Paramedics Conference (2016) Modes of Conveyance Case Study – Niagara Emergency Medical Services

Hi everyone! So in our experience in Niagara, we were one of the early adopters, I think, in Ontario of the full power stretcher with an actual power load system. I don’t know that we were first, but we were certainly one of the earliest adopters. And so we, we’ve had that since April of 2014 so going on just over two years now, so you’ll see some timelines in a moment in some of the slides that I show you. It seems to me that as we sort of implemented that stretcher, a lot of other services approached and said “What are you seeing? What’s your result?” And it seems to me that there’s three sorts of buckets with EMS services in regards to this sort of system in Ontario. There are those that have it, there are those that are currently actively growing it out, purchasing and doing that kind of thing, and then there are services that you know really would like it but they’re not sure that they’ll be able to, due to the fiscal realities, not sure that they’ll be able to secure the funding for it, or make the case for it. And so we do want to share our experience with, with folks and including the results that we’ve seen which have been pretty dramatic, so some of the speakers have talked about sort of the kind of the theoretical this is what you can expect to see in terms of reduced muscle use and etcetera. We’ll show you from the operational perspective, what we’ve actually experienced with the stretcher in our service. So Niagara region, it’s about eighteen hundred and fifty-two square kilometers just to give you a little bit of background. We have just over 430,000 residents in Niagara. We have our own communication centre, as well as the ambulance service. At peak during the day, we staff 32 ambulances and then at night were down to a low of 17, so we really ramp things up to match our call demand in Niagara. Which last year was about 55,000 unique requests, 911 calls for Niagara EMS to manage. And an interesting fact that Rob shared with me in an eighteen month period recently, we had over 1,600 patient’s that we transported that were greater than 350 pounds, so definitely, definitely patients out there that are putting more stress on paramedics from the physical perspective. Just some of things that we we’re seeing before we rolled out the power stretcher. In a twenty month period, we noticed that of all the MSD incidents at our service, forty-four percent of them directly involved the use of a stretcher. Seventeen percent of all incidents when you look at all the data stretcher related, and it says, those are just the stretchers we happened to be using at the time, In the Power flex stretcher, the 35X and P of course most you are familiar with that, that’s your manual stretcher, the Powerflex would be a power stretcher with a lift assist into the back of the ambulance. We know that in addition to the number of claims that represented it, it stood out to us that it was also the most expensive. That thirty percent of all our claims that were stretcher related, thirty percent of our costs were associated with that, so it was very you know it’s an injury type that was hard on our staff and it’s injury type that is expensive as well. Total costs just stretcher-related claims for that one year, for a one year period were over 48,000 dollars. So it’s definitely, you know, something that if you could address, there’s some economies to be had in terms of that as well. There is a study out there that we came across that looked at, you know, take away the manual stretcher and put in a load assist stretcher and you can reduce your workplace injury claims by forty one percent. Okay, well that’s sort of jibed with the numbers that we were seeing in terms of the percentage of injuries, as well as stretcher specific claims by sixty-nine to ninety-six percent. Now that study was done in 2009 and it’s not looking at, it’s looking at the power stretcher only it’s not looking at a power stretcher with the actual load into the ambulance. So, we looked at that data and we did some things, some interesting things in Niagara, we did some things very right but before we did that we did some things very wrong so I don’t mind telling you that and Rob will share some of that as well. Just to give you an idea of some of the timeline though. We’ve been using the track chair, sled type chair, I guess, that are in the track, its a Ferno EZ glide stretcher since mid 2009. We use in our fleet, we started using the Mercedes sprinter ambulance, so a different ambulance design rolled out. We received them in spring 2012 but it was a little bit before we actually got them onto the road. That vehicle eventually had air suspension put on it that allows the vehicle to kneel. When it first came out though it didn’t have that. So there’s a whole bunch of changes going on at the same time. During all of this, we also decided to introduce a power stretcher into the mix. And so, we had all these things going on, I’ll talk about the Stryker trial a little bit later, but before we got there we had some unexpected results. We started getting feedback from staff as soon as we put the power stretchers out there that these things, well we got two things because some staff saying these things are phenomenal thank you very much, and we get other feedback from other staff saying I can’t use this, it doesn’t work for me. And we started seeing increased injuries, we started seeing increased incidents and hazard reports being written up. So we were kind of confused by this because if you go back to the study that I mentioned, you know, how can this not be seen as a good thing? How can this be causing a negative backlash? We made a few mistakes. When we went and implemented it and Rob’s going to speak to this more, there was probably a couple of steps that we forgot. I’ll talk to this in a second but what I’d like to do is ask Rob to just talk about, Rob being a front line paramedic at the time that all of this was going on, I’d like to have him give you some perspective as to what he was seeing from the road – and I know he’ll be brutally honest. Thanks Rick. So as we all know with paramedics weight is everything. We don’t like to lift any more than we have, cause we all believe we only have a certain amount of lifts in our backs. Our careers are limited basically to our backs, we really want to take care of them. We go from a stretcher that weighs about seventy so odd pounds, to one now they’re gonna give me that’s 130 pounds. That sounds great I appreciate it, because I did see the benefit of it because it’s going to reduce those cumulative lifts. But unfortunately what happens, is you still have to pick up the stretcher and load it onto the vehicle. And one of the challenges we had as Rick was saying is we had vehicles now with a deck height which is actually higher. The stetcher we were trialing at the time again, did do the up and down, it was great but there was no load system so with those challenge some staff became very apprehensive. As well the unit we we’re using at that time some medics weren’t able to use it due to their stature. We found them have trouble using the controls and things like that. So now we have logistical nightmare of we have three stretchers X, Y, and Z out they’re trialing and we had to have this crew on this truck, this crew on that truck, and this crew on the other truck. So as you could imagine how much trouble that gave us and our service. So it wasn’t very well accepted by all and unfortunately, once the bad vibe went out there, it squashed it pretty quickly. So obviously some change management steps that we missed along the way. We’ve heard a lot today about change management and so you know we were nodding our heads, yup we know that. Sometimes you forget and you think that if you’re just doing something really good it will naturally be accepted and that’s not really necessarily the case. So as Rob said, we had crews that were refusing to work on the new stretcher, and so we had to find ways to accommodate them and put them on a vehicle that didn’t have it. And on the other side of that, we had crews that were refusing to work on the old manual stretcher because “I want to be accommodated and make sure that I get put on that vehicle with the power stretcher.” So this was getting rather cumbersome. And so we went back to the drawing board. And we said listen first of all, let’s see if we can understand exactly what’s going on out here. Do we have kind of a vocal minority that are driving this feedback? And so we did survey of all the staff and these are the questions that we ask the staff and we put it over there, and we were basically asking them to compare three different types of stretchers: the two manual that we had over there in the system, one being kind of lighter than the other, as well as a power cot that we had in the system. And some interesting results came out of that, the Green Line is the power and whereas with the two manuals you had most paramedics saying, “Yeah it does a decent job either you know good enough or very good.” There wasn’t too many people saying it was poor. With the power stretcher we had this dichotomy, you had half the feedback coming back saying this is wonderful the other half saying I hate this. So very eye opening results for us and that basically told us it wasn’t just a vocal minority we had a huge problem in our implementation process. So we went back to the drawing board. One of the things that we received on some of the surveys we allowed staff to just comment, and make their own comments as they went along. A number of them said, “Well if you really care about our opinion, why aren’t you looking at everything that’s out there? Why are you just looking at this or this, why aren’t you also looking at the devices that are out there that actually load the ambulance into the back -or the stretcher to the back of the ambulance?” And so we thought okay, yeah, let’s do that. We designed a trial, we engaged epidemiology at the Niagara region to help us sort of put this together beforehand with a detailed survey that I will show you in a moment. First, we did a couple of things differently this time. We did a demonstration to all staff in the service and then we did a field trial. And then we went back and asked paramedics again their opinions in a much more detailed way. And Rob was an instrumental part of that. There was, you know, some of the things that we had learned the first time around we were trying to correct, so we know that the survey that we did the first time around probably wasn’t detailed enough to give us a really good idea of exactly what the source of the problem was. We know that there were certain staff that weren’t engaged in the process and that we had multiple simultaneous changes at the same time without really trying to, Rob was referring to the height of the stretcher or the height of the vehicle for example as I said, when we first put the vehicle out there the air kneeling suspension wasn’t a feature, it’s now been added in all the ambulances. The actual deck height on the new ambulance was no different than the former design. The problem was, medics perceived it to be different because the sprinter style ambulance is a smaller ambulance with a narrower opening. So when they were shrugging that stretcher up and trying to get it in there and they felt like they were being restricted and the height felt much higher. So there was a bunch of different things going on at the same time and we really sort of putting ourselves behind the eight ball. So staff, you know, felt like they had this, some of them felt like they had this stretcher foisted on them without being asked first, basic change management mistake. And I heard Doug this morning talk about that Nash equilibrium and you know, if I’m going to be given a stretcher that’s heavier right? what is the advantage to me accepting that? What is the ergonomic advantage, right? It wasn’t there, it’s a heavier stretcher but where is the big win for me as a medic if I have to change practice? So I’m gonna let you talk to some of the changes, some things we did differently. So the reason I became a service instructor with Niagara EMS is because I did see the benefits of a power stretcher. I did think that it would help prolong my career and give me a chance to retire which in EMS is relatively new term. What we did is the, Niagara hired two of us basically to go out there full-time, and we would take these stretchers around and get engagement from all the staff. So following steps from our guests from the Ohio State University, basically we try to engage the staff and use many of those same things. So we did field trials with everybody, we had crews out there using them full time, like super user groups, we had surveys being filled out, and another big thing we had now is a loading system. So it wasn’t just the fact that we brought the stretcher up and down, now we had a unit who would actually pick it up and help you assist in to the vehicle. So then it cleared all those extra hurdles that we had originally with the other product. So a lot of that we got excellent buy in from the staff because again, they felt their views were heard, we engaged the staff and it was very successful at that point. So we had some champions, we had a champion in Rob. And I didn’t mention Rob and his partner were actually one of the crews that when we put out the first power stretcher wrote us saying, “we love this thing, don’t even consider taking this away.” And then we went and said you know they’re obviously, Rob and his partner are very passionate about this, if we’re going to do this differently let’s see how we can bring them aboard and, and let them be part of this change process. The other service instructor that worked with Rob was our union president, so he was also part of this change process and we thought that worked quite well. Both did a great job in, in helping us manage that change. So the comparison, you probably can’t read all of that you’ve got to, the print out but the comparison evaluated many more facets of the stretchers the second time around than it did the first time around. Not surprisingly though in all categories, having a power stretcher with a power lift into the ambulance was the overwhelming favorite amongst staff. And there was some some really good feedback about it, really the bang for the buck is this this magic of a stretcher basically levitating itself into the ambulance and now all of a sudden we had that buy in, we had that ergonomic advantage that could say to a medic because this is still heavier stretcher, you still have to approach your work differently, but now there’s something really in it for you at the end of the day which is the feedback we received from staff. I can go home at the end of the day feeling less tired like that was said elsewhere. Can I speak to that for a second, Rick? Yup. Sorry, just out of play on what Rick was saying, so what this is also done is it’s encouraged these other two modes conveyance. So now we’re using our stair chair more, back in few years ago and I might’ve carried a stretcher up four or five stairs, I don’t dare do that now. I’m much smarter about it I use prescribed equipment, I use my stair chair, I use my rescue seats, I use my other extrication devices which are designed, which are safer for the patient and safer for the paramedic. So that’s one thing that has kind of started to change that culture change that we all need to do which can be very difficult in EMS, it definitely has helped with that change of culture. So this is a just a bit of a graphic representation of some of the MSD incidents that we had seen starting in January ’13, well before most of these changes took place and carrying on through until you know sort of 2015, a year after we implemented the new stretcher. You can see various spikes, here and here, that are probably associated with when we rolled out a new ambulance and then rolled out a new stretcher that staff weren’t particularly keen on. The air suspension coming in seemed to sort of help momentarily, but then we went right back to seeing a number of incidents, these are all incidents that are including actual injuries as well as just reports. Staff were really starting to inundate us with hazard reports saying you know I feel sore, I don’t need medical attention but you need to know this is affecting me. The Stryker implementations started I think we were fully implemented by April 2014, we had started kind of February-March ish but by the time April ’14 came around all of our front line vehicles had the new Stryker stretcher and you can see the resulting tail off of incidents. And the interesting thing to note the the red is all MSD incidents, the blue is stretcher related incidents and you can see that you know, that they were really the driving force here, stretcher related. The other thing I mentioned earlier in terms of cost, stretcher related MSD’S being the biggest driver of lost time incidents, which is therefore one of the biggest drivers in terms of cost. You can see that after the Stryker was implemented, there was a little bit of a spike there and we’ll talk to, you know, what that was and how we addressed it. But for the most part after that we’ve seen virtually nothing in terms of stretcher related MSD’s. It’s, it’s gone down to almost zero, so we’re working with Dr. Fischer, Dr. McPhee. We’d like to share this, we’d like to first determine that it’s statistically significant so that we can share that with others. And the study that I referred to in 2009 it would be interesting to to look at something similar now comparing the power stretcher with the load assist against a regular stretcher. So looking at some of that information moving forward. In terms of the spikes you see, there’s obviously gonna be a learning curve associated with a new piece of equipment, and there was a learning curve with this one. So did you want to talk a little about that? Yeah just those are actually due to incorrect use of the stretcher, they weren’t actually a problem where somebody got hurt using stretcher, it was because they weren’t sure of how to lift it, or their trying too much with the power stretcher. Once we did a little bit of bumper training which is been a big theme in our service, which has worked very well, going doing the one-on-one while on duty, all those were curtailed. So some of the adaptations that staff had to make in terms of you know, your stretcher might be shaped a little bit differently than your old one, you may have to approach bed to bed transfers a little bit differently than what you did before, and once we regrouped and again engaged Rob and John to go ahead and get that knowledge back out there to staff. And I think there was a couple of safety items that were identified early on as well, reminding staff things like, don’t power up stretcher with the straps under the wheels or you’re gonna have a serious issue. Went out and did a little further education and took care of the rest of that. Some of the feedback we’ve gotten from staff, this is just some of the samples from the surveys that we did, the two over arching themes were; thank you very much I feel like when I go home I’m less exhausted physically and that I can you know carry on with my family without being sore and that sort of thing. And the other theme was; thank you very much I’ll now be able to retire, I can actually see myself doing this to the point of retirement. So those are the two major themes that we saw on all the feedback that we got from staff, so it’s been a very positive thing in terms of not only the rates of injuries that we’ve seen, but we’ve been capitalizing on it in terms of employee morale now for quite some time. The other, the other thing that we need to look at next is the stair chair. We, as I said, we’re using the track chair. I know that there’s a power model out there and and we would be curious to see whether that would be of further benefit to staff. Our health and safety committee took one look at it and said that looks cool but we’re not going to endorse that. And the reason is it’s too heavy. Because staff, they don’t want to see staff getting injured lifting that off the ambulance. So when we can figure out a way to make that a process that’s relatively seamless, then I think we’d like to look at another alternative to the stair chair as well because we know the patients go up as well as down stairs in our in our context, so. So some of the things that we learn in terms of the change, again having a champions, having a front line staff engaged in that process. And again, one of the predictors that was mentioned earlier about that perceived economic advantage. If we’re not doing a good enough job of selling that at the outset, you know in this case it was great. That with the power lift staff immediately recognized that, but in the first instance you know that would be our job to make sure that that economic or that ergonomic advantage or whatever the case may be is is something that staff understand at the outset. So, a bit of a learning experience but overall pretty positive and the results are showing it. So that’s it!

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