Annual Report 2012 - 2013

Northeastern Ontario Prehospital Care Program ANNUAL REPORT 2012 - 2013

ANNUAL REPORT

TABLE OF CONTENTS

A. SUBMISSION DATE OF ANNUAL REPORT ______6

B. NEOPCP KEY FUNCTIONS ______6

C. BASE HOSPITAL STAFF ______7

D. PROGRAM HIGHLIGHTS ______8 ELECTRONIC CHART REVIEW ______8 PARAMEDIC PROFESSIONAL ACTIVITY REGISTRY ______8 RESEARCH PARTICIPATION ______8 NEOPCP WEBSITE ______10 VIDEOCONFERENCE ______10 STEMI ALERT ______10

MEDICAL DELEGATION ______11 1.0) DESCRIBE THE PROCESS USED TO ENSURE EMERGENCY MEDICAL ATTENDANTS AND PARAMEDICS ARE QUALIFIED TO PERFORM THE CONTROLLED ACTS AND/OR PROCEDURES OUTLINED BY THE PROVINCIAL MEDICAL ADVISORY COMMITTEE (PMAC). ______11 2.1) DESCRIBE THE PROCEDURE USED TO ENSURE PARAMEDICS ALREADY CERTIFIED UNDER THE AUTHORITY OF ANOTHER BASE HOSPITAL PROGRAM MEDICAL DIRECTOR ARE RECOGNIZED BY THE BASE HOSPITAL PROGRAM. ______11 2.2) TOTAL NUMBER OF PARAMEDICS THAT WORK FOR MORE THAN ONE EMPLOYER. ___ 12 3.0) PROVIDE A LIST OF AFFILIATED AMBULANCE SERVICES WITH WHOM THE BASE HOSPITAL HAS SIGNED AGREEMENTS. ______12 3.1) TOTAL NUMBER OF PCPS FOR THIS REPORTING YEAR. ______13 3.2) TOTAL NUMBER OF ACPS FOR THIS REPORTING YEAR. ______13 3.3) A LIST OF THE DELEGATED CONTROLLED ACTS. ______13 3.4) A LIST OF THE CONTROLLED ACTS THAT HAVE BEEN REMOVED THIS REPORTING YEAR. ______13 4.0) DOES THE HOST HOSPITAL ADHERE TO PROVINCIAL MEDICAL DIRECTIVES RECOMMENDED BY THE PMAC AND APPROVED BY THE DIRECTOR? ______13 5.1) HAVE THE PROVINCIAL CERTIFICATION, RECERTIFICATION, CHANGE IN CERTIFICATION AND REMEDIATION POLICIES, AS RECOMMENDED BY PMAC WITHIN RECOMMENDED TIMELINES BEEN ADHERED TO? ______13 5.2) TOTAL NUMBER OF INITIAL PCP AND ACP CERTIFICATIONS AWARDED IN THE REPORTING YEAR. ______13 5.3) TOTAL NUMBER OF PCPS AND ACPS REACTIVATED/RECERTFIED IN THE REPORTING YEAR ______14 5.4) TOTAL NUMBER OF PCPS AND ACPS DEACTIVATED/DECERTIFIED IN THE REPORTING YEAR. ______14 ANNUAL REPORT

6.1) DOES THE MEDICAL DIRECTOR PRACTICE EMERGENCY MEDICINE FULL TIME OR PART TIME IN THE HOSPITAL EMERGENCY UNIT? ______14 6.2) DOES THE MEDICAL DIRECTOR HOLD RECOGNIZED MEDICAL SPECIALTY CREDENTIALS IN EMERGENCY MEDICINE? ______14 7.1) DO ALL BASE HOSPITAL PHYSICIANS HAVE KNOWLEDGE OF PARAMEDIC PRACTICE AND PROVINCIAL MEDICAL DIRECTIVES? ______14 7.2) TOTAL NUMBER OF EMERGENCY PHYSICIANS ENGAGED AS A BASE HOSPITAL PHYSICIAN. ______14 8.1) TOTAL NUMBER OF BASE HOSPITAL PHYSICIAN AND PARAMEDIC ONLINE INTERACTIONS THAT HAVE BEEN REVIEWED FOR MEDICAL QUALITY. ______15 8.2) DESCRIBE THE MEDICAL QUALITY REVIEW PROCESS. ______16

MEDICAL OVERSIGHT ______17 9.0) LIST THE DATES OF PROVINCIAL MEDICAL ADVISORY COMMITTEE (PMAC) MEETINGS ATTENDED BY A MEMBER OF THE BASE HOSPITAL PROGRAM. ______17 10.0) ARE BASE HOSPITAL PHYSICIANS AVAILABLE FOR ON-LINE MEDICAL DIRECTION AND CONTROL ON A 24 HOUR/7 DAYS A WEEK BASIS? ______17 11.0) DOES EACH LAND AMBULANCE SERVICE AGREEMENT LIST THE REQUIREMENTS WITH REGARDS TO QUALIFICATION, ONGOING MEDICAL OVERSIGHT AND RE-QUALIFICATION OF PARAMEDICS TO DELIVER CONTROLLED MEDICAL ACTS UNDER THE AUTHORITY OF THE BASE HOSPITAL PROGRAM MEDICAL DIRECTOR? ______17 12.0) DESCRIBE THE ACTIONS TAKEN TO MONITOR THE DELIVERY OF PATIENT CARE IN ACCORDANCE WITH THE ADVANCED LIFE SUPPORT PATIENT CARE STANDARDS. ____ 17 13.0) PROVIDE A LIST OF ANY OF THE AGREEMENTS WITH UTM OR DDA THAT REQUIRES MONITORING OF THE DELIVERY OF PATIENT CARE IN ACCORDANCE WITH THE BASIC LIFE SUPPORT PATIENT CARE. ______18 14.1) TOTAL NUMBER OF PREHOSPITAL MEDICAL CARE ISSUES RAISED BY THE UTM OR DDA THAT REQUIRED ADVICE FROM THE BASE HOSPITAL. ______18 14.2) LIST THE TOP 5 SUBJECT AREAS THAT ADVICE WAS REQUESTED FROM UTMS AND DDAS. ______18 15.0) THE TOTAL NUMBER AND DATES OF PROVINCIAL, REGIONAL, AND COMMUNITY PLANNING MEETINGS. INDICATE THE MEETING HOSTS. ______19 16.1) HOW ARE REQUESTS FOR MEDICAL ADVICE, DIRECTION OR ASSISTANCE FROM AN EMERGENCY MEDICAL ATTENDANT, PARAMEDIC OR COMMUNICATIONS OFFICER PROVIDED? ______19 16.2) TOTAL NUMBER OF FORMAL REQUESTS FOR MEDICAL ADVICE DIRECTION OR ASSISTANCE FROM AN EMERGENCY MEDICAL ATTENDANT, PARAMEDIC OR COMMUNICATIONS OFFICER PROVIDED? ______19 17.0) THE TOTAL NUMBER AND NATURE OF INCIDENT REPORTS PROVIDED TO THE SENIOR FIELD MANAGER RELATED TO MEDICAL ADVICE DELAYS. ______21 18.1) DESCRIBE THE PROCESS USED TO ASSIST OPERATORS WITH REQUEST FOR ASSISTANCE AND INFORMATION REGARDING DIRECT PATIENT CARE COMPONENTS AND ELEMENTS OF LOCAL POLICY AND PROCEDURES. ______21

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18.2) LIST THE TOP 5 SUBJECT AREAS THAT INFORMATION WAS REQUESTED FROM OPERATORS. ______22

EDUCATION ______22 19.0) LIST THE TOPIC, DATE, AND LENGTH OF EACH CONTINUING MEDICAL EDUCATION PROGRAM OFFERED TO AND HELD FOR MEDICAL, NURSING AND OTHER ALLIED HEALTH STAFF OF THE HOST HOSPITAL AND RECEIVING HOSPITALS IN THE MINISTRY- APPROVED GEOGRAPHIC COVERAGE AREA. ______22 20.0) PROVIDE THE TOPICS AND TIME ALLOTTED FOR EACH EDUCATIONAL SESSION DELIVERED THIS YEAR TO PARAMEDICS. ______23 21.0) HOW IS THE EDUCATIONAL PLAN FOR THE REGION LINKED TO CONTINUOUS QUALITY IMPROVEMENT INITIATIVES? ______23 22.1) TOTAL NUMBER OF HOURS OF CME DELIVERED PER PCP. ______24 22.2) TOTAL NUMBER OF HOURS OF CME DELIVERED PER ACP. ______24

CONTINUOUS QUALITY IMPROVEMENT ______24 23.1) TOTAL NUMBER OF PARAMEDICS THAT HAVE BEEN PROVIDED WITH COMMENTARY BY THE HOST HOSPITAL AND A BRIEF DESCRIPTION OF THEIR PROGRAM. ______24 23.2) TOTAL NUMBER OF COMMENTARY PROVIDED TO ALL PARAMEDICS? ______24 23.3) WAS A MINIMUM OF ONE CHART REVIEW COMMENTARY PROVIDED TO EACH PARAMEDIC? ______24 24.0) THE HOST HOSPITAL SHALL ENSURE THE IMPLEMENTATION OF A CQI PROGRAM FOR EACH PARAMEDIC EMPLOYED OR ENGAGED BY LAND AMBULANCE SERVICE OPERATORS AS SET OUT IN APPENDIX D, AND ENSURE THE PROVISION OF REGULAR COMMENTARY TO EACH PARAMEDIC AND OPERATOR. ______24 25.0) LIST THE CQI ACTIVITIES FOR EMERGENCY MEDICAL ATTENDANTS AND PARAMEDICS. INCLUDE A SUMMARY OF EACH ACTIVITY. ______25 26.0) HOW AND WHEN WAS CQI DATA SHARED WITH EMERGENCY MEDICAL SERVICES SYSTEM STAKEHOLDERS? ______26 27.0) WHAT ON-LINE METHODS ARE USED TO ENSURE BASE HOSPITAL PHYSICIANS ARE ABLE TO PROVIDE ON-LINE CONTINUOUS MEDICAL DIRECTION? ______26 28.0) DESCRIBE THE MECHANISM THAT IS USED TO TRACK CUSTOMER INQUIRIES AND ORGANIZATIONAL RESPONSIVENESS TO THESE INQUIRIES AND SURVEY LAND AMBULANCE STAKHOLDER GROUPS ON A REGULAR BASIS, AND THAT ALL CONSUMER FEEDBACK WILL BE REVIEWED AND INTEGRATED INTO QUALITY MANAGEMENT PLANNING. ______26 29.1) TOTAL NUMBER OF AMBULANCE CALL REPORTS (ACRS) REQUIRING AUDITING. _____ 28 29.2) TOTAL NUMBER OF MEDICAL DIRECTIVE/PROTOCOLS AND CASES THAT HAVE BEEN AUDITED. ______29 29.3) HAVE ALL PARAMEDICS THAT HAVE PERFORMED AT LEAST 5 ACTS WITHIN THE ALS PCS HAD A MINIMUM OF 5 ACR AUDITED THIS YEAR? ______30 29.4) TOTAL NUMBER OF NEW PARAMEDICS (LESS THAN 6 MONTHS) AND TOTAL NUMBER WHO HAD 80% OF THEIR CHARTS AUDITED. ______31

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29.5) NUMBER OF CANCELLED CALLS WHERE PARAMEDICS MADE PATIENT CONTACT THAT WERE AUDITED. ______31

APPENDIX A: NEOPCP CONTINUING MEDICAL EDUCATION POLICY ______32

APPENDIX B: NEOPCP MEDICAL DIRECTIVES AND SKILLS REGISTRY ______35

APPENDIX C: NEOPCP MEETINGS ______40

APPENDIX D: 2013 QUALITY PROGRAMMING OVERVIEW ______43

APPENDIX E: QUALITY PROGRAMMING CLINCIAL AUDIT REPORTS ______49

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ADMINISTRATIVE INFORMATION

A. SUBMISSION DATE OF ANNUAL REPORT

. June 30, 2013

B. NEOPCP KEY FUNCTIONS

A Base Hospital is a hospital that has applied for and been designated as such by the Minister of Health and Long Term Care. A Base Hospital provides medical direction, leadership and advice in the provision of ambulance based pre-hospital emergency health care within a broad based, multi-disciplinary community emergency health services system in a specified geographical area. Base Hospital is a resource centre and facilitator assisting in ensuring that ambulance based pre-hospital care and transportation is meeting each community’s needs. The Base Hospital also functions in an advisory capacity to the Ministry of Health & Long-Term Care on matters relating to ambulance based pre-hospital emergency care.

Health Sciences North was designated as a Base Hospital by the Ministry of Health in 1986 (formerly the Sudbury General Hospital then Sudbury Regional Hospital). At that time, the Base Hospital was involved solely with the Ontario Air Ambulance Program. The program expanded to include Land Ambulance in 1988 with the advancement of land ambulance paramedic skills from Basic Life Support (BLS) to Advanced Life Support (ALS) including semi-automatic defibrillation and the administration of Symptom Relief drugs.

In 2008, Ontario Base Hospitals were realigned which resulted in a reduction of Programs from 21 to 7 and in 2009 the Sudbury Regional Hospital was designated as the Host Hospital for the Northeastern Region. Our core functions include: On-Line Medical Direction; Certification and Medical Delegation at the level of Primary Care Paramedic (PCP) and Advanced Care Paramedic (ACP), a rigorous Quality Assurance Program to ensure the safe delivery of prehospital care and Medical Education to 9 Designated Delivery Agents, encompassing 13 land ambulance services, and over 650 paramedics.

Medical Research Delegation

Education & CQI Certification

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C. BASE HOSPITAL STAFF . NEOPCP SITES Central Site Timmins Site Sault Ste Marie Site North Bay Site 202 - 7 Cedar Street 700 Ross Avenue East 65 Old Garden River Road 1164 Devonshire Avenue Sudbury, ON Timmins, ON Sault Ste. Marie, ON North Bay, ON P3E 1A2 P4N 8P2 P6B 5A5 P1B 6X7 Tel: 705.675.4783 Tel: 705.267.1711 Tel: 705.575.3199 Tel: 705.494.7246 Fax: 705.675.4713 Fax: 705.267.1712 Fax: 705.575.3891 Fax: 705:494.6163

MEDICAL ADVISORS Dr. Chris Loreto (.2 FTE) Dr. Derek Garniss (.2 FTE)

PARAMEDIC PRACTICE COORDINATORS Eric Levasseur (1 FTE) Marty Pilkington (1 FTE) Dan Langevin (1 FTE) Danny Raymond (A) Paramedic Practice Coordinator

PARAMEDIC EDUCATORS (Casual Staff) Steve Beaton Jason Cameron Karen Hatton Paul Kaldwell Dennis Quenneville Daniel Raymond Melissa Roney Cory Sohm Mark Trinier Curtis Watson

REGIONAL ADMINISTRATION Nicole Sykes (LOA Paul Myre (1 FTE) Dr. Jason Prpic (.6 Corey Petrie (1 FTE) since November 2012) (A) Regional Program FTE) (A) Regional Education Regional Program Manager Regional Medical Director Coordinator Manager Sylvie Michaud (1 FTE) Monique Lapointe Jim Scott (1 FTE) Tiffany Whiting (1 FTE) Performance Improvement (1 FTE) Performance Administrative Secretary Lead Special Projects Lead Measurement Lead

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D. PROGRAM HIGHLIGHTS

ELECTRONIC CHART REVIEW

In 2009, the NEOPCP adopted a 100% paperless audit process. Since then, eight EMS Services have adopted iMedic as their electronic platform and five EMS Services are utilizing Zoll. The purpose of the patient care record is to document the patient's clinical situation, history, and treatment. The chart is later used for NEOPCP quality improvement purposes. Our records are held on an internet-based server and paramedics access them through field computers or by using computers in their stations. The laptop computers communicate with the server through a broadband connection at the EMS station or Hospital. Privacy of electronic patient care records is extremely important, and NEOPCP has taken the proper steps to ensure that the information recorded is kept private. Not only is the information encrypted, but the software records any attempt to view a patient record. Information gathered from the cardiac monitor can be transferred to the electronic patient care record, including 12-lead ECG, blood pressure and other vital signs. Though this has not been adopted by all EMS Providers at this time, the NEOPCP strongly supports this endeavour in order to monitor the quality of care rendered on the call. An added feature to electronic platforms is that when the chart is completed by the medic, he or she then submits the form to the server which causes the chart to be faxed to the receiving hospital. Receiving hospitals can also opt to purchase electronic options to read the chart and see the ECG via the internet.

PARAMEDIC PROFESSIONAL ACTIVITY REGISTRY

The PPAR is a web based human resources and learning management system which tracks paramedic activities and provides online courses and examinations. Each Paramedic is provided an account which allows them to track their progress, review and register for upcoming courses, and take online examinations which provide them with their results through their email within minutes. This system also allows paramedics who take courses from other providers to upload certificates for consideration toward their CME credits.

RESEARCH PARTICIPATION

In 2012, NEOPCP participated in the Northern Ontario School of Medicine's Summer Studentship Program for the first time. The NOSM Summer Studentship provides summer employment to learners pursuing careers in professions outlined in the Regulated Health Professions Act. It encourages learners to set up practice in Northern Ontario upon graduation by addressing the recruitment of Health Care Professionals in Northern Ontario. NEOPCP recruited a first year medical through the NOSM Summer Studentship Program to work on a 12 Lead ECG and CPAP Study. This project was a non-interventional, retrospective chart review of all patients who presented via EMS between 2009 and 2011 to Timmins District Hospital or Sault Ste Marie Hospital who either had a ST-Elevation Myocardial Infarction OR were candidates for prehospital CPAP. This study looked for any variances in prehospital patient treatments, types of treatments received in hospital and the patient outcomes. Timmins and

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Sault Ste. Marie were selected based on their demographics and access to prehospital 12 Lead ECG and CPAP. Timmins did not have prehospital 12 Lead ECG or CPAP versus Sault Ste. Marie who did have prehospital 12 Lead ECG and CPAP. The data collection for this project was completed and the findings are currently in draft.

The primary aim of the Continuous Chest Compressions trial is to compare survival at hospital discharge after continuous chest compressions (CCC) versus standard American Heart Association-recommended cardiopulmonary resuscitation with interrupted chest compressions (ICC) in patients with out-of-hospital cardiac arrest. For this study, CCC consists of a series of three cycles of continuous chest compressions without pauses for ventilation followed by rhythm analysis, until restoration of spontaneous circulation or completion of the three cycles of CPR whichever occurs first. ICC consists of series of 3 cycles of standard CPR, each cycle comprised of six sets of 30 chest compressions with interposed ventilations at a compression:ventilation ratio of 30:2 (per AHA guidelines) followed by rhythm analysis until ROSC or three cycles of CPR whichever occurs first. Other aims of the trial are to compare survival to discharge and adverse events between control and intervention groups. The CCC trial is being done at 8 locations across the US and Canada. Almost 125 fire and EMS organizations, involving more than 20,000 fire and emergency medical service (EMS) providers who serve a combined population of nearly 15 million people from diverse urban, suburban and rural regions will participate in the study. Approximately 23,600 patients will be enrolled at all of the ROC regions in the United States and Canada. The study is expected to last approximately 3 years.

The Epistry Registry is an epidemiologic databank intended to help understand the burden of out-of-hospital cardiac arrest and life-threatening traumatic injury and to shed light on whether and how EMS process and geographic, socioeconomic and periodic variation may be associated with differences in outcome. The Epistry is designed to collate high-quality comprehensive Emergency Medical System (EMS) based data using uniform standardized criteria for consecutive cases of cardiac arrest and traumatic injury within the Resuscitation Outcomes Consortium (ROC). Epistry data collection commenced December 1, 2005. An approximate 20,000 episodes were enrolled in Epistry in the first year. In the 2012-13 fiscal, 273 cases were enrolled from the Sudbury Site.

The aims of Epistry include: 1. Establish a comprehensive ongoing data infrastructure to facilitate the design, implementation, and interpretation of ROC interventional trials. 2. Define the incidence and outcome of out-of-hospital cardiac arrest and traumatic injury. 3. Describe the relationships between resuscitation performance and EMS structure, adjusting for episode-specific factors 4. Evaluate the relationships between outcome and patient, EMS, regional, and periodic factors.

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NEOPCP WEBSITE

The program’s website located on the Health Sciences North platform is a public repository for communications, policies and procedures, medication references, forms, provincial medical directives, a library of training materials and archived presentations, upcoming events, current research activities, published research of interest and important links. Coming soon is the paramedic self-reporting tool, in praise of paramedics and ask a medical advisor forum.

VIDEOCONFERENCE

Providing education to over 650 paramedics across one of the largest geographical regions in Ontario can pose significant challenges. To meet these challenges, the NEOPCP has partnered with the Ontario Telemedicine Network (OTN) in 2009. As the largest videoconferencing network in the world, OTN is available in telemedicine studios located at more than 1500 sites across the Province thus enabling over 350,000 health care professionals to participate in OTN- facilitated education sessions annually. Using point-to-point and multi- point videoconferencing, the NEOPCP is able to offer reasonably equitable learning opportunities to the entire region via live streaming and webcasting (live and archived) platforms. Videoconferencing enables the connectivity by the Northeast Region Paramedics to the Base Hospital for real time educational, certification and administrative purposes. By reducing the barriers of time and distance, videoconferencing makes it possible for paramedics to participate in a higher level of learning.

STEMI ALERT

The Heart and Stroke Foundation of Canada estimates 70,000 heart attacks occur in Canada every year which equates to one every 7 minutes. STEMI (which stands for ST segment-Elevation Myocardial Infarction) is representative of the most severe type of heart attack involving a sudden blockage of one of the coronary arteries. The Health Sciences North Cardiodiagnostics and Emergency Department, with collaboration from the NEOPCP and the City of Greater Sudbury EMS, developed a protocol whereby when a STEMI is recognized in the Pre-Hospital setting, a “STEMI ALERT” is declared. This declaration triggers the pre-notification of the receiving department (either ED or Cath Lab) activating a series of intra-departmental processes where resources are rapidly focused on preparing for definitive interventions. This protocol drastically reduces the diagnosis to intervention times by allowing the receiving departments to prepare for the patient's arrival and streamline the continuum of care. The 2012-13 statistics were not available to accommodate the deadline of this report however these statistics will be added to this report once they become available..

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RBH PERFORMANCE AGREEMENT INFORMATION

MEDICAL DELEGATION 1.0) DESCRIBE THE PROCESS USED TO ENSURE EMERGENCY MEDICAL ATTENDANTS AND PARAMEDICS ARE QUALIFIED TO PERFORM THE CONTROLLED ACTS AND/OR PROCEDURES OUTLINED BY THE PROVINCIAL MEDICAL ADVISORY COMMITTEE (PMAC).

The NEOPCP is mandated by the Ambulance Act (Ontario Reg. 257/00) to ensure that paramedics are competent to practice. The method by which paramedics are certified is strongly influenced by the Delegation of Controlled Acts policy developed by the College of Physicians and Surgeons of Ontario. In short, it is the responsibility of the Regional Base Hospital Programs to provide an ongoing process by which the ‘providers’ are continuously informed of best practice guidelines and new trends and are competent to practice in the pre-hospital environment. As no single process can accomplish these goals, the NEOPCP combined various methodologies and techniques to be utilized as part of a comprehensive continuing education program. The goal of the CME program is to prepare paramedics to respond appropriately to a wide range of patient situations both routinely and infrequently encountered in the field.

The Ministry of Health and Long Term Care’s Emergency Health Services Branch has mandated that PCPs must receive a minimum of 8 hours of CME and that ACPs must receive a minimum of 24 hours of CME annually. To meet the needs of the service operators, paramedics and the Regional Base Hospital Programs, these hours have been converted to credit hours. In order for Northeast Paramedics to remain in good standing and maintain certification, ACPs must accumulate 24 credit hours while PCPs must accumulate 8 credit hours by the first week in December of each calendar year. Further, every Paramedic must successfully complete an annual written Certification Examination. Paramedics who do not meet these requirements are subject to a performance review by the Medical Director or delegate and may have their certification temporarily suspended until such a time that all mandatory CME credit hours are accumulated.

Refer to Appendix A: NEOPCP’s Continuing Medical Education Policy

2.1) DESCRIBE THE PROCEDURE USED TO ENSURE PARAMEDICS ALREADY CERTIFIED UNDER THE AUTHORITY OF ANOTHER BASE HOSPITAL PROGRAM MEDICAL DIRECTOR ARE RECOGNIZED BY THE BASE HOSPITAL PROGRAM.

Cross Certification applies to paramedics already certified by an Ontario Base Hospital who are seeking certification from another Base Hospital. In order to be eligible for cross certification, once the paramedic is deemed eligible as per regulations of the Ambulance Act, the Paramedic must complete our Certification Request Form which includes: 1. Certification from previous Ontario Base Hospitals. 2. A declaration of any deactivation and/or decertification.

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3. Current certification status from previous Base Hospitals under which the paramedic is certified. 4. Permission for the prospective Base Hospital to obtain information from other Base Hospitals regarding paramedic performance and skills. Following these steps the Paramedic must successfully complete a Base Hospital orientation and/or evaluation process which may include an interview/clinical evaluation with the medical director or delegate and should not exceed one (1) day in duration. It may also include an evaluation using written, scenario based, and oral examinations. Upon the NEOPCP review of documentation received and orientation, the medical director may recommend educational certification [1] pending completion of further clinical or field education. After completion of these steps, the Base Hospital Medical Director renders a decision whether or not to certify the paramedic.

2.2) TOTAL NUMBER OF PARAMEDICS THAT WORK FOR MORE THAN ONE EMPLOYER.

. 54

3.0) PROVIDE A LIST OF AFFILIATED AMBULANCE SERVICES WITH WHOM THE BASE HOSPITAL HAS SIGNED AGREEMENTS.

UTM/DDA AFFILIATED AMBULANCE SERVICES

Algoma District Services . Algoma EMS Administration Board City of Greater Sudbury . City of Greater Sudbury Emergency Services Cochrane District Social Services . Cochrane District EMS Administration Board . Notre Dame Hospital AS . Sensenbrenner Hospital AS The Corporation of the City of . Sault Ste. Marie EMS Sault Ste. Marie District of Nipissing Social . North Bay and District EMS Services Administration Board . Mattawa General Hospital AS . Temagami AS District of Timiskaming Social . District of Timiskaming EMS Services Administration Board Manitoulin-Sudbury District . Manitoulin-Sudbury EMS Services Board The Town Parry Sound . Parry Sound District EMS Weeneebayko Health Authority . James Bay Ambulance Service

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3.1) TOTAL NUMBER OF PCPS FOR THIS REPORTING YEAR.

Reporting Period: April 01, 2012 to March 31, 2013 Total PCPs 669

3.2) TOTAL NUMBER OF ACPS FOR THIS REPORTING YEAR.

Reporting Period: April 01, 2012 to March 31, 2013 Total ACPs: 69

3.3) A LIST OF THE DELEGATED CONTROLLED ACTS.

The NEOPCP certifies paramedics under the designations of Primary Care Paramedic and Advanced Care Paramedic. To hold certification at any given designation, a paramedic must meet and maintain all requirements for that designation. Paramedics practicing at the primary or advanced care level, under the authority of the NEOPCP, are certified in the controlled acts and medical directives enumerated in Appendix 1 and 2 of the Advanced Life Support Patient Care Standards, Version 3.0. In addition to this, Paramedics practicing in specified areas within the NEOPCP are certified in the controlled acts and medical directives found in Appendix 3 and 4 (Auxiliary Medical Directives) of the Advanced Life Support Patient Care Standards, Version 3.0. Refer to Appendix B: NEOPCP Medical Directives Skills Registry

3.4) A LIST OF THE CONTROLLED ACTS THAT HAVE BEEN REMOVED THIS REPORTING YEAR.

None

4.0) DOES THE HOST HOSPITAL ADHERE TO PROVINCIAL MEDICAL DIRECTIVES RECOMMENDED BY THE PMAC AND APPROVED BY THE DIRECTOR?

Yes

5.1) HAVE THE PROVINCIAL CERTIFICATION, RECERTIFICATION, CHANGE IN CERTIFICATION AND REMEDIATION POLICIES, AS RECOMMENDED BY PMAC WITHIN RECOMMENDED TIMELINES BEEN ADHERED TO?

NEOPCP adheres to the Provincial Maintenance of Certification Policy, Appendix 6 in the Advanced Life Support Patient Care Standards, Version 3.0.

5.2) TOTAL NUMBER OF INITIAL PCP AND ACP CERTIFICATIONS AWARDED IN THE REPORTING YEAR.

Reporting Period: April 01, 2012 to March 31, 2013 Total ACPs: 0 Total PCPs 52

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5.3) TOTAL NUMBER OF PCPS AND ACPS REACTIVATED/RECERTFIED IN THE REPORTING YEAR

Reporting Period: April 01, 2012 to March 31, 2013 Total ACPs: 6 Total PCPs 28

5.4) TOTAL NUMBER OF PCPS AND ACPS DEACTIVATED/DECERTIFIED IN THE REPORTING YEAR.

Reporting Period: April 01, 2012 to March 31, 2013 Total ACPs: 8 Total PCPs 65

6.1) DOES THE MEDICAL DIRECTOR PRACTICE EMERGENCY MEDICINE FULL TIME OR PART TIME IN THE HOSPITAL EMERGENCY UNIT?

Yes.

6.2) DOES THE MEDICAL DIRECTOR HOLD RECOGNIZED MEDICAL SPECIALTY CREDENTIALS IN EMERGENCY MEDICINE?

. Doctorate of Medicine at the University of Ottawa . Completed his CCFP Certification in 2001 . Completed CCFP (EM) Certification in 2002 at the Northern Ontario Family Medicine Program, Sudbury, Ontario.

7.1) DO ALL BASE HOSPITAL PHYSICIANS HAVE KNOWLEDGE OF PARAMEDIC PRACTICE AND PROVINCIAL MEDICAL DIRECTIVES?

NEOPCP has centralized all BHP patching to the Health Sciences North Emergency Department. Base Hospital Physicians are all Emergency Department Physicians and final year Residents credentialed through Health Sciences North. The Emergency Department Physicians receive an orientation program which includes an overview of their roles and responsibilities as base hospital physicians and an introduction to the ALS Patient Care Standards. Dr. Prpic, Medical Director, regularly reviews the directives and/or amendments with the emergency physicians and shares CQI findings.

7.2) TOTAL NUMBER OF EMERGENCY PHYSICIANS ENGAGED AS A BASE HOSPITAL PHYSICIAN.

. 27 emergency physicians are engaged as base hospital physicians. o Refer to 8.1 Figure 2 for list of physician names.

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8.1) TOTAL NUMBER OF BASE HOSPITAL PHYSICIAN AND PARAMEDIC ONLINE INTERACTIONS THAT HAVE BEEN REVIEWED FOR MEDICAL QUALITY.

Figure 1

Online Interactions Reviewed by Medical Director for Medical Quality n=369

Audited Non Audited

70 (19%)

299 (81%)

NOTE: Nineteen percent of the interactions could not be audited due to the inability to match an ACR with the patch form.

Figure 2

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8.2) DESCRIBE THE MEDICAL QUALITY REVIEW PROCESS.

BHP Provides On Line Medical Advice and completes a record on the "Patch Form".

Patch Form is forwarded to NEOPCP. Form is "married" with ACR and enterred in Database.

Medical Director or Advisor reviews Patch Form and ACR. Feedback is given to BHP as needed. Initiates an Ambulance Call Evaluation for investigation, if required.

Data is reviewed by the Quality of Care Committee & Regional Progarm Committee on regular basis and CQI findings are shared with BHPs and ED physician staff meetings.

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MEDICAL OVERSIGHT

9.0) LIST THE DATES OF PROVINCIAL MEDICAL ADVISORY COMMITTEE (PMAC) MEETINGS ATTENDED BY A MEMBER OF THE BASE HOSPITAL PROGRAM.

. May 9, 2012 . September 10, 2012 . December 10, 2012 . February 11, 2013

10.0) ARE BASE HOSPITAL PHYSICIANS AVAILABLE FOR ON-LINE MEDICAL DIRECTION AND CONTROL ON A 24 HOUR/7 DAYS A WEEK BASIS?

Yes.

11.0) DOES EACH LAND AMBULANCE SERVICE AGREEMENT LIST THE REQUIREMENTS WITH REGARDS TO QUALIFICATION, ONGOING MEDICAL OVERSIGHT AND RE-QUALIFICATION OF PARAMEDICS TO DELIVER CONTROLLED MEDICAL ACTS UNDER THE AUTHORITY OF THE BASE HOSPITAL PROGRAM MEDICAL DIRECTOR?

Yes, a current signed MOU between the Regional Base Hospital Program and each UTM/DDA is on file.

12.0) DESCRIBE THE ACTIONS TAKEN TO MONITOR THE DELIVERY OF PATIENT CARE IN ACCORDANCE WITH THE ADVANCED LIFE SUPPORT PATIENT CARE STANDARDS.

Continuous quality improvement (CQI) is a complex responsibility that requires the collective effort of varied focus areas. Within the NEOPCP, CQI is attained through an integrated system of performance measurement, performance improvement and continuing medical education within a broad based system of quality management and medical leadership. Refer to Appendix D: 2013 Quality Programming Overview.

Performance Measurement is accomplished primarily by collecting and randomly reviewing ambulance call reports (ACRs) where Advanced Life Support (ALS) skill sets were performed and/or not performed when they should have been. Skills and specific patient conditions are categorized as either high or low risk procedures by the Northeastern Ontario Prehospital Care Program (NEOPCP) Quality of Care Committee (QCC). Tables 1 & 2 from Appendix N of the NEOPCP Performance Agreement (PA) are then applied to determine the total number of calls to be reviewed through the Ambulance Call Evaluation (ACE) process.

Performance Improvement endeavours are essential in the development of a strong system that allows the NEOPCP to examine how the overall patient care system is working and identifies general areas of weakness or concern to enable wide spread

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change. The NEOPCP continues to develop benchmarks that we measure against and develop Continuing Medical Education (CME), which is disseminated to our paramedics and services, as a means to improving overall system and practitioner quality. Refer to Appendix E: Quality Programming Clinical Audit Reports.

The need and importance of a wide overlap between performance measurement, performance improvement and Continuing Medical Education (Fig. 3) is vital to ensure ongoing quality patient care as demonstrated in the well-known and widely used Plan- Do-Study-Act cycle (Fig. 4).

Figure 3 Figure 4

13.0) PROVIDE A LIST OF ANY OF THE AGREEMENTS WITH UTM OR DDA THAT REQUIRES MONITORING OF THE DELIVERY OF PATIENT CARE IN ACCORDANCE WITH THE BASIC LIFE SUPPORT PATIENT CARE.

None.

14.1) TOTAL NUMBER OF PREHOSPITAL MEDICAL CARE ISSUES RAISED BY THE UTM OR DDA THAT REQUIRED ADVICE FROM THE BASE HOSPITAL.

The NEOPCP does not log the number of times Paramedic Practice Coordinators and/or Medical Directors provided routine feedback. When an inquiry requires investigation involving patient care, an incident is opened in the iMedic Program and the information is shared electronically with the service (iMedic/email). Final outcomes are copied to the Field Office.

14.2) LIST THE TOP 5 SUBJECT AREAS THAT ADVICE WAS REQUESTED FROM UTMS AND DDAS.

1) Auxiliary Skills

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2) Medical Pharmacological 3) Various Equipment

15.0) THE TOTAL NUMBER AND DATES OF PROVINCIAL, REGIONAL, AND COMMUNITY PLANNING MEETINGS. INDICATE THE MEETING HOSTS.

Refer to Appendix C: NEOPCP Meetings

16.1) HOW ARE REQUESTS FOR MEDICAL ADVICE, DIRECTION OR ASSISTANCE FROM AN EMERGENCY MEDICAL ATTENDANT, PARAMEDIC OR COMMUNICATIONS OFFICER PROVIDED?

The following are the primary methods of communication: . 24/7 Online Medical Direction and Control through the Base Hospital Physicians. . iMedic which is used to discuss audit findings and patient care dialogues. . Email which is used for the communication of general information and notifications. . Live chats during webcasts are a means for paramedics to ask questions and interact with their medical directors.

16.2) TOTAL NUMBER OF FORMAL REQUESTS FOR MEDICAL ADVICE DIRECTION OR ASSISTANCE FROM AN EMERGENCY MEDICAL ATTENDANT, PARAMEDIC OR COMMUNICATIONS OFFICER PROVIDED?

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Figure 5

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Figure 6

17.0) THE TOTAL NUMBER AND NATURE OF INCIDENT REPORTS PROVIDED TO THE SENIOR FIELD MANAGER RELATED TO MEDICAL ADVICE DELAYS.

. Five incidents reported to the Senior Field Manager. . There is no formal tracking system available to the NEOPCP therefore this is not reliably quantifiable. ‘Patch failure’ is a poorly defined entity that varies from Base Hospital to Base Hospital. The only means the NEOPCP has to track delays is to rely on someone making a complaint and these occurrences would be tracked via our investigations process.

18.1) DESCRIBE THE PROCESS USED TO ASSIST OPERATORS WITH REQUEST FOR ASSISTANCE AND INFORMATION REGARDING DIRECT PATIENT CARE COMPONENTS AND ELEMENTS OF LOCAL POLICY AND PROCEDURES.

Once a request for assistance and/or information has been received in writing by the program it is triaged by the receiver to determine if its nature is Medical, Educational, CQI, Research, Operational or Other. . Medical advice and/or inquiries are reviewed by the applicable Medical Advisor or the Regional Medical Director and, when required, forwarded to the Quality of Care Committee to be reviewed by the Medical Program as a whole. . Educational advice and/or inquiries are assigned to the Regional Education Coordinator for review and, when required, brought to monthly Council meetings. A Medical Advisor or the Regional Medical Director may be consulted, as needed.

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. Quality improvement advice and/or inquiries are forwarded to the Performance Improvement Lead for review. A Medical Advisor or the Regional Medical Director may be consulted, as needed. . Assistance or information related to reportable program metrics are forwarded to the Performance Measurement Lead for review. . Operational advice and/or inquiries are forwarded to the applicable Paramedic Practice Coordinator and, when required, forwarded to the monthly Council meetings for review. . Research inquiries are forwarded to the Performance Improvement Lead or Regional Manager and when required, the Regional Medical Director is consulted.

18.2) LIST THE TOP 5 SUBJECT AREAS THAT INFORMATION WAS REQUESTED FROM OPERATORS.

1) Cardiac Arrest, ALS PCS 2) 12 Lead ECG, ALS PCS 3) Continuous Positive Airway Pressure Devices (CPAP), ALS PCS 4) Medical Pharmacological advice 5) ACR Overview Advice (QA)

EDUCATION

19.0) LIST THE TOPIC, DATE, AND LENGTH OF EACH CONTINUING MEDICAL EDUCATION PROGRAM OFFERED TO AND HELD FOR MEDICAL, NURSING AND OTHER ALLIED HEALTH STAFF OF THE HOST HOSPITAL AND RECEIVING HOSPITALS IN THE MINISTRY-APPROVED GEOGRAPHIC COVERAGE AREA.

Date Topic / Presenter Hours September 17, Hidden Gems within the Vital Signs 1.25 2012 Dr. Derek Garniss September 27, Drugs in My Pocket 1.5 2012 Dr. Chris Loreto September 2012 - Party Program 2.5 March 2013 Jim Scott, Dan Langevin October 18,19 Nipissing EMS Symposium 12 2012 Nicole Sykes, Paul Myre, Dr. Jason Prpic November 22, 2012 Not Documented - Not Done 1.5 Dr. Chris Loreto January 22, 2013 Diagnosis not as evident as you may think. Are they 1 really just intoxicated? Dr. Derek Garniss February 2013- CPR & AED 4 March 2013 March 27, 2013 Point of Care Ultrasound for Paramedics 1.25 Dr. Steven Socransky Various dates CPR Programs 5

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20.0) PROVIDE THE TOPICS AND TIME ALLOTTED FOR EACH EDUCATIONAL SESSION DELIVERED THIS YEAR TO PARAMEDICS.

Date Topic Hours April 1, 2012 – Clinical Practicum for ACPs, 4 hr MD shadowing in 4 October 25, 2012 ED April 1, 2012- Clinical Practicum: Hospital Rotation 8 December 1, 2012 8 hour rotation based on needs assessment July 2012 - August, ACP Summer CME Series 4 2012 September 17, Hidden Gems within the Vital Signs 1.25 2012 Dr. Derek Garniss September 27, Drugs in My Pocket 1.5 2012 Dr. Chris Loreto October 2012 - Autonomous Intravenous Program 12 March 2013 November 22, 2012 Not Documented - Not Done 1.5 Dr. Chris Loreto January 22, 2013 Diagnosis not as evident as you may think. Are they 1 really just intoxicated? Dr. Derek Garniss March 27, 2013 Point of Care Ultrasound for Paramedics 1.25 Dr. Steven Socransky Spring 2012 Paramedic Practice Rounds for ACPs and PCPs 4 Presented by Paramedic Practice Coordinators Fall 2012 Paramedic Practice Rounds for ACPs and PCPs 4 Presented by Paramedic Practice Coordinators

21.0) HOW IS THE EDUCATIONAL PLAN FOR THE REGION LINKED TO CONTINUOUS QUALITY IMPROVEMENT INITIATIVES?

Data captured as per Quality Programming Plan

Presented to Results Monitored Quality of Care Committee

Presented to Reviewed and Regional Program recommendations Committee made

Education Forwarded to Education for CME implemented development

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22.1) TOTAL NUMBER OF HOURS OF CME DELIVERED PER PCP.

. 8 Minimum. . Refer to section 20.0 for a complete list of courses.

22.2) TOTAL NUMBER OF HOURS OF CME DELIVERED PER ACP.

. 24 Minimum. . Refer to section 20.0 for a complete list of courses.

CONTINUOUS QUALITY IMPROVEMENT

23.1) TOTAL NUMBER OF PARAMEDICS THAT HAVE BEEN PROVIDED WITH COMMENTARY BY THE HOST HOSPITAL AND A BRIEF DESCRIPTION OF THEIR PROGRAM.

All paramedics certified under the Program receive commentary on a regular basis, generally via the applicable Paramedic Practice Coordinator for their area. Commentary may include electronic distribution of memos, policies and other documents. As part of auditing activities, paramedics are provided with commentary on at least 5 of their ALS scope ACRs, if that many calls have been completed. Additionally, paramedics receive positive commentary via the Program’s electronic Ambulance Call Evaluation system whenever possible.

23.2) TOTAL NUMBER OF COMMENTARY PROVIDED TO ALL PARAMEDICS?

Program only tracks the total number of commentary provided with respect to Ambulance Call Evaluations. For fiscal 2012-2013, the Program completed this commentary on 4,399 (40%) calls. (Refer to Section 29.3)

23.3) WAS A MINIMUM OF ONE CHART REVIEW COMMENTARY PROVIDED TO EACH PARAMEDIC?

A minimum of one chart review was completed if the paramedic completed at least one ALS call in the system. . Refer to Section 29.3 for the total number of ambulance call reports (ACRs) completed.

24.0) THE HOST HOSPITAL SHALL ENSURE THE IMPLEMENTATION OF A CQI PROGRAM FOR EACH PARAMEDIC EMPLOYED OR ENGAGED BY LAND AMBULANCE SERVICE OPERATORS AS SET OUT IN APPENDIX D, AND ENSURE THE PROVISION OF REGULAR COMMENTARY TO EACH PARAMEDIC AND OPERATOR.

Refer to Sections 12.0, 23.1 to 23.3, 25.0, 26.0.

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25.0) LIST THE CQI ACTIVITIES FOR EMERGENCY MEDICAL ATTENDANTS AND PARAMEDICS. INCLUDE A SUMMARY OF EACH ACTIVITY.

Initial Certification Paramedics seeking certification from the NEOPCP must complete an orientation program and, when applicable, an initial certification prior to commencement of their first shift. This session provides the paramedic with an in depth introduction to the Program’s Medical Directives and operational expectations and provides an overview of paramedic readiness to practice. When a paramedic is not able to achieve the minimum standard as per NEOPCP policy “Initial Evaluation Standards”, the paramedic is provided with a remedial plan to prepare for additional attempts. The Program permits a maximum of 3 attempts if supported by the employer. Unsuccessful paramedics are not able to return for a fourth challenge unless there are exceptional circumstances and only after extensive, in-depth remediation is completed.

Annual Recertification Paramedics seeking Annual Recertification must complete the required annual education including the associated evaluation process consisting of written, oral and simulated evaluations as applicable. Paramedics unable to meet the minimum standards are either provided with provisional status and given time to remediate or, if applicable (i.e. critical errors), may be temporary deactivated until such time the Program deems the paramedic safe to practice.

CME Topics offered during the Lectures Series and Education Sessions are based on CQI findings and/or paramedic requests.

Chart Reviews Chart audits are completed on a monthly basis and results are compiled. Critical Errors and/or Major errors are managed immediately while minor errors are communicated using Memorandum, Web Tutorials, etc. The PPAR is used to monitor compliance rate.

Skill Reviews Skills Reviews are compiled and shared biannually. High Risk/Low Volume skills are reviewed at Paramedic Practice Rounds and/or assessed during OSCE style evaluations.

Paramedic Practice Rounds NEOPCP provides a minimum of 2 face to face educational opportunities per year in the form of Paramedic Practice Rounds. Those who cannot attend rounds are able to view a web cast of the session via OTN. These sessions are planned around CQI findings.

Training Bulletins Training Bulletins are used when information is required to be disseminated to all paramedics.

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26.0) HOW AND WHEN WAS CQI DATA SHARED WITH EMERGENCY MEDICAL SERVICES SYSTEM STAKEHOLDERS?

What Who Frequency Access to Chart Audits . All Services Once ACE created and EMS copied in electronic platform Immediate notification of Major . Paramedics Upon discovery and Critical inquiries to . Service Providers Paramedics and EMS Provider Individual performance . Paramedics Quarterly measurement reports detailing . Service Providers number of audits completed, level of deficiency (minor, major, critical), Call Number and Paramedics’ name Individual Paramedic Skill Report . Paramedics Annually . Service Providers Ad Hoc CQI Findings . Service Providers Regional Program Committee

27.0) WHAT ON-LINE METHODS ARE USED TO ENSURE BASE HOSPITAL PHYSICIANS ARE ABLE TO PROVIDE ON-LINE CONTINUOUS MEDICAL DIRECTION?

Due to the vast square footage of the Emergency Department, BHPs are not always in the proximity of one of the dedicated BHP phones therefore all RNs in the Emergency Department have been trained, through the Nurse Educator, to answer the patch phone to advise medics that a BHP will be in attendance shortly. The RN answering the phone is responsible for notifying the BHP of the call and advising the paramedic if there will be any delay. This has helped to decrease the number delayed patches. Reminder emails are sent on a regular basis to help keep this process consistent.

NEOPCP has provided formal education to the paramedics on patching to help improve the process. This was achieved via lecture series and information has been posted on the NEOPCP website. The key objectives are to improve communication, provide direction to the BHP during the patch and to provide guidance to the paramedic in the event of a failed patch.

28.0) DESCRIBE THE MECHANISM THAT IS USED TO TRACK CUSTOMER INQUIRIES AND ORGANIZATIONAL RESPONSIVENESS TO THESE INQUIRIES AND SURVEY LAND AMBULANCE STAKHOLDER GROUPS ON A REGULAR BASIS, AND THAT ALL CONSUMER FEEDBACK WILL BE REVIEWED AND INTEGRATED INTO QUALITY MANAGEMENT PLANNING.

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ANNUAL REPORT survey results were used to address the quality and quantity of stakeholder reporting and the quantity of research participation by implementing the following recommendations. Realignment of staff with the creation of a Performance Measurement Lead and an amendment of the current CQI position to the Performance Improvement Lead. Development of the 2012 Quality Programming Overview. This document was brought back to the program committee for review in the Fall of 2012. A refined 2013 Quality Programming Overview was developed as a result of further feedback.

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29.1) TOTAL NUMBER OF AMBULANCE CALL REPORTS (ACRS) REQUIRING AUDITING.

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29.2) TOTAL NUMBER OF MEDICAL DIRECTIVE/PROTOCOLS AND CASES THAT HAVE BEEN AUDITED.

. Refer to 29.1.

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29.3) HAVE ALL PARAMEDICS THAT HAVE PERFORMED AT LEAST 5 ACTS WITHIN THE ALS PCS HAD A MINIMUM OF 5 ACR AUDITED THIS YEAR?

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29.4) TOTAL NUMBER OF NEW PARAMEDICS (LESS THAN 6 MONTHS) AND TOTAL NUMBER WHO HAD 80% OF THEIR CHARTS AUDITED.

The Program monitors a minimum of 80% of ALS Calls performed by newly certified Paramedics. This activity is an ongoing and ever changing as new paramedics are brought into the numerous services throughout our area with many differing start dates. (Refer to section 5.2 for number of new hires.)

29.5) NUMBER OF CANCELLED CALLS WHERE PARAMEDICS MADE PATIENT CONTACT THAT WERE AUDITED.

. 519 (Refer to 29.1)

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APPENDIX A: NEOPCP CONTINUING MEDICAL EDUCATION POLICY

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APPENDIX B: NEOPCP MEDICAL DIRECTIVES AND SKILLS REGISTRY

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APPENDIX C: NEOPCP MEETINGS

TOTAL MEETINGS BY TYPE Regional: 23 Provincial: 38 Community: 9

Date Subject Location REGIONAL MEETINGS April 25, 2012 NEOPCP Quality Care Committee Sudbury/Videoconference May 25, 2012 NEOPCP Quality Care Committee Sudbury/Videoconference May 25, 2012 NEOPCP Council Sudbury/Videoconference June 19, 2012 NEOPCP Program Committee Sudbury/Videoconference June 20, 2012 NEOPCP Quality Care Committee Sudbury/Videoconference June 20, 2012 NEOPCP Council Sudbury/Videoconference September 19, 2012 NEOPCP Quality Care Committee Sudbury/Videoconference September 19, 2012 NEOPCP Council Sudbury/Videoconference October 3, 2012 NEOPCP Program Committee Sudbury/Videoconference October 24, 2012 NEOPCP Quality Care Committee Sudbury/Videoconference October 24, 2012 NEOPCP Council Sudbury/Videoconference November 28, 2012 NEOPCP Quality Care Committee Sudbury/Videoconference November 28, 2012 NEOPCP Council Sudbury/Videoconference December 13, 2012 NEOPCP Council Sudbury/Videoconference December 19, 2012 NEOPCP Quality Care Committee Sudbury/Videoconference January 23, 2013 NEOPCP Quality Care Committee Sudbury/Videoconference January 23, 2013 NEOPCP Council Sudbury/Videoconference February 12, 2013 NELHIN Regional Stroke Review Sudbury/Videoconference February 27, 2013 NEOPCP Quality Care Committee Sudbury/Videoconference February 27, 2013 NEOPCP Council Sudbury/Videoconference March 20, 2013 NEOPCP Program Committee Sudbury/Videoconference March 27, 2013 NEOPCP Quality Care Committee Sudbury/Videoconference March 27, 2013 NEOPCP Council Sudbury/Videoconference

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PROVINCIAL MEETINGS April 10, 2012 OBHG Education Teleconference April 19, 2012 AMEMSO Board Meeting Teleconference May 7-10, 2012 OBHG Conference Sudbury May 8, 2012 OBHG Quality Management Sudbury May 8, 2012 OBHG Directors Sudbury May 8, 2012 OBHG Executive Sudbury May 9, 2012 OBHG MAC Sudbury May 9, 2012 OBHG Directors and Medical Directors Sudbury May 17, 2012 Panel Presentation, AMEMSO Spring Meeting Toronto June 26, 2012 OBHG Education Toronto June 28, 2012 AMEMSO Board Meeting Teleconference July 20, 2012 OBHG Directors Toronto August 28, 2012 OBHG Education Teleconference August 28 & 29, 2012 Sudbury Base Hospital Review Sudbury September 10, 2012 OBHG MAC Toronto September 11, 2012 OBHG Executive Toronto October 18, 2012 AMEMSO Board Meeting Teleconference October 30, 2012 OBHG Education Teleconference November 15, 2012 AMEMSO Board Meeting Teleconference November 27, 2012 OBHG Directors Teleconference December 10, 2012 OBHG MAC Toronto December 11, 2012 OBHG Executive Toronto December 17, 2012 OBHG Education Toronto December 18, 2012 OBHG Education Toronto December 20, 2012 AMEMSO Board Meeting Teleconference January 2, 2013 OBHG Directors Teleconference January 17, 2013 AMEMSO Board Meeting Teleconference January 17, 2013 OBHG/OPA Meeting Teleconference January 25, 2013 OBHG Directors and Medical Directors Teleconference February 11, 2013 OBHG MAC Toronto February 11, 2013 OBHG Quality Management Teleconference February 12, 2013 OBHG Executive Toronto February 21, 2013 AMEMSO Board Meeting Teleconference

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February 25, 2013 OBHG Education Toronto March 12, 102 Pilot Data Transfer between HSN and Sunnybrook Teleconference March 21, 2013 AMEMSO Board Meeting Teleconference March 22, 102 Pilot Data Transfer between HSN and Sunnybrook Teleconference March 25, 2013 OBHG Directors and Medical Directors Teleconference COMMUNITY MEETINGS April 12, 2012 CACC Advisory Meeting Sudbury June 13, 2012 NEOPCP/GSEMS Meeting Sudbury June 20, 2012 Emergency Preparedness Sudbury September 18, 2012 NEOPCP/GSEMS Meeting Azilda October 25, 2012 NEOPCP/GSEMS Meeting Sudbury November 21, 2012 Emergency Preparedness Sudbury February 6, 2013 NEOPCP/Manitoulin Sudbury EMS Meeting Sudbury March 20, 2013 Emergency Preparedness Sudbury March 27, 2013 NEOPCP/GSEMS Meeting Azilda