In July, Ontario's coroner released the results of his long-anticipated investigation into 40 patient transport deaths between 2006 and 2012 at the Canadian province's troubled air ambulance service known as Ornge. Most of Ornge's travails have been well-publicized over the course of the last two years, and it is not my intent to rehash them here. Just Google "Ornge" and "Toronto Star," and you will get multiple stories with the aggregate word count of "War & Peace" in a narrative that reads like a cross between "Bonfire of the Vanities" and "Fanny Hill."
Rather, I think it is useful to look at what the coroner said were gaps in decision-making and communications at Ornge because they are instructive in improving service in any EMS organization.
The report found "issues" with decision-making in 21 of the 40 cases, and most of these involved the wrong people making decisions about the wrong things. Specifically, the coroner found that "medical professionals were making operational decisions and vice versa" and that "many avoidable delays occurred when the responsibility for different aspects of the decision-making became blurred."
Dated or incomplete information contributed to the morass and therefore "efficient and effective transport was potentially compromised." This is a polite way of saying patients needing transport lingered for hours while people bickered and/or twiddled their thumbs.
Part of the problem: Too many cooks in the kitchen. The coroner found that, "When many people become involved in the decision-making on a given case, the ability to maintain situational awareness may become compromised. For instance, when multiple call takers and flight planners take part in coordinating a flight, incomplete or inaccurate information hand-offs and lack of awareness of 'the big picture' may result in incorrect decision-making."
One of these incorrect decisions: The helicopter is always faster. Well, not if it is down for maintenance, the weather is bad or you don't have a crew.
"Often the most appropriate form of transportation is not via air ambulance, and this information and the rationale supporting this conclusion needs to be communicated and acted on promptly. Similarly, if the ability to meet expected timelines is impacted by unforeseen developments during the course of transport, revised decisions may be required and must be communicated," the coroner said.
The coroner made five specific recommendations to improve decision-making and communications at Ornge. They included:
- Coordinate the decision on mode of transport (air versus land) for interfacility transfers between Ornge's transport physician, Ornge operations staff, and physicians at the sending and receiving hospitals;
- Transport physicians should not make operational decisions such as which aircraft to send. This is the purview of Ornge dispatchers who are better aware of all competing pressures for assets systemwide;
- The decision to send an airplane versus a helicopter should not be governed by cost but strictly by which asset is likely to provide the best outcome in terms of medical staffing and transport time;
- Any delay in the availability of an air asset should immediately trigger a review to determine if a land ambulance would be a better option for the patient; and
- Ornge should minimize call hand-offs between staff at its communications center to better "maintain situational awareness of calls in progress, assets available, and other critical operational information."
You can view the coroner's entire report. If you have decision-making and/or communications issues in your organization, or want to avoid them, it's an instructive read.
