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ESC102 Engineering Science Praxis II Spring 2012

|Request for Proposal:

Reducing EMS Vertical Response Time for High-Rise Buildings in Church-Yonge Corridor Neighbourhood
February 19th, 2012

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ABSTRACT
Toronto Emergency Medical Services (EMS) is the sole provider of ambulance service in the City of Toronto1. This RFP identifies the exclusion of vertical response time, which is measured from arrival on-scene to arrival at-patient, fromthe current definition of EMS response time. Furthermore, this proposal investigates the key factors that increase vertical response time and explores the significance of the need to reduce vertical response time which reduces patients impairmentand increases the survival rate of acute emergencies. More specifically, this RFP focuses on addressing the issue of vertical response time in ChurchYonge Corridor Neighbourhood, due to its high density of high-rise buildings2 and relatively high rate of emergency department visits among its population, comparing to the rate of the entire City of Toronto3. The high ratio of emergency department visits is due to high density of people who live is high-rise buildings in this neighbourhood. The engineering problem is to provide a more accessible solution for EMS to reach the patients who live on fifth floor or above. Through the interview with EMS paramedics, the proposal confirms the genuine need of the community to reduce vertical response time. With the objective of reducing vertical response time, the design implementation must consider the needs, positions, and actions of stakeholders, such as ambulance patient and EMS paramedics. The solution must take into account the designs functionality with consideration of singly responsible ambulance services, the safety of all the stakeholdersand the response time standard. With an improved design, patients who live in high-rise buildings in Church-Yonge Corridor Neighbourhood will have a lower risk of mortality.

References: [1] Toronto Emergency Medical Services, "Toronto Emergency Medical Services Overview," 2012. [Online]. Available: http://www.torontoems.ca/main-site/about/ems-overview.html. [Accessed 15 February 2012]. [2] Statistics Canada, "Church-Yonge Corridor (75) Social Profile #3- Neighborhoods Families & Dwellings," 2006. [Online]. Available: http://www.toronto.ca/demographics/cns_profiles/2006/pdf3/cpa75.pdf. [Accessed 14 February 2012]. [3] Toronto Community Health Profile Partnership, "N75 Church-Yonge Corridor Profile: Emergency Department Care," 2009. [Online]. [Accessed 18 February 2012].

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Request for Proposal

Reducing EMS Vertical Response Time for High-Rise Buildings in Church-Yonge Corridor Neighbourhood

1. Introduction
Toronto Emergency Medical Services (EMS) provides emergency ambulance service to the City of Toronto [1]. In 2011, EMS receives over 334,000 calls, which had increased by 21.4% since 1998[2]. EMS response time is a key indicator of evaluating the performance of EMS [3]. According to Ministry of Health and Long-Term Care, EMS response time is defined as the elapsed time from the notification of the ambulance crew by the ambulance dispatcher of a patient requiring emergency care, to the arrival of the ambulance crew at the scene[3]. However, this measurement does not include vertical response time, which is defined as the time interval from arrival on-scene to arrival at the patients side in high-rise buildings. The purpose of this proposal is to identify the significance of vertical response time in EMS and the need of reducing EMS vertical response time in buildings, in order to increase accessibility to emergency medical attention and improve the survival rate of ambulance patients. This proposal first examines the impact of vertical response time, identifies the critical factors of this issue. Furthermore, based on the background information and existing problems of the chosen community: Church- Yonge Corridor Neighbourhood, the proposal explores the genuine need of reducing EMS vertical response time. Finally, it proposes project requirements and criteria for this issue with reference to current solutions.

2. Framing as an Engineering System Problem

Based on our defined understanding of engineering design, this section identifies the significance of evaluating EMS vertical response time, and investigates the main factors of vertical response time and its subsequent issues in the City of Toronto.

2.1. Definitions:
Engineering Design: engineering design incorporates scientific and mathematical knowledge and systematic approaches in order to develop structures, products, systems, methods and/or processes to meet specific needs. It should be functional, practical, creative and comprehensible, subject to constraints which may be governed by standards or legislation or customers' desires.

F216506 Sustainability: the capacity to maintain and manage resources. This can be further broken down into financial sustainability, social sustainability, and environmental sustainability. This proposal primarily focuses on the two relevant divisions of sustainability, financial and social. Financial sustainability of an implementation is its ability to operate with limited budget and without additional financial reimbursement, as well as providing revenue or long-term reimbursement. With respect to this proposal, the financial sustainability is attained when the solution design proves to be a worthy investment for the long-term well-being of the community, whereby the implementation cost for the design is more economical than risk management expenditures for all stakeholders. Social sustainability is the basis for the welfare of the people in the society. Some components of social sustainability include human rights, health benefits, security, and accessibility to social resources. One aspect of social sustainability the proposal focuses on is the health welfare of the society, which relates to the life expectancy of the society. Increasing the life expectancy of the society increases social sustainability and reducing the EMS response time can increase the survival rate of the patient which leads to longer life expectancy. Also, while environmental sustainability is not a primary priority for this design, it is an additional merit to the design if it does not in any way pollute the environment or manufactured in a way it consumes natural resources irresponsibly.

These developed definitions of engineering design and sustainability will be the basis for the engineering framing and scoping, as well as the specifications of project requirements in this proposal.

2.2. Exclusion of EMS Vertical Response Time

EMS response time is defined as the interval from 9-1-1 call assignment to arrival of an emergency medical response unit at the scene (street location)[3]. This does not, however, include any additional time that it may take for emergency responders to get from the on-scene location to the patients side[4]. A study in 2005 from Pre-hospital Emergency Care shows that vertical response time is significantly long and represents a substantial component of the total EMS response time interval, especially among ambulance calls originating three or more floors above groundin Toronto Downtown [5]. The standard EMS response time is 8:59 minutes. In 2010, Toronto EMS arrived at the critical calls within 8:59 minutes 62% of the time[4]. However, the median patient access time is 2:44 minutes among calls from patients located three or more stories above ground compared with 1:15 minutes among those at lower levels[5]. Therefore, the vertical response time represented 12.2% of the total EMS response time interval for calls originating from than three floors above or below ground and 23.3% of those located three or more storeys above ground[5].

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95% CI: 95% condence interval Note: data is measured in Toronto Downtown. [5]

EMS paramedics, Officers Brian and Joel from Mount Sinai Emergency Medical Services, said that the vertical response time can range from 1 minute to 5 minutes or more, due to various difficulties during patient access (refer to Appendix C)[6].This substantial time interval is crucial to the patients survival. For instance, in cardiac arrest, which has only a survival rate of 2.5% in Toronto [7], for each minute that passes when sudden cardiac arrest (SCA) strikes, the victim loses up to 10% chance of survival [8]. In SCA situations, reducing the response time

to 8 minutes increased the predicted survival to 8%, and reducing it to 5 minutes increased survival to 10-11%. Generally, the mortality risk is higher when EMS response time is longer, despite the fact that in some emergency situations, the survival rate does not significantly decrease after 8 minutes [8][9].

2.3. Factors Affecting Vertical Response Time

Vertical response time is related directly with various factors. Based on the interview with EMS officers and study from Pre-hospital Emergency Care, some key factors of vertical response time are[5, 6]:
Speed of the elevators:

Paramedics always take the elevators, if available, rather than stairs, according to EMS officers, because they carry over 40-pound equipment and elevators are faster especially for multi-storey buildings. However, the speed of elevators varies from building to building; furthermore, there can other unexpected delays during the patient access interval, such as other residents use the elevators at the same time. Direct measurement of speed of different elevators is demonstrated as below[10]: Table 2: Measurement of Different Elevators Travel Time Arrive at 5th floor Fastest 9.6 s Slowest 25.0s Arrive at 10th floor Fastest 18.2s Slowest 1min 4s Arrive at 20th floor Fastest 37.0s Slowest 1min 10s

Note: The measurement is taken in the ideal situation, which means there is no delay during the travel and no interruption by other residents in the buildings. Also, due to the time constraint and limitation of access to private properties, only a limited amount of elevators are investigated. Sample taken from 10 elevators in high rise buildings within Church-Yonge Corridor Neighbourhood by authors of RFP.

F216506 According to Table 2, the data of slowest elevators demonstrates that even in ideal situations, the vertical response time can range from 10 seconds to more than 1 minute. Furthermore, for buildings with more than 20 stories, vertical response time is longer. Therefore, vertical response time can be much longer when unexpected delay happens, thus lengthening the patient access time.
Size of the elevators:

When the size of the elevator is too small and the stretcher cannot fit in, the paramedics have to leave out the stretcher and thus they can only bring chairs to take the patient down. The time for adjusting the equipment into the elevators increases vertical response time.
Entry code required:

Due to lack of communication in some emergencies, when paramedics arrive, they have to buzz or force the entrance.
Absence of elevators:

When elevators are not available, paramedics have to take the stairs with the equipment of over 40 pounds. Taking stairs with heavy equipment increases vertical response time as well.
Insufficient information to identify the patients location:

The EM dispatcher does not receive sufficient information regarding the specific location of the patient. This usually occurs when the patient is unconscious, partially-conscious or mortally wounded.

The affecting factors mentioned above will also be referred in this RFP as access barriers.

2.4. Significance of the Problem

Immediate emergency medical services response is needed for acute medical events such as respiratory distress, cardiovascular emergencies, and trauma [11]. Vertical response time is measured from EMS arrival on-scene to arrival at-patient. It reflects the particular challenges associated with reaching patients in multistory residential and office buildings [11]. However, this time interval is not included in the measurement of total EMS response time, which implies that the actual EMS response time for the patient is longer. As a result, this can mislead the publics understanding of EMS performance as well. For patients who are not in acute medical events, decreasing vertical response time can reduce their suffering. Toronto EMS strives to meet the changing needs of the community for pre-hospital and out of hospital care so that they can decrease suffering, improve the health of the community and save lives[12].To achieve the goal of decreasing mortality rate, reducing vertical response time becomes one of the crucial steps in providing rapid emergency pre-hospital medical services.

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3. Community and Needs4

High rise buildings represent the majority of new residential developments built Downtown since 2001, almost one-third of which are 30 storeys or taller. According to development records, high- rise buildings account for almost all residential developments constructed Downtown since 2001[13]. The geographical area being focused on in this proposal is Church Yonge Corridor Neighbourhood. The community in need of reducing vertical response time is the residents, who live in highrise buildings in the Church-Yonge Corridor Neighbourhood. In this scope, highrise buildings are defined as buildings that have 5 storeys or more.

3.1. Background
Church Yonge Corridor Neighbourhood is bounded vertically by Yonge Street in the west and Jarvis Street in the east and bounded horizontally by Bloor Street in the north and Front Street in the south. According to Statistic Canada, the Church-Yonge Corridor Neighbourhood has a high density of high rises. There are a total of 13900 private dwellings in apartment building that are five or more stories which makes up of 89.0% of the 15630 total dwellings in the area[14], as compared to 37.6% of high-rise buildings to the total

Figure 3.1 Church-Yonge Corridor Neighbourhood[14]

dwellings in City of Toronto[15].

3.2. Identification of Genuine Need

3.2.1. Reasons of Focusing on Church Yonge Corridor Neighbourhood:
The amount of high-rise buildings:

89% of the dwellings in Church Yonge Corridor Neighbourhood are five stories or more. A larger amount of high-rise buildings increases the probability of patients locating in high-rise buildings. Consequently, the probability of EMS accessing the building with longer vertical response time is higher. Therefore, this neighbourhood with high density of high-rise buildings will likely to have greater illustration of the benefit when vertical response time is reduced.

Community and Need as defined in Appendix A.

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Health Profile of the Neighbourhood: According to data from Toronto health profile in 2009, the rate of emergency department visits5 per 1000 population of this neighbourhood is 1.55 times higher than the rest of city of Toronto(refer to Table 3)[16]. A total of 27.9% of the population in this neighbourhood has at least one emergency visit since 2009 which is much higher than the 19.2% from the total population of Toronto [16]. This implies that this neighbourhood has a heavy distribution of emergency medical cases within the city, and has one of the highest demands for emergency medical service in the city of Toronto.

Since the majority of the residents in this neighbourhood live in high rises, an implementation of a solution to reduce vertical response time is needed in the community of residents who live in high rises in the Church-Yonge Corridor Neighbourhood.

3.4.2 Genuineness of Need:

Based on the defined understanding of need (refer to appendix A), the community, Church-Yonge Corridor Neighbourhood, has a genuine need of reducing vertical response time. Church-Yonge Corridor Neighbourhood has a total of 11,050 Emergency Department (ED) visits in 2009 [16], whose ED visit ratio is 1.55 times higher than the city of Toronto rate. In particular, two population age groups: 5 19 years old and 45 64 years, have ED visit ratio 2.69 and 2.03 times higher than the city of Toronto rate [16]. Therefore, this neighbourhood requires more frequent emergency medical services and immediate pre-hospital support than other Toronto neighbourhoods. The ultimate goal of Toronto Emergency Services is to minimize the mortality rate of ambulance patients. Reducing vertical response time, which decreases the actual total response time of reaching the patients, can increase the chance of survival by receiving more immediate medical care [1]. Therefore, for an increasing trend of emergency cases in the community [4], a need of reducing vertical response time is essential to the ambulance patients, since increasing patients life-expectancy enhances the sustainability of the community based on the definition of sustainability. Furthermore, the investigation of current state of various elevators indicate that slow operation (refer to Table 2 in section 2.2) can increase the vertical response time. Also, some other potential barrier access problems exist in the buildings in the community, such as the size of elevator is too small for a
5

This data is based on visits due to community based ambulatory care.

F216506 stretcher to fit and there is no elevator available for some old 5-storey buildings. Therefore, the need to address these issues and reduce vertical response time is genuine. In the interview with EMS paramedics (Officer Brian and Officer Joel), they verified that calls can come from anywhere and without the specific data the officers believe that there is not a particular neighbourhood in Toronto where they receive most calls from[6]. However, the officers confirm that the Church Yonge Corridor Neighbourhood is one of the geographical areas that have the most need to reduce vertical response time due to the high density of high rises in this neighbourhood.

4. Stakeholders
The following constitutes the primary stakeholders: 1. Ambulance patients within the Community: people who need and seek medical attention from EMS. Reducing vertical response time is important because patients need to be attended to quickly as possible to ensure the well-being of their health. However the timing is the most critical to patients under life-threatening circumstances and who need immediate medical attention, such as people suffering from cardiac arrest and stroke. According to data from EMS Toronto, sudden cardiac arrest kills over 30,000 Canadians each year and survival rate is less than 5% [7]. The average response time is 8.1 minutes, in which only 2.5 % survive within that response time interval [7]. Since the vertical response time can add in between 1 to 5 minutes to the arrival response time, this will greatly decrease the survival rate of the patient under critical condition. 2. Toronto EMS Paramedics: their duty include reaching the patient in the short time interval as possible, attending to the patient on site, and transporting the patient to the hospital. Paramedics need a fast vertical response time once arrived at the building; however, they are unable to control the vertical response time as it is affected by external factors such as the access barriers6. They also carry emergency medical equipment which weighs about 40 pounds when attending to a patient. 3. Emergency Medical Dispatchers (EMD): a 911 operator receives the 911 call from either the patient, patient family, or someone addressing the patient, and redirects the call to an Emergency Medical Dispatcher at the Toronto EMS Communication Centre[2]. The EMD will continue to ask some scene-specific questions (e.g. entrance location) and then provide the caller with instructions on how to help the patient prior to the arrival of paramedics. The EMD is responsible to deploy paramedics to the scene and provide information to the paramedics. The remaining stakeholders are the secondary stakeholders, which will be concerned or affected by the development of the solution design, whether directly or indirectly.

Access barriers as previously defined in Section 2.3.

F216506 1. Patients family member: are interested in the well-being of the patient being attended by the EMS and wants the paramedics to arrive as fast as possible. In the case where the family member is the caller addressing the patient, they are responsible for assisting the patient during paramedics pre-arrival, according to the instructions by the EMD. They should also make sure some of the access barriers do not hinder the paramedics operation, including providing the information of the location of the patient in the building, helping the paramedics getting into the building if an access card or key is required, and making sure the door is not locked. 2. Mount Sinai Hospital Emergency Care Unit: being the hospital with closest proximity to the Church-Yonge Corridor that provides emergency care, the units medical staffs attend to the patient once the EMS arrives at the hospital. They are interested in the well-being of the patients health and want to attend to the patient as fast as possible, especially for life threatening injury in which the response time is critical for the survival rate. 3. Building manager/security/concierge: the personnel who can help assist paramedic access the building and reach the patient as quickly as possible. 4. Media: in occurrence of emergencies, often mass media provide coverage of the event. These emergencies often include the EMS to provide medical attention to victims involved. The media help the public to examine and evaluate the performance of Toronto EMS. They are also interested in any technological development implemented for the Toronto EMS. Also, the solution design highly probably would involve innovation of the elevator. In that case, three more stakeholders came into consideration: 5. Residences in the building: they can possibly delay the process of the paramedics getting to the patient. If the paramedics are taking the elevator it is possible for other residence in the building to delay the elevator by stopping at other floors which can increase significant vertical response time to the operation. 6. Owner of high rise building: any changes to the building that involves capital expenditure will concern the owners of high rise buildings. They will want to evaluate the solution designs financial impact, but at the same time they value the safety of their tenures. 7. Elevator maintenance personnel: the performance of the elevator can greatly impact the process of getting to the patient. The elevator maintenance personnel have to make sure that all elevators in the building are operating at the fullest capability. According to EMS officers, they would always choose to take the elevator if possible so the performance of the elevator is crucial to the response time.

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5. Reference Designs
The need of reducing the vertical emergency response time is a priority; therefore there have been several presently available solutions that are developed to address this problem:

5.1 SkyLoc Floor Localization System[17]

This design developed in cooperation by researchers of University of Toronto and Intel Research attempts to overcome the problem of paramedics being unable to locate the patient in high rise buildings. This access barrier occurs when insufficient information is provided to the EM dispatcher regarding the specific location of the patient usually occurs when the patient is collapsed, disoriented or incapacitated. When a mobile user dials 911, a key to prompt arrival at the emergency scene is to know the location of the mobile user. The SkyLoc is a GSM fingerprinting-based localization system that runs on a mobile phone and identifies the current floor of the caller in a multi-storey building. As the SkyLoc works on the Global System on Mobile Communication (GSM), which is the most widespread mobile telephony standard in the world, it does not require the retrofitting of mobile phones of users. This system too uses feature selection technique to the localization domain, as opposed to the naive localization approach, in which doubles the localization accuracy. This system is also overcomes the lack of direct line-of-sight limitations of triangulation-based localization method such as GPS. This design is currently in testing phase and has not yet been implemented for the EMS services.

5.2 Elevator Service Key[18]

The elevator service key allows personnel to operate an elevator car with a key and which override any signal from other floors and allow the operator to have total control of the elevator. This allows the operator to get to the level of destination as fast as possible without having to stop in between floors due to exterior signals.

Figure 5.1 Sample picture of Elevator Service Key

This reference design is widely used by the fire department, which has been using it since as early as the 1900s it has not been implemented for the EMS. From the interview with EMS Officer Brian, the EMS staffs has always suggested the access key because they also believe it would help to reduce the vertical response time in a high rise building; however, no such key has been authorized yet. From the reference design of the elevator access key of the fire department, an engineer would understand that solution to the proposed problem exists and it is possible for first year engineering students to implement such solution.

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6. Project Requirements
The following section will provide the specifications for the Solution Vendors in order to come up with a proposed solution in response to this Request-for-Proposal. The objectives to be achieved and the specified constraints are based on the genuineness of need of the community. The effectiveness of the design will be measured against specified criteria to measure how well a design approaches the accomplishment of the objectives of the design.

The proposed solution design may be in the form of a modular device, an engineering system, a retrofit of already-present system, or introducing (a) new process(es) or method(s).

6.1. Objectives:
To reduce the vertical emergency response time from in high-rise building, i.e. from time emergency call is received to the time paramedics arrive at the patient. To develop a solution design that sustainably improves the quality of life of the community in-need as defined in Section 3.0.

6.2. Overview of Constraints:

The design of the solution must adhere to the following constraints: Functionality: solution must not require any more than one (1) paramedic7 to operate[19]. Safety: solution must not compromise the safety of any stakeholders during its operation. (metric: compliance to the National Occupancy Competence Profile for EMS [20]) The vertical emergency response time must not exceed the median8 of patient access time interval[5]. (metric: time, in minutes and seconds)

6.3. Overview of Criteria:

The following are the criteria involved in determining the merit of the solution design. The design should maximize its coverage to each criterion stated, but it is not compulsory to do so. A larger reduction in the vertical emergency response time is preferred. (metric: time, in minutes and seconds)

The minimum number of Toronto EMS Paramedic manning an Emergency Response Vehicle is one. The number of paramedic manning the primary emergency vehicle (Type 3 Ambulance) is two people.
8

2.38 minutes for apartments, 1.89 minutes for office buildings,(with 95% confidence interval) based on the study from Pre-hospital Emergency Care. Vertical emergency response time as defined in this RFP refers topatient access time as defined in the study.

F216506 Cost: a lower capital expenditure is preferred, and should the solution is implemented by City of Toronto Emergency Medical Services, the cost should be within the allocated operating budget for Toronto EMS within reasonable9 projected financial years to come. The allotted budget is available in City Budget 2012 for Emergency Medical Services[21]. Note that City of Torontos recommended budget for other expenditure categories is $31,200. (metric: Canadian dollars) Implementation time: should the solution require retrofitting of the EMS fleet or building design, a shorter time of implementation is preferred. (metric: time, in months) Additional EMS training hours: the solution, if not requiring zero additional training time, should add as minimum as possible, to the minimal training time for a Level I Paramedic. A standard Level I Paramedic undergoes 1400 hours of primary care training[22].(metric: time, in hours) The extent10 to which access barriers are reduced or nullified. Access barriers refers to doors requiring access keys, unavailability of elevators, slow elevators, inability to locate patients inside building, and limited mobility11 for emergency medical equipment in building. Solution Vendors are allowed to propose a solution for a justifiable access barrier(s) other than specified above.

Reasonable implies the Solution Vendors are allowed to propose a cost beyond the Toronto EMS yearly allocated budget for Program Development, spanning to several years, with proper justification.
10

Solution is expected to either reduce or completely eliminate; of one or more of the specified access barriers. Common mobility issues include equipment not fitting into the elevator and unavailability of stair chairs.

11

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Appendices

Appendix A: Definitions

Access Barriers: an obstacle or hindrance that stops or slows down ones accessibility to a destination. The access barrier for EMS paramedics entering a high rise building may include entry code, unavailability of elevator, lack of directional signs, small elevator which cannot fit a stretcher. Community: a group of people living in a common geographical region, or people who shares common interest. Constraints: a set of requirements that has to be met by an engineering design. Criteria: a set of indicators that measures how well a design approaches the accomplishment of the objectives of the design. Engineering design: as defined in Section 2.1. Need: a necessary objective in the community to upgrade the sustainability of each individual in the community and community as a whole. Quality of Life: an indicator of the fulfillment of needs and wants of an individual or community, and with respect to engineering design, how much a product/process/method/system satisfy those requirements. Often quality of life act as a metric for assessing the performance of an engineering design against objectives involving needs. Retrofitting: the addition of new technology or features to older systems. Sustainability: as defined in Section 2.1.

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Appendix B: Images

Figure B.1: The floor indicators do not light up, making it difficult to estimate the elevator arrival time.

Figure B.2: Absence of floor indicator at the elevator lobby.

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Figure B.3: Stairs as alternative path when elevators are unavailable. Note that paramedics have to carry 40 lb of EM equipments along these, inclusive of stretchers.

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Appendix C: Notes from Interview in Mount Sinai Emergency Center

Interviewee: EMS Officers Brian & Joel from Mount Sinai Emergency Center Community: Church-Yonge Corridor neighbourhood Problem: Reduce Buildings Vertical Response Time in High-rise

Key points for interview in Mount Sinai on Feb 17, 2012: (EMS officers: Brian and Joel) - EMS receive 800 1000 calls per day - They only include vertical response time in cardiac arrest - Emergency calls come from everywhere - They cant control the vertical access time - Usually paramedics need to take 40 pounds equipment, so they always take the elevators if available. - Yonge-Church neighbourhood has a lot of high rise buildings, which is related to our concern and thus they confirmed it is a community in need. - Emergency happens on everyone, not just mainly seniors and children. (Therefore no need to talk about dependency ratio in the decision of community.) - The vertical access time can range from 1min to 5mins or more. - Some factors of vertical response time: 1. Size of elevators: sometimes when the stretchers do not fit in, they have to leave out the stretchers and use chairs to take the patients down. 2. Speed of elevators varies 3. Sometimes they have to buzz or force the entrance 4. Insufficient (sometimes) information to find the patient

- Suggestions: EMS key, similar to fire keys.

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