CritiCall: The Continuum of Communication

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The Ontario CritiCall Program assists physicians caring for critically ill or trauma patients by facilitating consultations with on-call specialists who can provide immediate patient management and, if necessary, secure a bed for the patient at the nearest facility with the appropriate level of care. For the 2001 fiscal year, CritiCall received 7491 calls from physicians across the province.

Referrals are not always life threatening, but may require a higher level of care than is available at a particular centre. For physicians in community hospitals, CritiCall is a vital link to the resources of larger tertiary care hospitals in their region and the province. The Ontario CritiCall Program facilitates the optimal use of all specialized hospital-based resources in the province. And with the help of technology and physicians across the province, it does just that.

In order to operate efficiently and effectively, the Ontario CritiCall Program relies on its Ontario Central Bed and Resource Registry for immediate access to accurate bed and resource availability for each hospital, as well as contact information for on-call physicians in 50 different medical specialties. Developed by CritiCall in association with Rincon Technologies and housed on the Internet, the Registry is encrypted to ensure privacy and can only be accessed by those with authorization. Over 140 Ontario hospitals use the Registry to update acute and tertiary hospital bed availability, emergency department and intensive care unit status, and on-call physician contact information.

When a physician contacts CritiCall, the call taker can access information about hospitals that provide the services required, and the name and contact numbers of the physician on-call for that specialty. In 2001, 17.2 per cent of calls were trauma related, 16.4 per cent were neuroscience related, and 13.7 per cent of all calls were for perinatology.

It’s 9:00 a.m. on Sunday morning. A patient has been brought by ambulance to a hospital in northern Ontario. Among other things, the patient is unconscious with unstable vital signs. The attending Emergency Department physician can find no reason for the patient’s condition. Within an hour, a second patient presents at the same hospital with the same symptoms only comatose. The physician contacts CritiCall to transfer the patients to a hospital offering a higher level of care. The physician speaks with a CritiCall call taker and passes along all patient information. During the call, the physician indicates they have two patients in the same condition and that authorities are investigating a link between the two cases but have yet to find one.

On the same day, at roughly 10:30 a.m. another physician in another northern Ontario hospital (approximately 3 hours from the first hospital) calls CritiCall to request a consult with a specialist. The physician indicates he has a patient who is unconscious with unstable vital signs (in addition to other conditions) and is at a loss to explain the patient’s comatose state. The CritiCall call taker immediately recognizes the symptoms as being similar to the patients being treated in the neighbouring community and connects the physician to an intensivist from a tertiary centre in Toronto. This physician has lab capabilities and expertise for immediate patient management and accepts the patient to his centre. The patient is subsequently found to be suffering from methanol poisoning and after careful investigation, it is found the three patients had all attended a bush party in a nearby community. The link has been made and it is determined the poisoning was acquired through the consumption of tainted ‘moonshine’.

If CritiCall had not been contacted, the physicians could have been treating their patients without realizing the common symptoms. The uncovering of the ‘common link’ also allowed investigators to better focus on their case while at the same time notifying neighbouring centres of a possible poisoning outbreak. Over the next three days 15 patients were diagnosed and later transferred to tertiary care centres.

After getting the necessary information from the sending physician, the call taker pages a specialist physician at an appropriate hospital, and connects the physicians so they can discuss the case. If necessary, the call taker can facilitate the transfer of the patient.

In many cases, a consultation with a specialist is all the physician requires and a transfer is not necessary. This past year, 16.4 per cent of calls to CritiCall were consultations. If a consultation alleviates the need for an air or land ambulance transfer, then CritiCall has fulfilled its mandate by assisting in bed management and the appropriate and timely use of regional services and hospitals.

The Ontario CritiCall Program has been Ontario’s sole emergency patient referral program since April 1, 1996. Prior to that, there were separate programs in each area of the province facilitating emergency patient referrals. In 1995, Ontario’s Ministry of Health recognized the need to link all emergency referral programs, creating a unique and comprehensive system to serve the province as a whole. Regional coordinators and medical directors work to ensure the integrity of the program and represent the interests of their regions. According to Shelley Moneta, CritiCall’s program manager, “the cooperation and commitment from stakeholders across the province is the basis for CritiCall’s continued success.”

Since its inception, the Ontario CritiCall Program has been consistent in providing effective resource utilization at all levels of care, promoting health-care accessibility to a greater number of people at less overall cost and offering physicians a more efficient use of their time. On occasion, it has also been able to uncover the “common link” between seemingly unique cases in different communities (see example at sidebar). In addition, CritiCall enhances ambulance and emergency communications services and communication within hospitals by providing real time information about available hospital resources across the province.

Because CritiCall is recognized as a key provincial resource, it has partnered with several projects around the province to work towards improving the emergency health care system and has been an integral component in a variety of government initiatives.

In mid-2000, the Ontario government implemented the Emergency Services Strategy designed to provide Ontarians with better access to hospital emergency services. As part of this strategy, Emergency Services Networks were implemented in each region to address system-wide inflow and outflow pressures. These networks work to ensure that patients who require emergency health care services receive the appropriate care in a timely fashion. A representative from CritiCall participates in these networks, working in association with other stakeholders to ensure goals are met.

In the fall of 2001, the new provincial Patient Priority System (PPS) was implemented to streamline communication when transporting ambulance patients to Emergency Departments. PPS uses the Canadian Triage and Acuity Scale (CTAS) to accurately assess and define the patient’s need for care. CritiCall played an instrumental role in developing an on-line resource screen for ambulance dispatch that tracks the number and acuity level of each patient transported.

Since 1999, CritiCall has been working with the Perinatal Partnership Program of Eastern and Southeastern Ontario (PPPESO). The PPPESO Perinatal database was founded in 1997, as a tool for collecting and disseminating perinatal information in the Eastern and Southeastern regions on Ontario. The CritiCall system now provides the platform for the perinatal database, allowing real-time access via the Web. The selection of the CritiCall system allowed significant savings in development time and costs, by preventing duplication of efforts and technology. Most Ontario hospitals already had access to CritiCall, thus eliminating the need for additional hardware or software. The data structure of the original perinatal database has been retained, while CritiCall technology has allowed significant improvements in accessibility, efficiency and reporting functionality.

In the future, CritiCall will continue to be involved in a variety of projects that will enhance health care services around the province. “CritiCall’s role in the healthcare continuum is an important one and I’m proud of the support we receive from hospitals and healthcare providers,” explained Moneta. “Year after year our call volume has continued to increase. As the healthcare landscape in Ontario changes and evolves, CritiCall will continue to provide a vital service.”

The Ontario CritiCall Program is managed by Hamilton Health Sciences in Hamilton, Ontario. For more information on the Ontario CritiCall Program, contact Shelley Moneta, program manager via email at moneta@ hhsc.ca or by phone at (905) 575-6260.