Purpose and guiding principles

The purpose of this policy is to outline the minimum expectations of Ontario’s health service providers to ensure that persons with an episode of treatable time-sensitive critical illness (meaning threats to Life or Limb) receive timely and appropriate care. These expectations are supported by the following guiding principles:

  • People in Ontario can expect to receive the right level of care at the hospital most appropriate for their needs.
  • Health service providers across the province have a shared accountability in providing timely, high quality, safe, and accessible care.

Scope

This policy covers all parties who participate in the identification, consultation, and transfer of persons with an episode of treatable time-sensitive critical illness who may benefit from treatment available at hospitals other than the one at which they are present, and those who provide oversight to this process. This includes, but is not limited to:

  • the Ministry of Health
  • Ontario Health and Critical Care Services Ontario
  • CritiCall Ontario
  • emergency medical transport providers (Ornge, regional paramedic services, neonatal-pediatric transport teams)
  • health service providers
  • physicians

Terminology

For the purpose of this policy, the following terms are defined:

Person includes adults, children, and infants.

Life or Limb is defined as an episode of treatable time-sensitive critical illness. This is an episode of illness that has all three attributes (treatable and time sensitive and critical) where:

  1. Treatable — clinical intervention(s) within standard of care is available.
  2. Time-sensitive — critical threats are mitigated with treatment received within 4 hours.
  3. Critical — a clinical condition that poses a threat to a person’s life and/or a threat to the minimally essential function of an organ or body system (such as vision, limb function). This includes threats related to pregnant persons and/or in-utero transfers when newborns are anticipated to need a higher level of care.

Adjustment of logistics reflects an individualized approach to identifying a target destination for consultation and transfer with the overarching objective of risk mitigation. Adjustment of logistics may include the provision of virtual critical care services.

Referring hospital is the hospital at which the person initially presents.

Referring physician is the most responsible physician, or in the absence of a physician the appropriate most responsible practitioner, for the person at the hospital at which they initially present.

Receiving hospital is the target destination for treatment that is the closest most-appropriate hospital for consultation and transfer. Identifying the receiving hospital is predicated on the availability of a uniquely higher bundle of services that is not available at the referring hospital and on transport times. This includes the adjustment of logistics based on case-specific circumstances.

Consulting physician is the consulting physician at the receiving hospital.

Hospital for repatriation is the target destination that is the closest to home most-appropriate hospital for repatriation following the critical phase of the illness episode. When the person no longer requires the bundle of services unique to the receiving hospital, repatriation to the referring hospital or to the closest to home hospital that has the appropriate services is considered.

Policy statement

Persons with an episode of treatable time-sensitive critical illness (meaning threats to Life or Limb) presenting at one Ontario hospital who would benefit from specific treatment at another hospital, will have access to that treatment at the closest most-appropriate hospital within a best effort window of four hours.

The three central accountabilities within this policy are:

  1. identification and consultation
  2. transfer of person to the receiving hospital
  3. when required, repatriation of person to the closest to home most-appropriate hospital following the critical phase of illness

Identification and consultation

The referring physician declares the person provisionally a Life or Limb case. The consulting physician provides timely consultation and if appropriate, confirms the case is Life or Limb. The target for responding to a request for consultation is 10 minutes.

The consulting physician is also responsible for providing advice virtually, guiding the stabilization and immediate management of the person while at the referring hospital.

Transfer of person to the receiving hospital

Once confirmed Life or Limb, persons are accepted by the receiving hospital on a priority and no-refusal basis. The absence of hospital beds, including intensive care unit beds and post-procedural beds, is not a consideration. Regional boundaries will not limit a patient’s access to appropriate treatment.

Persons are transferred to the receiving hospital, the target for achieving access to appropriate treatment is within four hours once a patient is confirmed life or limb. Adjustment of logistics based on case-specific circumstances may be required.

Established clinical pathways for other time-sensitive life and limb conditions include the additional features of those pathways. At this time, these include trauma, STEMI, and stroke pathways. Additional specialty groups may define a minimum set of clinical criteria that warrant transfer under this policy.

Repatriation to closest to home most-appropriate hospital

After the critical phase of the illness and when specific treatments have been completed, if required, the person is accepted and transferred on a priority and no-refusal basis to the closest-to-home most appropriate hospital. The hospital accepting the repatriation must be able to provide the required services for the phase of illness at the time of transfer.

The acceptance at the hospital for repatriation is prompt, while allowing up to 48 hours from when the transfer request is initiated for arranging transport logistics.

Compliance

The expected compliance rate of this policy is 100%. It will be assumed that hospitals acknowledge their compliance with this policy. The three central accountabilities for care to persons with an episode of treatable time-sensitive critical illness (meaning threats to Life or Limb) is understood to be shared. A person entering one hospital in Ontario is entering a provincial system of care, whereby all parties under this policy are required to participate.

The policy requires time-sensitive decision making. If there is deviation from the policy in which access to treatment and/or patient safety may be compromised, escalation pathways will be invoked to facilitate patient access within the scope of this policy.

Responsibilities

Referring and consulting physicians

Referring physician

Responsibilities regarding Identification and Consultation include:

  • Provide care to life or limb patients with the services available at the hospital.
  • Contact CritiCall Ontario if the required bundle of services are not available within the hospital.
  • Provide the CritiCall Ontario call agent with the requested patient information and provisionally declare a Life or Limb case.
  • Collaborate with the consulting physician to confirm the Life or Limb case.

If Life or Limb is not confirmed:

  • The referring physician may request a second opinion through CritiCall Ontario.
  • If the person’s condition does not meet the definition of Life or Limb, the consulting physician may recommend a transfer to a higher level of care via the urgent/emergent pathway. In this case, the referring health service provider is responsible for coordinating the transfer. The referring physician should follow their health service provider’s process for arranging transfer.
  • If the person’s condition does not meet the definition of Life or Limb, the consulting physician may recommend the person may remain at the referring hospital to receive care as appropriate.

If Life or Limb is confirmed:

  • Initiate the referring hospital’s administrative process for a Life or Limb transfer (see Hospital administrative processes).
  • If a patient is transferred to an out of country (OOC) facility by CritiCall Ontario, submit an application to the Ministry of Health within 24 hours, as per the Ministry of Health’s OOC Prior Approval Program.

Responsibilities regarding Transfer include:

  • Provide the CritiCall Ontario call agent with the requested patient information to support identification of the appropriate mode of transportation.
  • Follow your hospital’s administrative process to prepare the person for transfer (see Hospital administrative processes).

Consulting physician

Responsibilities regarding Identification and Consultation include:

  • Without exception, respond to pages for consultation from CritiCall Ontario regarding a provisional life or limb case within 10 minutes.
  • Provide medical consultation, to determine whether the patient meets the definition of Life or Limb and recommend a course of action.
  • Confirm or decline Life or Limb case.

If Life or Limb is not confirmed:

  • If the person’s condition does not meet the definition of Life or Limb, the consulting physician may recommend a transfer to a higher level of care via the urgent/emergent pathway. In this case, the referring hospital is responsible for coordinating the transfer.
  • The consulting physician should provide guidance for the stabilization and immediate management of the person and remain accessible as they may be required to provide ongoing guidance to the referring hospital/physician following the initial consultation.

If Life or Limb is confirmed:

  • The consulting physician will accept the person and initiate their hospital’s administrative process to accept a Life or Limb transfer from the referring hospital (see Hospital administrative processes).
  • The consulting physician should provide guidance for the stabilization and immediate management of the person and remain accessible as they may be required to provide ongoing guidance to the referring hospital/physician following the initial consultation.

Responsibilities regarding Repatriation include:

  • The consulting physician, or the physician who is the most responsible, will ensure that the care needs of the person can be achieved at the target destination for repatriation prior to initiating transfer.

CritiCall Ontario

Call agents

Responsibilities regarding Identification and Consultation and Transfer include:

  • Facilitate conference call between the referring physician and the consulting physician and initiate the Life or Limb Case Facilitation Algorithm when a Life or Limb case is confirmed.
  • When applicable, coordinate transport from the referring to the receiving hospital.
  • When applicable, 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.

Responsibilities regarding Repatriation include:

  • Facilitate repatriation for those persons with Life or Limb threatened conditions transferred to an OOC facility by CritiCall Ontario.

Medical Director and Associate Medical Directors

Responsibilities regarding Identification and Consultation and Transfer include:

  • CritiCall Ontario’s Medical Director and Associate Medical Directors will support time-sensitive decision making. If there is deviation from the policy such that access to treatment and/or patient safety may be compromised, the Medical Director or Associate Medical Directors will invoke escalation pathways.
  • If in the judgment of the Medical Director or Associate Medical Directors there is a material delay in achieving a decision to transfer, then they will make the decision on whether to proceed with transfer.

Emergency Health System Services

Responsibilities regarding Transfer include:

  • Provide patient transfer within a best effort window of four hours. Adjustment of logistics based on case-specific circumstances may be required.
  • Ensure safe and timely arrival of the patient at the receiving site.

Responsibilities regarding Repatriation include:

  • Assist with repatriation, including crossing regional and municipal boundaries.
  • Follow triage protocols to ensure patients are repatriated within a best-effort window of 48 hours. Follow established escalation process for alternative transport options if repatriation is beyond this time frame.

Hospital administrative processes

Referring hospital

Incorporate the three central accountabilities (Identification and Consultation, Transfer, and Repatriation) into hospital policy and procedures.

Specifically, responsibilities regarding Transfer include:

  • When Life or Limb is confirmed, the referring physician will initiate the hospital’s administrative process for patient transfer. Appropriate resources should be activated to support the referring physician in this process. This includes, but is not limited to, preparing the person for transfer and ensuring medical records and imaging are readily available.

Receiving hospital

Incorporate the three central accountabilities (Identification and Consultation, Transfer, and Repatriation) into hospital policy and procedures.

Responsibilities regarding Identification and Consultation include:

  • Establish a process for contacting the consulting physician 24 hours a day, 7 days a week, 365 days a year and identifying the Life or Limb calls as highest priority.

Responsibilities regarding Transfer include:

  • When a Life or Limb case is confirmed, the consulting physician will initiate the hospital’s administrative process for accepting the patient. This includes, but is not limited to, supporting no-refusal of confirmed Life or Limb cases and ensuring the appropriate resources are activated in anticipation of patient arrival.
  • Ensuring the on-call administrative lead is available 24 hours a day, 7 days a week, 365 days a year to participate in the escalation of real-time issues if there is deviation from the policy in which access to treatment and/or patient safety may be compromised.
  • Notify Ontario Health regional leadership and CritiCall Ontario when experiencing any impact in their ability to participate in the responsibilities outlined in the policy.

Responsibilities regarding Repatriation include:

  • Participate in the escalation pathways for issues if there is deviation from the policy which may lead to a delay in transfer to the closest to home most-appropriate hospital.

All hospitals

Incorporate the three central accountabilities (Identification and Consultation, Transfer, and Repatriation) into hospital policy and procedures.

Specifically, responsibilities regarding Repatriation include:

  • Initiate hospital surge protocol if required, in order to receive persons on a priority basis.
  • Identify senior leadership that would navigate issues and concerns regarding quality and deviations from the policy.
  • Participate in finding solutions with Ontario Health regional leadership and regional partners, when escalation has occurred.

Accountability and performance management

Ontario Health

Ontario Health, including the clinical leads for critical care, will collaborate with the Ministry of Health and health system partners to address system challenges and operational improvements related to the policy. This includes, but is not limited to, education to ensure policy awareness and implementation supports.

Ontario Health regional teams, including regional clinical leads for critical care, will collaborate with health system partners to address regional challenges and operational improvements related to the policy. This includes, but is not limited to education, implementation tools, quality improvement and performance monitoring and management of hospitals.

Ontario Health regional teams, including regional clinical leads for critical care, will support escalation of issues if there is deviation from the policy in which access to treatment and/or patient safety may be compromised. This includes real-time issues as needed, in collaboration with CritiCall Ontario, and issues regarding delays in repatriation.

CritiCall Ontario

CritiCall Ontario, including the CritiCall Ontario Medical Director and Associate Medical Directors, will facilitate the policy through effective case facilitation, arranging transportation, and if needed, through escalation of real-time policy issues or infractions.

CritiCall Ontario will collect data and produce reports to support provincial, regional and health service provider performance monitoring, management and quality improvement.

All health service providers

All health service providers will monitor their performance and ensure compliance with the policy and participate in quality improvement.

Related resources

Accompanying protocols, procedures and resources for the Ontario Life or Limb Policy are available at https://criticalcareontario.ca/solutions/life-or-limb/.

Policy review cycle

This policy will be reviewed at least every 5 years.

Policy consultations

In a process led by Ontario Health, the following were engaged to review and update the Ontario Life or Limb Policy (2013):

  • Ontario Health
  • Critical Care Services Ontario
  • CritiCall Ontario
  • Ornge
  • Ontario Association of Paramedic Chiefs
  • Ontario Base Hospital Group
  • Ministry of Health Provincial Programs Branch and Emergency Health Services Division
  • Regional critical care clinical and hospital operations tables
  • Neurosurgery and trauma provincial advisory councils
  • Neonatal and pediatric provincial advisory committees and transport committee
  • Patient and Family Advisory Committees

Policy document

Access the Life or Limb Policy document.