 The map at Appendix G2b highlights the locations that exceed capacity (as given in the station database in Appendix G1).
10.1.8 There are some clusters of locations where capacity is exceeded that may have the potential for developing into a ‘hub and spoke arrangement’. Where this is the case, this is noted in the following paragraphs. Potential hub-and-spoke
locations are discussed in more detail in sub-section 10.2.
10.1.9 Station 205 (Mt Lehman) receives a PRU in the 2020 scenario, which exceeds the capacity since the station is currently at its maximum capacity of
four vehicles. This station is leased, and the contract expires at the end of May 2017.
10.1.10 Station 244 (Pearson) receives a PRU in the 2020 scenario, which exceeds
the capacity at this location since the station is currently at its maximum capacity of three vehicles. This site is owned by ‘OBLL’, and the contract does not end until 2030. However, the annual rent for the site is $1, and it may be
possible to negotiate an additional vehicle bay at the hospital, or find an alternative location. Alternatively, there could be some potential for a hub and spoke arrangement in this area.
10.1.11 Station 250 (Richmond North) has recently been vacated. However, this location was found to be well-located in terms of incident coverage, and receives additional BLS and PRU deployments. It is recommended that a
replacement location be found in this area, with capacity for six vehicles. Alternatively, there is some potential for a hub and spoke arrangement here.
10.1.12 Station 258 (Burnaby/Douglas) has five peak vehicles in the base position,
but the maximum capacity of the station is listed as two. An additional PRU has been deployed at the station in the 2020 scenario. This results in the station exceeding capacity by four although, since the site currently seems to
exceed capacity by three vehicles, it is not clear what the actual capacity shortage in 2020 would be.
10.1.13 An additional BLS has been deployed at station 270 (YVR Airport) in the
2020 scenario. Although an ambulance here may not contribute to the 9-minute performance standard at the airport (due to the ‘pre-alert’ nature of many of the incidents that occur here), a vehicle deployed here would prevent
other ambulance vehicles being pulled in to the airport for transports. Currently, there is no room for an ambulance at the airport (paramedics respond on mountain bikes), but there is potential to develop a designated site
for an ambulance in the future. The modelling in the 2020 scenario supports this. There is some potential for a hub/spoke arrangement in this area as well.
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10.1.14 An additional BLS ambulance has been located at station 247 (currently New West – Rousseau). The deployment of this additional ambulance would result in the station being over capacity. However, there is potential to
relocate the station to the Royal Columbian Hospital. This relocation was built into the 2020 scenario, on the assumption that such a relocation would then allow a third vehicle to be deployed at the hospital site.
10.1.15 Station 253 (Cloverdale) receives an extra PRU to allow targets to be met in the 2020 scenario, which results in capacity being exceeded by one vehicle. The lease on this site is due to expire at the end of November 2015.
10.1.16 Station 254 (Surrey/White Rock) receives an additional BLS ambulance in the 2020 scenario, exceeding capacity by one. The lease on this station ends
at the end of April 2016.
10.1.17 Station 260 (New West) is currently located within a hotel, and has one BLS ambulance. By 2017, this station will close (along with station 246), and with
the vehicle there relocating to the new Waltham-Burnaby site. Whilst performance targets can still be met in 2020 without a station at or near the current 260 site, a station in this area would significantly boost emergency
incident coverage. If a site could be found here, up to three vehicles (2 BLS and a PRU) could be re-deployed from the Burnaby location to this area.
10.1.18 Station 263 (Port Coquitlam) receives many additional BLS units in the
2020 scenario, exceeding current capacity by two vehicles. A hub/spoke arrangement is recommended in this area, which would replace this location with other locations in the area. This site is owned by SSBC. No contract
termination date has been provided for this location.
10.1.19 Station 266 (North Delta) receives a PRU in the 2020 modelling scenario, and will be over capacity by one vehicle. The contract termination date for this
property is the end of April 2016. There is potential for a hub and spoke arrangement in this area.
10.1.20 Station 242 (Richards) has been vacated, and the current St Paul’s Hospital
is being used as a standby/annex facility. This location is key for providing cover to the city area, and more vehicles will be required by 2020. It is strongly recommended that a hub and spoke arrangement be incorporated in
this area, potentially taking advantage of the new St Paul’s Hospital being built, since other nearby stations in this area also receive additional deployments in the 2020 scenario.
10.1.21 Station 261 (West 7th) receives additional BLS ambulances and a PRU in the 2020 scenario, and is expected to be over capacity by three vehicles. This location is similar to station 242 described above, in that it would also be a
strong candidate for inclusion in a hub and spoke arrangement based around a site at or near the new St Paul’s Hospital development.
10.1.22 In addition to the stations above, the following cross-cover points were found
to provide significant benefits to incident coverage: XCCLA; XCFRA; XCKING; XCMCB; XCNOR; XCSTE; XCTUR.
Fig
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10.1.23 Efforts should be made to provide facilities at these locations by 2017 (either as a station or as an annex) to ensure vehicles can reliable be deployed to these locations. An additional new location was also identified in Fraser Valley,
south of Chilliwack. This location would be suitable for as use an annex location.
10.2 Configuration Modelling Results
Riverview
10.2.1 There is potential to replace stations 259 (Port Moody) and 263 (Port
Coquitlam) with a hub and spoke system, with the hub based at Riverview Hospital. This was investigated in the 2020 model scenario.
10.2.2 Riverview Hospital is located close to station 259. If no additional sites are
added to the configuration, this is very similar to the impact of simply closing station 263 and relocating the vehicles to 259, and would result in a performance fall.
10.2.3 The modelling identified that the cross-cover points ‘XCCOM’ and ‘XCCOQ’ were well located for emergency coverage. If locations could be found at, or close to, these locations, these could operate as spokes to a hub located at
Riverview Hospital, and would provide improved response coverage in this area with the same level of resources.
Potential Hub and Spoke Clusters
10.2.4 Five potential hub and spoke clusters were identified. These are shown opposite in Figure 26, in the shaded areas. These have been classified into three groups; strongly recommended (green), strong possibility (orange) and
possible (red). The clusters are described below.
10.2.5 Stations 242 and 261 will be over capacity by 2020, as additional resources are required to provide cover in the city as demand increases. Station 242 is a
particularly important location, which needs to be resourced appropriately. This cluster (Cluster A in the map opposite) would involve three response locations (stations 242, 248 and 261). The new St Paul’s Hospital site would
be a natural site for a hub, being relatively central in terms of location to the three spokes. There may be potential for the ambulance service to acquire space as the new hospital site is developed. Depending on the available space
available to the ambulance service at the new hospital site, further use could be made of station 248, which has capacity for nine vehicles.
10.2.6 Due to the lack of capacity at key stations 242 and 261, and the difficulty in
finding property in this area, it is recommended that the service consider a hub and spoke system to ensure that the required number of vehicles can be deployed here.
10.2.7 Modelling has shown that the introduction of a hub and spoke system at Cluster B, utilizing Riverview Hospital as a hub and using spokes near to the cross-cover points XCCOM and XCCOQ improves response coverage in this
area. It is recommended that the service considers a hub and spoke system here.
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10.2.8 The proposed Cluster C revolves around the introduction of more permanent ambulance presence near to the current cross-cover points XCMCB, XCNOR and XCTUR. Central to these three new locations is the Royal Columbian
Hospital, which station 247 is due to relocate to. Therefore, the possibility of developing a hub at the hospital as part of the relocation should be considered by BCEHS.
10.2.9 The proposed Cluster D includes station 266 (which will be over capacity in 2020), and a new facilitated location close to the cross-cover point XCFRA. The possibility of utilizing station 249 as a hub (relocated to the Memorial
Hospital) should be considered.
10.2.10 The proposed Cluster E includes three locations, all with capacity issues.
Station 250 has recently been vacated, but is an important site in terms of incident coverage and contribution to response performance. Station 244 (Pearson) will be over capacity by 2020, and the modelling has identified that
an ambulance should be located at the airport. There may be potential to develop a hub to feed these locations at the Dogwood Pearson redevelopment (a health village near station 244), and this should be investigated by the
ambulance service.
Phasing Change
10.2.11 The order in which the above hub and spoke clusters are implemented will
depend on other factors as well as resource capacity and response coverage considerations.
10.2.12 The modelling for 2017 reported at sub-section 9.2 has assumed that there
will be sufficient capacity to introduce an ALS PRU resource tier together with some BLS unit additions (see Figure 22).
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11 SENSITIVITY MODELLING
11.1 Introduction
11.1.1 The modelling results presented in Sections 9 and 10 are based on a number of assumptions that have been made based on the results of critical analysis
and appropriate benchmarking, then agreed with the BCEHS Steering Committee.
11.1.2 However, in taking time horizons to 2017 and 2020, and acknowledging that
the value of some of these key input parameters is uncertain when projected to these future years, it is worthwhile undertaking some ‘sensitivity modelling’ to test the impact of variation in key factors.
11.1.3 In this section, referencing Appendix H, the following factors are tested in the modelled 2020 scenario for meeting targets:
an improved activation/mobilization time reduction;
a reduced time at hospital;
a reduced demand projection increase; and
further improvement to Fraser Valley standards.
11.2 Sensitivity Modelling Results
Improved Activation/Mobilization Time
11.2.1 The main modelling used a reduction in the average activation/mobilization
time of 80 seconds (applying specifically to Delta/Echo incidents, but assuming commensurate reductions for other incident types). The modelling results
shown at Appendix H1 assume a 100-second reduction in the 2020 scenario.
11.2.2 As can be seen at H1a, this would give an improved Delta/Echo 9-minute response percentile of 78.0% Metro-wide – an improvement of 2.4% – with
improvements in all districts for all incident categories.
11.2.3 This would be translated into a resource equivalent of 252 ALS PRU hours per week and 168 BLS unit hours per week (see H1b). So to meet response
targets in 2020 with a 100-second reduction in activation/mobilization times would require 8 fewer ALS staff and 10 fewer BLS staff compared to the figures shown at paragraph 9.1.11.
Reduced Time at Hospital
11.2.4 The impact of reducing time at hospital to no longer than a 30-minute average at any hospital has a more significant impact than increasing the activation/
mobilization time reduction by a further 20 seconds as shown at Appendix H2a. As can be seen, the benefit of the increased availability of ALS and BLS units gives response standard improvements across all categories, with more
significant improvements for the lower acuity incidents.
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11.2.5 The resource equivalent of this is set out in Appendix H2b – 624 BLS unit hours per week and 252 ALS PRU hours per week. So, if such a reduction in time at hospital could be achieved by 2020, the paragraph 9.1.11 staff
requirements would reduce by 39 BLS staff and 8 ALS staff.
Reduced Demand Projection
11.2.6 The demand projection made in this review gives an annual emergency
demand increase of 6.1% (see Section 6). This takes account of the projected population increases and age profile changes by LHA, and also of the increasing demand rate per head of population that has been measured for the
last few years. From a 2014 base position, this gives an emergency demand increase of 19.4% in 2017 and 42.5% in 2020.
11.2.7 An alternative projection can be made that assumes no increase in the basic demand rate per head of population in each age/sex group. The impact of the increasing population and increasing proportion of elderly alone would then
drive the demand change. Such an assumption would give an annual projected increase in emergency demand of 4.2%: 13.1% by 2017 and 28.0% by 2020 from the 2014 base.
11.2.8 The results of using this alternative projection are shown at Appendix H3. The improvement in standards (H3a) seen is very similar to that shown for reduced time at hospital at H2a. The resource impact for 2020 – see H3b –
would be for 8 fewer ALS staff and 49 fewer BLS staff required for 2020.
Further Improvement to Fraser Valley Standards
11.2.9 The main modelling projections for 2020 which achieve the ‘shadow targets’
Metro-wide, including a 75th percentile achievement for the Delta/Echo 9-minute response time, result in a 60th percentile achievement for Fraser Valley (currently 41.1%).
11.2.10 Modelling work was undertaken to find the minimum additional resources required to raise the 60% Delta/Echo 9-minute achievement in Fraser Valley to 65% and to 70%. The performance outputs are shown in Appendices H4a-i
and H4a-ii respectively.
11.2.11 The resource requirements to achieve these improved standards in Fraser Valley are shown at Appendix H4b:
65% - 196 ALS PRU hours per week (6 FTEs);
70% - 546 ALS PRU hours per week (17 FTEs).
11.2.12 The expected utilization of the additional PRUs would be relatively low:
for 65% - one 12/7 PRU at 13%, one 20/7 PRU at 20%; and
for 70% - one 12/7 PRU at 10%, one 20/7 PRU similar to the one
above, and an additional 12/7 PRU which would be 11% utilized.
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12 SUMMARY
12.1 Overview of Review
12.1.1 This analysis and modelling review of Metro Ambulance operations has been undertaken by ORH in parallel with a review of Aeromedical service provision
across British Columbia. The review has been conducted over a five-month period starting in March 2015.
12.1.2 The tendered requirement called for comprehensive analysis of current
provision to give BCEHS an in-depth quantitative understanding of the service, together with recommendations for future development covering service standards, station locations and resource deployments. Proposals for
improving the equity, efficiency and effectiveness of service provision were required [Section 2].
12.1.3 The approach taken was to take 2014 as the sample year, first gathering a
wide range of data to quantify service provision. This included CAD activity and workload data, resourcing data and key geographic data for BCEHS Metro Ambulance and for the Fire Services that provide First Responder (FR) support
across the area. These data were subject to wide-ranging analysis, the results of which were presented in a series of Progress Reports that were discussed with a BCEHS Working Group, a BCEHS Steering Committee and, for the FR
analysis, with Metropolitan and Fire Service representatives [sub-sections 3.1 and 3.2].
12.1.4 The analysis allowed the relationship between resources deployed, demands
met and response standards achieved to be exemplified. It also was geared to creating and validating a model of Metro operations which was used in simulation and optimization modes to identify and assess options for change
[sub-sections 3.3 and 3.4].
12.1.5 The results of the BCEHS analysis were validated by the Service and gave the base 2014 position for the review, allowing current output indicators to be
discussed [see sub-sections 4.1 to 4.3]. A separate stream of Progress Reports on FR activity allowed that analysis to be validated and gave insights
into the combined response of FRs and BCEHS ambulances [sub-section 4.4].
12.1.6 An appraisal of current service provision was then undertaken, highlighting where efficiency and effectiveness needed to improve. This was supported
with some benchmarking comparisons. This appraisal informed the identification of options for modelling [Section 5].
12.1.7 A demand projection was made to 2020, using historical trends coupled with
forecast population profiles [Section 6].
12.1.8 Once the model for Metro operations was prepared and validated [Section 7], it was used to assess a wide range of options in the current 2015 year [Section
8] and also in 2017 and 2020 [Section 9].
12.1.9 Specific modelling runs examined issues relation to the station configuration [Section 10] before finally undertaking sensitivity modelling [Section 11].
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12.2 Current Service Profile
12.2.1 The current service profile is described in Section 4 and appraised in Section 5.
Demand and Resource Use
12.2.2 In 2014 Metro Ambulance responded to an average of 827 incidents per day: 714 emergency response and 113 transfers. Mainland Metro accounts for 86%
of this demand, and Metro Island 14%.
12.2.3 The highest acuity Delta/Echo incidents make up a quarter of emergency responses, with Bravo/Charlie 43% and Alpha/Omega, the least acute
category, 31%. Red and Yellow transfers account for about 30% of transfer workload, with 70% categorized as Green or Blue (the least urgent).
12.2.4 The hourly demand frequency across emergency and transfer cases ranges
from 16 to 50 per hour across the 24-hour period. The geographic demand pattern is highly clustered in the more urban districts and more scattered towards Fraser Valley.
12.2.5 Fire Service First Responders (FRs) are used extensively, responding to 243 Metro incidents per day (across 17 Fire Services covering Metro Vancouver); the RAP identifies 29% of incidents as ‘FR appropriate’.
12.2.6 There are 37 ambulance stations, most at or close to capacity, and 36 ‘cross-over points’ used for standby. Six ‘annexes are also used for unit deployments. ALS units are deployed to 13 stations (2,520 unit hours
deployed per week), BLS units to all stations (11,251 unit hours per week), and Transfer units to 11 stations (560 unit hours per week).
12.2.7 The utilization of ALS units is 30.5%, which is relatively low for a metropolitan
area, and BLS units are 52.1% utilized (broadly average). This tiering structure between ALS and BLS does not give good ALS cover to the Metro area. For example, 21% of incidents require an HLA response but, of these,
only 25% receive a first response from an ALS unit. ALS do not respond at all to 54.3% of Delta/Echo incidents, and when they do this is most often after the BLS unit has arrived on scene.
12.2.8 Transfer units undertake 30% of transfers, with BLS units undertaking the rest. ALS units do not undertake transfer work.
12.2.9 Non-conveyance rates are relatively low (when benchmarked) at 20%, and the
relatively low average time at scene of 17 to 18 minutes is associated with this. If more on-scene assessment were to be practiced then the times at scene would lengthen, the non-conveyance rate would fall, and there would be
fewer ambulance-borne emergency department attendances.
12.2.10 There is a high multiple attendance rate of 1.44 for Delta/Echo incidents (most typically a BLS unit arriving first on scene followed by an ALS unit).
12.2.11 The average time at hospital, including ‘offload’ delays, is 37 minutes, but there is a high variation by hospital and across the hours of the day – at least 10% are longer than an hour. The assumption agreed was that the current
times at hospital would neither shorten nor lengthen in the future.
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Response, Activation and Mobilization
12.2.12 Response times are measured from the time the call is answered to the first vehicle on scene. A nominal target of 90% within 9 minutes is set for
Delta/Echo calls (currently 51.2%), and a more formal target of 75% within 9 minutes for ‘Red Flag’ incidents (currently at 65%). Realistic targets need to be set based on best practice to allow resource plans to be developed.
12.2.13 There is significant variation in response performance between districts (eg, from 41.1% to 67.1% on the 9-minute Delta/Echo standard), and there is a requirement within the review objectives to set appropriate minimum levels.
12.2.14 It takes over two minutes on average to mobilize a First Responder (where indicated). However, their response is very quick (93% within 9 minutes from
time notified), and they often (75.5% of the time) have to wait for the first BCEHS unit to arrive (eg, average waiting time when an FR responds to a Bravo/Charlie call is 9:29). It was agreed between BCEHS and Municipality
representatives that reducing this waiting time should be an area of focus.
12.2.15 Analysis of all components has highlighted very long activation times (the assignment time from Call Answer to Vehicle Assign) and mobilization times
(the chute time from Vehicle Assign to Vehicle Mobile). For example, a Delta/Echo incident takes 4:13 to assign and mobilize. These times are definite outliers when benchmarked. Significant improvements are required in
this time to allow unit resources to be more efficiently used. Reducing activation and mobilization times is key to improving response times.
12.2.16 Whereas the first on scene 9-minute response percentile from Call Answer to
Delta/Echo incidents is 51.2%, for ALS response to Delta/Echo it is only 39.9%, and just 27.8% when they respond to HLA incidents. ALS units respond to 75% of ‘Red Flag’ incidents (the highest acuity needing their skills)
with a 9-minute response percentile of just 37%. As well as an overall improvement in response times it is also necessary to raise the ALS response standard to higher acuity calls, ie, Delta/Echo, HLA and Red Flag incidents.
12.2.17 In consideration of these issues and the need to give a basis for the modelling of options, ORH proposed a set of ‘shadow targets’ for emergency response [see Figure 12] based on best practice elsewhere and some comparative
benchmarking. For Delta/Echo incidents the 9-minute response target is set at 75% – between the 51.2% currently being achieved and the 90% nominal target set. These targets give 75th and 95th percentiles response by call
category.
12.2.18 For transfers, currently a quarter of Red transfers arrive within a 10-minute window of their appointment time, and 55% of Yellow transfers within a 30-
minute window. No specific targets were set here, rather assessments noted whether this standard improved for any option for change.
12.2.19 Discussion of this service profile concluded that options for change should:
maintain response time monitoring from the time the call is answered;
target improvements in activation/mobilization times;
aim to meet the shadow emergency response targets;
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assume that conveyance rates, times at scene and times at hospital would not change;
improve the ALS response times to higher acuity incidents; and
aim to reduce the First Responder waiting time.
12.3 Future Service Development Options
12.3.1 This sub-section, which summarizes potential options for change, is supported by the analysis and modelling evidence provided in Sections 6 to 11.
Demand Projection
12.3.2 Emergency demand levels were projected forward based on demand rate trends coupled with forecast population growth by age/sex group and by LHA. Transfer demand was assumed to reflect recent trends and the overall Metro
population growth [see 6.1]
12.3.3 This gave a 6.1% per annum increase in emergency demand and a 2.0% per annum increase in transfer demand [see 6.2] distributed by LHA [see 6.3].
Reducing Activation/Mobilization Times
12.3.4 Reducing activation and mobilization times has a significant impact on response times equivalent to the introduction of 57 FTE Alpha car staff for a
45-second reduction and 114 FTE staff for a 75-second reduction.
12.3.5 In terms of response time impact therefore, management effort directed at improving the control and operational components of the activation and
mobilization time would clearly be well rewarded in terms of service improvement. It would also deliver a more efficient operational base for investing in further any resources to meet the shadow targets [see 8.3.5].
12.3.6 The evidence assessed here suggests that the cause of the long activation times is in part due to processing constraints within the Control. This review excluded assessment of Control, and it is not possible without a systematic
appraisal and review of the Control function to quantify the balance between operational and control causes that lie behind the long allocation times. Also, given the demand projection and the associated conclusions for increasing the
overall unit fleet size and mix, such a review of Control would be able to set out strategic development plans to ensure that there was sufficient capacity in the next five years.
12.3.7 It is therefore recommended that a Control review is undertaken with a scope that includes: call handling; dispatching practices; staff levels by function; dispatch desk jurisdictions; systems used; protocols followed; and
the use of the RAP. Such a review would need to be set in the context of increasing demand and resource levels.
12.3.8 A phased reduction in activation/mobilization times phased over the next few
years has been set and assumed in the future year modelling [see Figure 10].
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Reducing Time at Hospital
12.3.9 A reduction in the average time at hospital, and in the very long times, would improve the availability of resources and improve response times [see 8.3.6].
12.3.10 Such reductions cannot be confidently planned for. The assumption made in the future year modelling is that these times will not lengthen.
Incremental Improvement through adding Resources
12.3.11 The validated model [Section 7] was used to rank the best 25 locations at which to deploy an additional ALS or BLS unit to improve response performance around the existing operational regime [see 8.3.9 to 8.3.11].
12.3.12 This is provided for reference and to give BCEHS planning information on the relative value of each site for accommodating additional resources.
Mixed ALS/BLS Crewing
12.3.13 The impacts of mixed crewing were investigated within the model. The primary reason for investigating these options was concern over the current
ALS coverage [see 5.2.19]. In the base 2015 model, only 27.8% of HLA-required calls receive ALS skills on scene within 9 minutes.
12.3.14 Fully mixed crewing (where every ambulance is crewed with an ALS crew
member and a BLS crew member) would mean that 48.5% of HLA-required incidents received a response within 9 minutes, and 81.3% within 15 minutes. Multiple attendance rates would fall, in turn increasing vehicle availability,
which produces a performance boost to Delta/Echo calls of 2.9% in 9 minutes.
12.3.15 Currently, ALS ambulances are crewed with two ALS-skilled crew members. One option would be to ‘split’ or ‘de-couple’ current ALS crews, in effect
doubling the ALS ambulance unit provision. The impact of this was modelled, with the ‘extra’ ALS crews generated re-deployed to highly utilized stations that currently only have BLS ambulances. Doubling the number of ALS
ambulances in this way raises the number of HLA-required calls receiving ALS skill on scene in 9 minutes and 15 minutes to 41.8% and 72.1% respectively, and raises Delta/Echo 9-minute performance by 1.1%. Currently 16.8% of
deployed unit hours are ALS; under this scenario 33.5% of units deployed would have ALS skills.
12.3.16 Mixed crewing (either full mixed crewing or increased ALS deployment through
de-coupling existing ALS ambulances) has clear benefits in terms of getting higher clinical skills to those patients who require them in a more timely manner, and to response performance in general. It does, however, represent
a significant challenge in terms of implementation as it would require negotiations with the unions to amend previous commitments regarding ALS staffing.
12.3.17 This would be an effective measure if it were possible to implement. The number of high acuity incidents that individual ALS paramedics responded to within 9 minutes would be similar under the partial de-pairing option, and
given the current position. If the shadow targets were to be met then full mixed crewing would still ensure sufficiently frequent use of individual ALS staff skills in a timely manner.
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12.3.18 It is recommended that this should be noted as being an efficient and effective measure, but that implementation would require agreement with the unions to change the collective agreement.
Introducing ALS PRUs
12.3.19 As an alternative to the above the option of introducing single-crewed ALS PRUs in cars was modelled [see 8.3.17 to 8.3.25].
12.3.20 The results here identified an option for a 20% PRU utilization making a significant impact on ALS response standards to higher acuity calls.
12.3.21 It is therefore recommended that this measure is taken forward in future
year modelling (see sub-section 12.4).
Introducing BLS PRUs
12.3.22 This option was evaluated [see 8.3.26 to 8.3.28]
12.3.23 This option is much less favourable than the option for adding additional ALS PRUs. Although it raises the ‘first on scene’ response performance to
Delta/Echo calls, it does not improve ALS response to high acuity calls. The ALS PRU option does both.
Increasing the Transfer Fleet Size
12.3.24 The modelling here looked to see if an increase in the transfer fleet would raise transfer standards and, by releasing BLS units, would raise emergency response standards as well [see 8.3.29 to 8.3.33].
12.3.25 The conclusion reached was that this was not a cost-effective measure. Improving Red and Yellow transfer standards is best achieved by increasing the number of BLS units, not by increasing the transfer fleet size. It is
therefore recommended that beyond the impact of ALS PRUs, additional BLS units should be deployed to bridge the response gap to the shadow targets.
Resource/Demand Matching and Shifts
12.3.26 There is no indication from the analysis and modeling that the current system of shifts as this embraces Alpha, Bravo and Charlie systems needs to change. Adjustments need to be made to increase the cover during the evenings at
weekends [see 5.2.20 to 5.2.22]. Aside from this, changing shift timings in general would bring only marginal benefits.
Summary
12.3.27 Given the above results the modelling geared to meeting the shadow targets, improving the ALS response to higher acuity calls and reducing the First Responder waiting time was built around:
a phased reduction in activation/mobilization times; the introduction of ALS PRUs; and the introduction of additional BLS units.
12.3.28 The results of doing this are described in the next and final sub-section.
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12.4 Meeting the Shadow Targets
Achieving the Shadow Targets in 2015 with no Efficiencies
12.4.1 As a reference point, modelling first aimed to find the resources required to meet the shadow targets in 2015 (with projected demand for that year) with no efficiencies being made [see sub-section 8.4]. This was achieved by adding
ALS PRUs and BLS units as efficiently as possible.
12.4.2 An additional 110 BLS and 87 ALS staff FTEs would be required, and the peak vehicle deployment increase by 14 BLS ambulances and 26 PRU cars.
Achieving the Shadow Targets in 2020 with Efficiencies
12.4.3 The base 2020 model was created by:
increasing the demand to the 2020 projected demand level;
implementing expected station changes; and
implementing an 80-second reduction in the combined activation and mobilization time.
12.4.4 To meet targets in 2020 [see sub-section 9.1], an additional 3,792 BLS
ambulance hours and 1,344 PRU hours are required per week (above current deployment levels) to ensure that all targets are met. This is a different profile from that found for 2015 above, requiring significantly more BLS ambulances.
This is driven by the projected demand increase, which in turn requires more vehicles to be deployed that are capable of transporting patients to hospital.
12.4.5 In overall resource terms, the conclusion reached is that the following increase
in resource levels by 2020 will be required:
an additional 235 BLS FTEs;
an additional 42 ALS FTEs;
12 ALS PRU vehicles plus relief; and
an additional 29 BLS unit vehicles plus relief.
12.4.6 With the first on scene ‘shadow targets’ being met in 2020, given the
deployments and assumptions modelled, there will be associated benefits for HLA incident response and Red Flag incident response, together with a reduction in the waiting time for First Responders. ALS skilled response is
currently made to 58% of HLA incidents with a 9-minute response performance of 27.8%. These percentages would rise to 83% and 50%.
12.4.7 Red Flag incidents would have a first on scene 9-minute response percentage
of about 78.5%, comfortably within target, and an ALS 9-minute response percentile of 58% (currently 37%).
12.4.8 In terms of the change in the response profile expected for joint responses
from BCEHS and First Responders (FRs) the following change is estimated from the modelling:
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For Delta/Echo incidents, the FR currently arrives first on 72% of occasions (2015 modelled) and this would fall to 47%, with an associated change in the average waiting time (when arriving first) from
4:37 to 3:11 (minutes:seconds);
For Bravo/Charlie incidents, the FR currently arrives first on 80% of
occasions (2015 modelled) and this would fall to 52%, with an associated change in the average waiting time from 9:29 to 6:01.
Improving Response Standards in 2017 with Efficiencies
12.4.9 The 2017 position modelled is on the same trajectory as that for 2020, with just the three years demand increase from 2014 and a reduction in
activation/mobilization time of 30 seconds.
12.4.10 To make the maximum impact for this year it is concluded that the same ALS PRU tier is implemented as for that in 2020 above, and BLS units are added at
the new locations identified [see Figure 20].
12.4.11 The additional resources required to meet this improved position for 2017 under the assumptions stated are:
35 BLS FTEs;
42 ALS FTEs;
12 ALS PRU vehicles plus relief; and
4 BLS unit vehicles plus relief.
12.4.12 This will give improvements in all standards but still short of the shadow targets [see Appendix F2b]. The Delta/Echo 9-minute standard will rise to
65%.
12.4.13 ALS skilled response is currently made to 58% of HLA incidents with a 9-minute response percentile of 27.8%. These percentages would rise to 70%
and 47% respectively.
12.4.14 Red Flag incidents would have a first on scene 9-minute response percentage of about 70% (outside the planned 75% target) and an ALS 9-minute response
percentile of 53% (currently 37%).
12.4.15 In terms of the change in the response profile expected for joint responses from BCEHS and First Responders (FRs) the following change is estimated:
For Delta/Echo incidents, the FR currently arrives first on 72% of occasions (2015 modelled) and this would fall to 59%, with an associated change in the average waiting time from 4:37 to 3:45
(minutes:seconds);
For Bravo/Charlie incidents, the FR currently arrives first on 80% of
occasions (2015 modelled) and this would fall to 62%, with an associated change in the average waiting time from 9:29 to 6:47.
Figure 27: Comparing Future Scenarios
Core demand projection assumed(6.1% per year)
Option 2017 2020 2017 20201 0 0 0 0
2 0 0 30 secs 80 secs
3 +42 0 30 secs 80 secs
4 +77 +200 30 secs 80 secs
AT/MT = Activation Time/Modelizaiton Time
Option 1: no efficiencies & no resources
Option 2: efficiencies & no resources
Option 3: ALS PRUs & efficiencies
Option 4: Meeting Shadow Targetswith ALS PRUs, BLS Units & efficiencies
Additional Staff AT/MT Reduction
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
enta
ge A
chie
ved
Year
D/E
Option 1 - 9 Option 1 - 15
Option 2 - 9 Option 2 - 15
Option 3 - 9 Option 3 - 15
Option 4 - 9 Option 4 - 15
Target - 9 Target - 15
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
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ge A
chie
ved
Year
B/C
Option 1 - 15 Option 1 - 30
Option 2 - 15 Option 2 - 30
Option 3 - 15 Option 3 - 30
Option 4 - 15 Option 4 - 30
Target - 15 Target - 30
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
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ved
Year
A/O
Option 1 - 30 Option 1 - 60
Option 2 - 30 Option 2 - 60
Option 3 - 30 Option 3 - 60
Option 4 - 30 Option 4 - 60
Target - 30 Target - 60
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Alternative Scenarios
12.4.16 This development path through 2017 to 2020 requires significant efficiency improvements in relation to allocation and chute times, and also significant
investment in ALS and BLS staff and vehicles. The modelling examined the implications of this not being achieved [see sub-section 9.3].
12.4.17 Figure 27 opposite summarizes the different scenarios using the core demand
projection. Clearly, if no changes are made, response performance will fall and FR waiting times will increase. The addition of just the ALS PRUs will maintain Delta/Echo response standards, but other standards will suffer as the
demand outweighs the ability of current BLS and ALS units to cope.
Station Configuration Changes
12.4.18 The station database provided was assessed in terms of future capacity constraints given the modelling undertaken for 2020 and a commentary on the position developed [see sub-section 10.1].
12.4.19 To meet the shadow response standards in 2020 efficiently, additional locations are required to improve emergency incident coverage. It was found that seven of the existing cross-cover points used by the Service were
particularly well placed in terms of access to emergency demand. BCEHS should endeavor to provide facilitated locations near to these identified points.
12.4.20 A new location was also identified in the Fraser Valley, south of Chilliwack.
This would be well suited to becoming an Annex-type location.
12.4.21 Potential ‘hub and spoke’ clusters have also been identified, in areas where either such an operational scheme would provide an improved response
potential, and/or capacity at neighboring stations could be relieved through the introduction of a larger central hub [see sub-section 10.2].
Sensitivity Modelling
12.4.22 The following factors were tested in the modelled 2020 scenario for meeting targets [see sub-section 11.1]:
a) an improved activation/mobilization time reduction;
b) a reduced time at hospital; c) a reduced demand projection increase; and d) further improvement to Fraser Valley standards.
12.4.23 The results of these modelling runs [see sub-section 11.2] show that the positive ‘resource equivalent' impact of b) is similar to c) and these are each now more significant than the impact of a). The improved unit availability for
b) and c) at 2020 projected demand levels have a more significant impact than improved activation/mobilization because of the need for sufficient transporting and responding ambulances.
12.4.24 The Delta/Echo standard in Fraser Valley can be raised from the final 2020 position of 60% within 9 minutes to 65% or 70% with the addition of a further 6 or 17 FTEs respectively introduced.
