Purpose

The purpose of the Life or Limb Policy is to facilitate timely access to acute care services, within a best effort window of 4 hours, in order to improve outcomes for patients whose life or limb is threatened.

The Ministry of Health developed the Life or Limb Policy in response to recommendations from the Office of the Chief Coroner for a provincial "no refusal" policy when critical injuries or conditions of life or limb are involved.

Scope

The Life or Limb Policy applies in all hospitals in Ontario. Paediatric patients (under the age of 18) with life or limb threatening conditions will continue to have timely access to tertiary level critical care resources through the extramural Paediatric Critical Care Response Team (PCCRT) service.

Please note: As per the Critical Care Information System Data Collection Guide for Automated Sites (v1.0) a paediatric patient is defined as any patient who is under the age of 18 at the time of admission to the critical care unit.

For clinical conditions with existing procedures for medical consultation and patient transfer and/or repatriation (such as the Ontario Stroke Network, Primary Percutaneous Coronary Intervention STEMI Program or extramural Paediatric Critical Care Response Team), established processes and timelines must be adhered to.

The Life or Limb Policy is designed to work in tandem with established policies and/or processes upon adoption.

The Life or Limb Policy

Introduction

There are many requests for medical consultation and patient transfers within and across Ontario Health (OH) regions and there are varying degrees of urgency for these patients. A small subset of these patients presents with conditions that potentially cause loss of life or limb if not managed in a timely manner and can only be cared for at certain hospitals due to the nature of the care they require and/or the complexity and severity of their condition.

The Life or Limb Policy embraces a philosophy of care for our sickest, most vulnerable critically ill patients, and promotes the patient’s clinical condition as priority. The perception of life or limb conditions is predicated on the clinical services available at a referring hospital to manage these cases - and for some hospitals in Ontario, these clinical services may be limited. Therefore, the provincial Life or Limb Policy aims to ensure that appropriate and timely acute care services are available to patients who are life or limb threatened. No patient with a life or limb threatening condition will be refused care.

The following sections articulate the principles of the provincial Life or Limb Policy and the responsibilities required of health care providers to ensure that life or limb patients receive access to timely and appropriate care. The Life or Limb Policy will contribute to optimizing patient care and reducing patient morbidity and mortality. As well, the policy will ensure standardization of the treatment of life or limb threatened patients both within and across OH regions.

Stakeholder consultation

In January 2012, the then-MOHLTC (Ministry of Health and Long-Term Care) requested that Critical Care Services Ontario (CCSO) lead the stakeholder consultation and policy development process. In April 2012, CCSO established the Life or Limb Policy Steering Committee, with representation from:

  • Critical Care LHIN Leaders
  • Emergency Department LHIN Leader
  • hospital administration
  • then LHINs, CritiCall Ontario
  • Emergency Health Services Branch (MOHLTC)
  • Ornge

The Life or Limb Policy Steering Committee was tasked with providing direction to CCSO on the development, implementation, and performance measurement and management framework for the provincial Life or Limb Policy. In addition, the Life or Limb Policy Steering Committee provided input to mitigate potential challenges with policy development and implementation.

In order to generate awareness and cultivate support for policy adoption across Ontario, the following stakeholders also provided feedback:

  • Emergency Department LHIN Leader group
  • then LHIN Chief Executive Officers (CEOs)
  • Canadian Medical Protective Association
  • College of Physicians and Surgeons of Ontario
  • the Ontario Hospital Association

Policy statement

Patients with life or limb threatening conditions will receive timely medical consultation, and if necessary, will be transferred to a hospital that can provide the clinical services required within a best effort window of 4 hours. For clinical conditions with existing procedures for medical consultation, patient transfer and/or repatriation, established processes and timelines must be adhered to.

Objective

The objective of the policy is to enable the development of standardized procedures for all health care providers within and across OH regions to ensure that patients with life or limb threatening conditions receive timely and appropriate care.

Guiding principles

  • The Life or Limb Policy is in effect when a patient’s life or limb is threatened and therapeutic options exist, which are needed within 4 hours
  • A patient’s life or limb threatening condition is a priority and the identification of beds is a secondary consideration
  • No patient with a life or limb threatening condition will be refused care
  • OH region geographic boundaries will not limit a patient’s access to appropriate care in another OH region
  • Repatriation within a best effort window of 48 hours once a patient is deemed medically stable and suitable for transfer is key to ensuring ongoing access for patients with life or limb threatening conditions (applies to both transfers within Ontario, and out-of-country (OOC) transfers)

Responsibilities

Critical Care Services Ontario

The responsibilities of Critical Care Services Ontario under the Life or Limb Policy are to:

  • collaborate with the MOH and OH regarding updates and/or revisions to the Life or Limb Policy
  • develop the Life or Limb Policy Implementation Guide
  • develop performance measurement and management framework to assess intended and unintended outcomes of the Life or Limb Policy
  • monitor indicators of performance related to the Life or Limb Policy
  • review performance measurement and management framework following implementation of the Life or Limb Policy to ensure that the appropriate information is being collected to meet performance measurement and evaluation needs
  • identify and address areas of process improvement in collaboration with the MOH, OH, OH regions, Emergency Medical Services and CritiCall Ontario to enable on-going compliance with the Life or Limb Policy

CritiCall Ontario

The responsibilities of CritiCall Ontario under the Life or Limb Policy are to:

  • facilitate conference call between referring physician and most appropriate consulting physician/service
  • initiate CritiCall Ontario’s Life or Limb Case Facilitation Algorithm when medical consultation or transfer is not readily available at the hospital with the clinical services required
  • arrange transfer to an OOC facility (find an available bed and a physician to accept the patient) for life or limb cases that arise inside Ontario and require services that are not performed in Ontario or cannot be obtained in Ontario without medically significant delay
  • facilitate repatriation for those patients with life or limb conditions transferred to an OOC facility by CritiCall Ontario
  • provide education and training to hospitals and OH regions on Repatriation Tool
  • Collect data and provide reports that will support hospitals, OH, OH regions, Emergency Medical Services, CCSO, and the MOH with on-going monitoring and performance measurement of the Life or Limb Policy. Reports are available upon request.

Ontario Health and Ontario Health regions

The responsibilities of Ontario Health and Ontario Health regions under the Life or Limb Policy are to:

  • collaborate with hospitals to develop repatriation agreements/processes with the aim of repatriation within a best effort window of 48 hours once patient is deemed medically stable and suitable for transfer
  • monitor hospital accountability as detailed in the Life or Limb Policy, and performance by reviewing data collected by CritiCall Ontario in collaboration with OH Critical Care Lead(s)
  • provide feedback on challenges and lessons learned in order to improve compliance with the Life or Limb Policy to hospitals within your OH region, OH Critical Care Lead(s), OH Emergency Department Lead(s), CCSO, CritiCall Ontario, OH and the MOH as necessary or requested

Emergency medical services

The responsibilities of emergency medical services under the Life or Limb Policy are to:

  • interfacility transfer of patients who are life or limb threatened to an appropriate receiving hospital within a best effort window of 4 hours (taking into account geographic limitations)
  • implement a triage system to ensure patients will be repatriated within a best effort window of 48 hours, once deemed medically stable and suitable for transfer

Hospital administrators

The responsibilities of hospital administrators under the Life or Limb Policy are to:

  • incorporate the Life or Limb Policy into hospital policies and procedures to ensure the responsibilities related to acceptance of life or limb patients are clearly understood
  • implement a process for paging physicians that will identify provisional life or limb pages separately from other pages and informs the physician to contact CritiCall Ontario directly
  • ensure that reporting in the Critical Care Information System is kept current
  • ensure that the hospital has a defined Critical Care Surge Capacity Management Plan and that administrators and clinical staff are aware of this protocol
  • implement the Critical Care Surge Capacity Management Plan (minor), when necessary, to:
    • provide appropriate and timely care to patients based on the clinical services available at the hospital
    • accommodate for the transfer of care from a referring hospital to a receiving hospital
    • accept patients that are being repatriated
  • triage life or limb cases from other hospitals in accordance to internal operational guidelines when an operative procedure is required
  • develop repatriation agreements/processes with the aim of repatriation within a best effort window of 48 hours once patient is deemed medically stable and suitable for transfer
  • repatriate patients deemed medically stable and suitable for transfer within a best effort window of 48 hours to the referring hospital
    • if the referring hospital cannot provide the patient with the clinical services required or is not in the OH region geographic area where the patient resides, the patient will be sent to the hospital closest to the patient’s home that can provide the clinical services required
  • accept patients for repatriation that reside within the OH region catchment area (even if the patient was not referred from your hospital) within a best effort window of 48 hours once deemed medically stable and suitable for transfer
  • utilize CritiCall Ontario’s Repatriation Tool to track and monitor repatriation processes
  • respond to CritiCall Ontario when the Case Facilitation Algorithm is invoked
  • monitor hospital accountability as detailed in the Life or Limb Policy, and performance by reviewing data collected by CritiCall Ontario

Referring hospital physician

The responsibilities of the referring hospital physician under the Life or Limb Policy are to:

  • provide care to life or limb patients with the clinical services available at the hospital
  • prior to contacting CritiCall Ontario regarding a provisional life or limb case, request a consultation from a specialist on call in your hospital, if this service is available, to confirm that the patient requires a higher level of care than the hospital is able to provide
  • contact CritiCall Ontario at 1-800-668-HELP (4357) to identify a provisional life or limb case that cannot be served by the hospital at which the patient is located
  • submit a prior approval (PA) application as per the MOH OOC PA Program, within 24 hours to the MOH, if a patient is transferred to an OOC facility by CritiCall Ontario

Consulting hospital physician

The responsibilities of the consulting hospital physician under the Life or Limb Policy are to:

  • respond to pages from CritiCall Ontario regarding a provisional life or limb case within 10 minutes
  • provide medical consultation even if a bed or resources are not immediately available, to determine if the patient is life or limb threatened and recommend course of action (for example, provide recommendations regarding management of life or limb patient to include stabilization, no transfer required, appropriate for urgent transfer)
  • accept patients with life or limb threatening conditions that cannot be served by the hospital at which the patient is located, provided the clinical expertise is available
  • if the patient requires urgent transfer to your institution, ensure minor surge plan has been implemented, in the event a bed is not immediately available, to meet the clinical needs of the patient

Evaluation

Reporting and Monitoring

The reporting and monitoring process will be informed by the following sources:

  • CritiCall Ontario’s Weekly Life or Limb Case Monitoring Report
  • CritiCall Ontario’s Life or Limb Summary Data Report
  • Reports generated from CritiCall Ontario’s Repatriation Tool
  • Qualitative information collected from hospital administrators, OH Critical Care Leads, OH Emergency Department Leads, OH regions, CritiCall Ontario and CCSO

To deal with all cases requiring follow-up, data review and feedback mechanisms have been established by CCSO and CritiCall Ontario.

Performance measurement and management

Data to measure the performance of the Life or Limb Policy will be shared with hospitals, OH Critical Care Leads, OH Emergency Department Leads, OH regions, Emergency Medical Services, CCSO, OH and the MOH, and may be publicly reported. Potential indicators include, but are not limited to:

  • total number of life or limb cases
  • total number of transferred life or limb cases (based on accept outcomes)
  • time to consult/accept/transfer
  • percentage of life or limb cases that receive consultation within 4 hours
  • total number of consult declined or transfer request declined
  • percentage of declared life or limb cases confirmed
  • reasons for refusal (based on decline outcomes)

Related initiatives

Provincial Extramural Paediatric Critical Care Response Team Program

Paediatric patients (under the age of 18) with life or limb threatening conditions will continue to have timely access to a paediatric intensivist through the extramural Paediatric Critical Care Response Team (PCCRT) program.

The extramural PCCRT program is a coordinated service requiring a phone call to access:

  • paediatric critical care expert advice
  • paediatric critical care transport resources
  • provincial paediatric critical care bed availability

Under the extramural PCCRT program, any physician who is caring for a critically ill child anywhere in Ontario can have immediate telephone access to a paediatric intensivist, 24 hours a day, 7 days a week. By calling CritiCall Ontario’s existing central number, 1-800-668-HELP (4357), referring physicians are able to consult with a paediatric intensivist regarding the management or potential transfer of a paediatric patient to a more appropriate care setting.

The Life or Limb Policy will not impact the management of paediatric patients and/or the extramural PCCRT program.

Critical Care Surge Capacity Management Plan

In 2009, hospitals across the province developed comprehensive Critical Care Surge Capacity Management Plans as part of Ontario’s Critical Care Strategy. This collaborative initiative between hospitals, OH regions, and CCSO provides a framework to accommodate for increased demands for critical care services and will serve as a tool for hospitals in the implementation of the Life or Limb Policy. Surge capacity management requires the consistent application of 5 key principles across all levels of surge (minor, moderate and major):

  1. Management
    • recognize the level of response that is required, and identify who is accountable for oversight of the surge event
  2. Human Resources
    • establish pre-determined plans for utilization of human resources to meet patient needs during a surge event
  3. Equipment and Technology
    • establish pre-determined plans for utilization of equipment and resources to meet patient needs during a surge event
  4. Physical Plant
    • establish pre-determined plans for utilization of alternative physical space to meet increased demand in patient volumes
  5. Processes to Address Surges
    • establish processes that will address surges in demand for critical care resources

The Critical Care Surge Capacity Management Plan ensures common principles and strategies are implemented across Ontario through integrated communication plans, streamlined use of information technology, and pre-determined strategies for the utilization of health human resources. The ability to respond to surges is a necessary capability for hospitals. The Critical Care Surge Capacity Management Plan provides hospitals with the strategies and tools to remain responsive to demands for critical care services, including the ability to accommodate life or limb patients. The introduction of the Life or Limb Policy, coupled with the Critical Care Surge Capacity Management Plan, aligns with Ontario’s Critical Care Strategy through standardized procedures for surge capacity response planning, patient referral and transfer, and repatriation; in addition to promoting efficient and effective critical care service delivery, and facilitating improvements to critical care access through performance measurement. Read more about Ontario’s Critical Care Strategy.

Out-of-Country Prior Approval Program

In exceptional circumstances, such as life or limb cases, it may not be possible for the necessary medical care to be provided in Ontario because of a medically significant delay or because equivalent services are not performed in Ontario (that is , it is necessary that the patient travel out of country to avoid a delay that would result in death or medically significant irreversible tissue damage). When it is necessary for a patient to be transferred OOC under emergency circumstances, prior written approval from the MOH is not required before the services are rendered. Emergency circumstances are medical circumstances in which an insured person faces immediate risk of death or medically significant irreversible tissue damage. These transfers should be coordinated through CritiCall Ontario. The referring physician or CritiCall Ontario is required to submit a prior approval application, as soon as possible to the MOH on behalf of the patient.

CritiCall Ontario has the authority to arrange a transfer to an OOC facility. When CritiCall Ontario is involved, the patient’s condition is monitored and arrangements for repatriation back to Ontario are made once the patient is medically stable and a bed is available in an Ontario hospital.

The MOH does not assume the expenses for transportation (transfer and repatriation) when CritiCall Ontario is not used for OOC transfers.

Policy document

Access the Life or Limb Policy document.

This document was published in 2013. Note that some organizations and structures referenced in this document have evolved since the time of publication. For example, MOHLTC is now MOH, LHINs are now Ontario Health regions, and LHIN leads are now Ontario Health leads. Where applicable, links and document titles in this policy have been updated.

This document is intended for use by all health care providers - clinicians, hospital administrators, Ontario Health (OH) and OH regions, Emergency Medical Services including Ornge, CritiCall Ontario and Critical Care Services Ontario (CCSO).