EMS education in Ontario: The present
Published: Tue November 10, 2009
In Ontario, after completing a two-year Ambulance and Emergency Care program from a recognized college, graduates are eligible to be employed by an operator of a land ambulance service. As per the associated legislation, the graduate may work with the EMS operator for up to 210 days after graduation. During this timeframe, the graduate is required to successfully pass the provincial Advanced Emergency Medical Care Attendant (A-EMCA) in order to continue employment.
Levels of paramedic care
Once hired by the land ambulance service, new employees typically receive additional training specific to policies and procedures of their new employer. During this orientation, new employees are also required to be certified by the medical director of a regional base hospital program. This certification allows the employee to perform controlled acts as a Primary Care Paramedic (PCP). The list of controlled acts that may be performed by a PCP includes: (1) administration of glucagon, oral glucose, nitroglycerin, epinephrine, salbutamol and ASA (80 mg form); (2) semi-automated external cardiac defibrillation; and (3) auxiliary protocols involving 12-lead ECG acquisition, diphenhydramine, gravol, taser probe removal and application of continuous positive airway pressure (CPAP).
Paramedics who have completed a provincially recognized Advanced Care Paramedic (ACP) training program are required to successfully pass an ACP exam. Thereafter, the paramedic must be certified by the medical director of a regional base hospital program to perform the following skills: (1) administration of the drugs and acts similar to the PCP; (2) other drugs approved by the province on the recommendation of one or more medical directors of base hospital programs; (3) non-automated external cardiac defibrillation and monitoring; (4) peripheral intravenous therapy; (5) endotracheal intubation; and (6) auxiliary protocols involving emergency cricothyrotomy, adult intraosseous access, application of central venous access device, and patient sedation.
Paramedics can also become Critical Care Paramedics (CCP). The list of controlled acts that a medical director can authorize a CCP to perform can be found in Ontario Regulation 257/00 at www.e-laws.gov.on.ca. Currently, only Toronto operates CCPs. Interestingly, a medical director can certify a PCP to perform one or more ACP acts, and certify an ACP to perform one or more CCP acts.
Regional base hospitals
A base hospital program in Ontario operates to (a) delegate controlled acts to paramedics (as described above); (b) provide the continuing medical education required to maintain the delegation of controlled acts to paramedics; (c) provide medical advice relating to prehospital patient care and transportation of patients; and (d) provide quality assurance information and advice relating to prehospital patient care.
In 2009, the province completed a restructuring of the base hospital programs. The former 21 base hospital programs were consolidated into seven regional programs.
The regional programs are now associated with Ontario's leading hospital systems. For example, the Centre for Paramedic Education and Research (western Ontario's regional base hospital program) is associated with Hamilton Health Sciences. A complete list of regional programs and their affiliated land ambulance service operators can be found at www.ambulance-transition.com/pdf_documents/contacts_bh.pdf.
The restructuring offered new opportunities for both land ambulance service operators and paramedics. In a regional format, the new base hospitals were able to recruit expertise to develop programming in association with both neighbouring ambulance services and their paramedics.
The new base hospitals have greater opportunities to share best practices and research with one another in an attempt to meet the ever-changing needs of the prehospital care community. And the dialogue between the base hospitals and the provincial regulator is more focused on providing services to their municipal EMS partners.
There are critics of the new regional base hospital system. Critics would argue that a self-regulating Ontario College of Paramedics (such as the colleges in Alberta and Nova Scotia) is the answer in certifying and educating paramedics. The issue of a self-regulating college is now before the Health Professions Regulatory Advisory Council (HPRAC). The HPRAC is deliberating the issue in order to make recommendations to the Minister of Health and Long-Term Care.
Continuing medical education
In Ontario, to maintain certification, a PCP needs to complete a minimum of eight hours of education per annum and an ACP needs to complete a minimum of 24 hours of education per annum. It is not clear how the number of certification hours was developed. Are eight hours per PCP per annum a sufficient amount to ensure paramedics deliver quality prehospital emergency care? Given the scope of practice of an ACP, are 24 hours of education per year sufficient? Greater evidence is needed to establish an appropriate level of continuing medical education hours.
The current trend among municipalities is to increase the number of ACPs in their operations. However, as you increase the number of ACPs, the number of emergency calls in which ACPs engage advanced skills declines.
The number of calls is further reduced when placing ACPs in suburban and rural areas. In lieu of the call volume, educators have developed clinical placements at acute care hospitals, didactic sessions and medical rounds, and simulation laboratories.
The other key issue is the actual curriculum delivered. Education needs to focus on the critical thinking and patient care skills that the paramedic requires in the field to produce positive patient outcomes.
There is limited research in the area of prehospital emergency care to assist in continuous medical education for paramedics.
Although there is limited research, municipalities are working towards promoting additional research initiatives.
The Association of Emergency Medical Services of Ontario (AMEMSO) recently developed a research consortium in order to stimulate paramedic research. There is also the Canadian EHS Research Consortium that is dedicated in increasing paramedic research at the national level (see www.paramedicresearch.ca).
Collecting the data
Researchers need data. As technology develops in prehospital emergency care, data is becoming readily available to researchers.
In Ontario, regulators are mandating the seven regional base hospitals to collect a minimum data set (MDS) for the purposes of providing quality assurance of paramedic care. The MDS also provides a comprehensive database for research. At the Centre for Paramedic Education and Research, a data warehouse is being developed to receive paper based paramedic documentation from six paramedic services and electronic paramedic documentation from three paramedic services.
From the MDS and quality assurance initiatives, education curriculums can be developed to address systemic trends at both the local and regional level. The MDS can also be utilized for research purposes to assist in developing evidence-based paramedic practice.
Overall, the paramedic education system in Ontario is off to a good start with the restructuring of the base hospital system. There is a viable alignment with the provincial regulators, base hospitals, EMS operators and paramedics in order to produce and maintain an effective education environment. The added value is promoting research initiatives that give credence to paramedic practice.
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