Examining an Alternate Care Pathway for Mental Health and Addiction Prehospital Emergencies in Ontario, Canada: A Critical Analysis
3.1.1. Program History and Objectives
The Middlesex–London Paramedic Service provides healthcare for a population of 515,000 in Southwestern Ontario. Healthcare changes in Ontario such as the deinstitutionalization of people with mental health needs and the closure of hospital psychiatric beds contributed to an increase in mental health emergencies [26,27]. In Ontario, starting in the 1960s, long-stay patients in large psychiatric institutions were reduced but without the associated funding or coordination of care for those in the community [28]. Currently, EDs and hospitals in Ontario continue to see an increase in the number of patients experiencing addictions and mental health-related emergencies [29]. In December 2015, CMHA Middlesex established a crisis walk-in clinic as part of the collaborative efforts of community and hospital services, individuals with lived experience, families, and the South West Local Health Integration Network (SWLHIN) with the goal of reducing barriers to crisis support. CMHA established and formalized a partnership and protocol with the London Police Service to facilitate the ‘warm transfer’ of individuals in mental health and/or addiction crisis from the police to the CMHA Crisis Centre. A ‘warm transfer’ indicates a transfer of care between care providers in front of, and with the patient, to provide them opportunity to clarify their perspective and be engaged in their care.
In 2017, the MLPS, SWLHIN, CMHA-Middlesex, and London Health Sciences Center (LHSC) began to work together to address the increased pressure on paramedic services and EDs caused by mental health emergencies. The objectives of this collaboration were to (1) reduce unnecessary ambulance visits to the ED, (2) reduce offload delays for paramedics, (3) enhance the ability of paramedics to manage mental health calls appropriately, and (4) enhance the individual and caregiver experience in dealing with mental health issues. The group looked at pilot projects in Sudbury [30] and Ottawa [31] for inspiration on how to structure the project. To achieve its objectives, the collaborative partners agreed to (1) establish a mental health crisis centre where paramedics could bring patients, (2) develop a protocol for identifying eligible ‘patients’ who had requested help from paramedics, and (3) a process for paramedics and patients to choose the most appropriate care.
3.1.2. Development of the Satellite CMHA Crisis Centre
At the start of the collaboration, CMHA Middlesex already provided mental health crisis support through its Crisis Centre at 648 Huron Street in London. People experiencing a mental health crisis could walk into the Crisis Centre for immediate help, and no referrals were needed. Through collaboration with the London Police Service, clients with a mental health crisis could be transferred from the police to the Crisis Centre. Under the Ambulance Act (1990), however, paramedics in Ontario are required to transport patients to a designated receiving facility. In practice, this means that paramedics can transport patients to hospitals but not to any community-based facility. To comply with existing regulations, a Satellite Crisis Centre within the ED of LHSC Victoria was established in October 2017. The Satellite Crisis Centre was staffed by LHSC and CMHA Middlesex staff with close collaboration between partners. The Satellite Crisis Centre was able to provide the service on weekdays from 8 am to 2 pm due to limitations in funding and infrequent use of the centre during the startup phase. The project was continuously evaluated by the partners through weekly meetings and rapid cycle improvement rounds. During Phase II of the project, the CMHA Crisis Centre moved back to its site at 648 Huron Street and began to operate 24/7.
Concurrently, the MoH in Ontario began working on legislative changes under its Patient Care Model Standards for selected 9-1-1 patients to enable alternative destinations for paramedics. The MoH recognized the changing role of paramedics, and the pressure on the ED, and aimed for these initiatives ‘to divert patients away from emergency departments and reducing repeat hospital visits, which helps reduce patient wait times and ensures these hospital beds are available for those that need them most’ [32].
3.1.3. Development of the Mental Health and Addiction Alternate Destination Protocol
In order to identify which 9-1-1 patients would be eligible to be offered to go to the CMHA Crisis Centre, the MLPS developed a Mental Health and Addiction Alternate Destination Protocol. Paramedics in Ontario provide emergency assessment, care, and transportation to the most appropriate care, based on standards. Paramedics in Ontario are regulated by the MoH and perform care based on the Basic Life Support Patient Care Standards (BLS PCS) and Advanced Life Support Patient Care Standards (ALS PCS) [33,34] under the direct authorization and control of a medical director of a regional base hospital. For example, paramedics are trained to recognize a cerebrovascular accident (stroke) through a specific set of assessments, identify possible contraindications, and then determine the best possible hospital for these patients, potentially bypassing the closest ED to go to a specialized hospital. Other destination guidelines (or bypass protocols) exist for situations, including, but not limited to, trauma patients and specific types of myocardial infarction (STEMI) (BLS 3.4).
To develop its protocol, the MLPS assessed similar projects, including, among others, those developed in Sudbury and Ottawa. In 2014, Dr. Prpic and his team in Sudbury developed a ‘Mental Health and Addictions Triage and Transport Protocol’ that identified eligible patients based on a prehospital early warning score, patient presentation (which includes CTAS), and additional criteria [34]. The Sudbury program was the first approved trial pilot by the Emergency Health Services Branch of the MOH in Ontario to divert patients with mental health problems or intoxication to an alternate medical facility, bypassing the closest ED [14,35]. Based on the learnings of this program, the MLPS, in collaboration with the Medical Director of the South West Ontario Regional Base Hospital Program, LHSC, and CMHA London, developed the Mental Health and Addiction Alternate Destination Protocol for the MLPS (see Figure 1. Mental Health and Addiction Alternate Destination Protocol).
The Mental Health and Addiction Alternate Destination Protocol is structured based on the Medical Directives of the ALS PCS, including ‘indications’, ‘conditions’, ‘contraindications’, ‘treatment’, and ‘clinical considerations’. Paramedics in Ontario are familiar with this structure, and this was implemented to assist paramedics with utilizing the protocol. The conditions, indications, and contraindications were clearly defined and set at conservative values so that any existing or potential medical condition would take precedence over the mental health complaint. The ‘indications’ define the ‘general medical complaint or problem to which the Medical Directive applies’ [34], which in this protocol means any patient for whom their complaint was an MHA-related primary problem and when patients were cooperative and non-combative. The MLPS defined cooperative as patients who were able to provide consent for the alternate destination and able to engage in meaningful safety planning with the paramedics.
The conditions and contraindications define the clinical parameters that must be present for a treatment to be performed. Under the MHA Alternate Destination Protocol, only adult patients that can obey commands, are alert and oriented, have a normal heart rate (between 50 and 110 beats per minute), are normotensive (SBP between 100 and 170 mmHg), have no respiratory distress (with an SpO2 > 92%), and who have not received any ALS interventions would be eligible to be offered to go to the CMHA Crisis Centre. Patients would be contraindicated if they were CTAS 1 or 2, had an acute medical or surgical condition, were apprehended under the Mental Health Act, or were placed on Form 1.
The ‘treatment’ part of the protocol offers patients a choice to consent to receive transport to the CMHA Crisis Centre, refuse any further paramedic service, or be transported to the ED. The patient would be given information about the CMHA Crisis Centre so that the patient can make an informed decision about their next steps. Once a patient consented to be transported to the CMHA Crisis Centre, the paramedics would contact the CMHA Crisis Centre directly to see whether the centre would accept the patient. The patient would then either be transported to the CMHA Crisis Centre and transfer of care to the centre would take place, or, if the CMHA Crisis Centre declined, the patient would be transported to the most appropriate ED for transfer of care at the hospital. As with any 9-1-1 emergency, patients with capacity retain their right to decline any treatment or transport. In those cases, paramedics could provide information about CMHA Crisis Services or ask for consent to call CMHA’s Crisis Response Team to support the patient.
The ‘clinical considerations’ provide guidance to paramedics on the proper performance of a procedure or treatment. One of the greatest potential risks of the alternate destination is that the CMHA Crisis Centre is not a medical facility and does not have physicians on staff 24/7 for emergency crisis care. Paramedics must use their clinical judgement, including the wishes of the patient, to determine the best treatment options.
During the implementation of the project, paramedic staff at the MLPS were trained to use the Mental Health and Addiction Alternate Destination Protocol as part of their continuing medical education. Ontario paramedics are very familiar with the structure of a destination guideline and medical directive, so it was relatively straightforward, and with minimal cost, to implement the change. Once the Satellite Crisis Centre was open, paramedics were encouraged to offer the Mental Health and Addiction Alternate Destination Protocol to eligible patients.
