Emergency medical services in Canada are the responsibility of each Canadian province or territory. As such, the services, including both ambulance and paramedic services, may be provided directly by the province, may be contracted to a private provider, or may be delegated to the local government level, which may in turn create its own service delivery arrangements with municipal departments, hospitals, or private providers. The approach, and the standards, vary considerably between provinces and territories.
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In Canada, responsibility for Emergency Medical Services, as a part of health care in general, has been allocated to the provincial/territorial level of government. With the exceptions of British Columbia and Alberta, which operates its EMS services directly, the method used for service delivery will vary to some degree between jurisdictions. Typically, the provincial/territorial government will provide enabling legislation, technical standard, accreditation or licensing,[1] and oversight to a variety of potential system operators, including municipalities, hospitals, or private companies. Municipalities or hospitals may also, in turn, elect to provide EMS service directly, as a branch of another municipal department, such as the fire department[2] or health department,[3] or may contract out this responsibility to a private company. The approaches used for service delivery are governed by what is permitted under the legislation of the individual province or territory, or under the by-laws of a local municipality, when that municipality accepts responsibility for EMS service.[4] Provincial governments may also, as in the case of the provinces of New Brunswick,[5] Nova Scotia,[6] and Prince Edward Island,[7] contract directly with a single private company, Medavie EMS[8] (the same one in these three cases) to provide seamless, province-wide services.
Canadian provinces are also served by air ambulance services. These arrangements may come in a variety of forms, including direct service provision, contracts between private companies and the provincial government, or they may be 'brokerage' arrangements, in which one private company takes the lead on service provision, perhaps even operating some of their own aircraft and providing dispatch services, but subcontracting many of the operations to smaller air charter services. In some cases, the inter-facility transport of high-acuity patients may be a mix or air-based and ground-based resources.[9] Canada is a vast country, and the sheer size dictates that in many cases, the traditional helicopter-based air ambulance service found in the U.S., the U.K., or Europe is impractical as the distances required exceed the flight range of the aircraft. For this reason, the use of fixed wing aircraft is commonplace. As another feature which is somewhat unique to Canada, in some jurisdictions not all air ambulance calls are emergencies; distances to tertiary care centres mean that patients with lower-acuity medical conditions will also be flown on occasion.
As examples of standards, individual provinces and territories will typically specify, generally through legislation and regulations,[10] the specifications and types of vehicles which may be used in EMS. These vehicles will include ambulances but may also include rapid response vehicles (sometimes called 'fly-cars'), and specialized Emergency Support Units, such as equipment vehicles and mass-casualty transport vehicles. To illustrate, each province or territory, and also the Canadian military, have their own unique ambulance specifications. Individual provinces or territories may also specify types of mandatory equipment in those vehicles, including medical equipment.
Ambulances type in Canada are based on United States federal KKK-1822 Standards requirements:
Bus based and air ambulances are not based on these standards. Buses are mostly for ambulatory transfer only and offer less advance care services.
Individual provinces and territories will also typically specify required levels of mandatory staff training for that particular province.[11] At the moment British Columbia, Alberta, Saskatchewan, Nova Scotia, Ontario, Prince Edward Island and the Yukon Territory are served by highly educated paramedics with advanced skill sets. Other jurisdictions have not yet reached these levels, and some jurisdictions have or are considering the introduction of critical care paramedics and/or paramedic practitioners.[12] On a province by province basis, the progress varies, driven primarily by public demand, acceptance by the medical community, and funding resources. A great deal of the recent advancement in standards of care and procedures have been driven by formal outcome-based research[13] and clinical trials. An excellent example of this was the groundbreaking research work on the management of S-T segment elevation myocardial infarctions (STEMI), undertaken in cooperation with the Ottawa Paramedic Service.[14] Indeed, particularly in larger services, some paramedics undertake their own formal research projects or collaborate with other researchers in the medical community, leading to publication, as with the preceding two references; both of which had paramedics in lead investigator roles.
Canada is such a diverse country, with 13 separate jurisdictions governing EMS operations, that no single standard for response time measurement currently exists. Urban areas, such as Toronto, will set standards according to percentiles, in this case the standard is 8 minutes and 59 seconds or less, 90 percent of the time on AMPDS triaged Delta and Echo calls.[15] There is no jurisdiction in Canada that is currently reporting successful achievement of this response time standard,[16] and services cite a variety of reasons for this failure, but continue to aspire to the standard.[17] This approach to response time monitoring is accepted in most urban areas of the country, however, there are some jurisdictions which reasonably set a second standard for rural (the majority of the country) response. Such standards can vary from one jurisdiction to the next. Additionally, there are jurisdictions that do not set specific response time objectives, instead simply reporting average response times for emergency calls.[18]
There are currently major initiatives for improved standardization of staff training underway in Canadian EMS. The Paramedic Association of Canada has produced the National Occupational Competency Profile,[19] and many provinces are working toward meeting these standards. Provinces and territories are also responsible for standards with respect to the dispatching of EMS resources, and some jurisdictions are measuring performance, benchmarking, and setting standards. In addition, initiatives by the EMS Chiefs of Canada[20] organization are working towards improved interoperability and a 'best practices' approach to the overall management of EMS systems.
The big problem is the tendency of demedicalization in the sense of non participation of Care Professionals and Paraprofessionals in this Canadian Ambulance First aid Ambulance like in USA.[21] In many Jurisdictions prehospital-care providers are evolving toward independent practice. They may have limited contact with other health care providers and can develop more allegiance to public service agencies, such as the police and fire services. The AAEMSP believes that collaboration between emergency medical technicians and knowledgeable, committed physicians providing medical control is essential for the provision of high-quality care based on sound, current scientific knowledge. Our belief, and that of others, is that abdication of or exclusion from this role increases the risk of inappropriate, cost-ineffective and potentially dangerous prehospital medical care.
EMS services in Canada are generally funded, at least in part, and to varying degrees, by the government of the province or territory in which they operate, through the Ministry of Health or Health Department of that level of government. However, paramedics and ambulance services are not mentioned in the Canada Health Act and are therefore not an insured service. Provinces may choose to subsidize some of the cost, usually just for patients with a valid provincial health card. Health insurance in Canada is universal and publicly funded, therefore the cost of emergency ambulance services is covered to some degree. The degree to which individual use of EMS is subsidized by provincial health insurance varies by province, and may be supplemented by either partial fees for service, or from the property tax revenues of local municipalities operating such services. The approach to such systems varies, as well. In some jurisdictions, funding is at the 100 percent level,[22] and occurs without the patient being aware of its existence. Other jurisdictions fund at varying levels, but may require 'up front' payment for service, which is subsequently reimbursed.[23] This may be particularly true of out of jurisdiction services, with an individual from one province, who requires EMS service in another province, being required to pay for that service and then submit the receipt to their own provincial health insurance scheme for reimbursement. In some jurisdictions, such as Ontario, a 'deterrent fee' scheme is used to discourage the medically unnecessary use of EMS by the public. In such cases, the provincial health insurance scheme will pay the majority of the cost of EMS service (around 80%) for medically necessary EMS service (when a physician decides that the service was not medically necessary, they can cause the patient to pay the full, uninsured amount of the charge),[24] with the patient receiving a bill for the additional 'deterrent fee' at some point after the emergency is over. Within Ontario, for example, such deterrent billing occurs through the receiving hospital, despite the fact that the hospital neither provides nor oversees EMS in most cases.
In addition to regular EMS, many jurisdictions also have non-emergency patient transport services operating. In many jurisdictions, these are companies who specialize in non-emergency patient transfers. Such companies have their own vehicles, which are similar to ambulances and carry similar patient care equipment. These services, certainly welcome and necessary, relieve the workload on public EMS through the elmination of some, or most, of the non-emergency transfer volume,[25] and some provide service to the public that is of the highest standard. In many cases, such services are small private business operations, using second-hand ambulances which have been retired from public EMS service, while others use vehicles expressly built for their purposes.[26] There has, however, been some controversy, in some jurisdictions, with respect to the operating procedures of some (but not all) of these services. In some cases, the vehicles are often made to look as much like an EMS ambulance as possible,[27] even retaining emergency lights and sirens (which they are forbidden by law to actually use), and incorporating the word 'Paramedic' (this term is not protected in Canada), variations on 'EMS' (in some cases, 'Event Medical Services') or spelling variations of 'ambulance' (e.g. 'ambu-lans'), or using the Star of Life logo on their vehicle markings. While such services may not be breaking any current Canadian law, many Canadian paramedics believe that such services work hard to create an erroneous public impression, and that such practises actually mislead the public into the belief that they are receiving an equivalent service, when in fact they are not. These services are not generally licensed, or required to meet any recognized standard, and despite the impression that they work hard to create, the operators will quickly insist that they are not 'ambulances', because becoming actual ambulance services would subject them to licensing and standards. These services generally attempt to recruit staff who meet provincial EMS qualification standards, but are under no legal obligation to do so. Such services are not covered by provincial health insurance, operating on a fee-for-service basis, and are not considered to be a legitimate part of mainstream EMS.[28]
EMS services are public operated and many by the provincial ministry of health (mostly since the 1970s). In Ontario services were downloaded to local municipalities in the 1990s:
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