Saskatchewan has 651,900 square kilometres with a population, in 2017, of 1,174,000 people; Half of the population is almost evenly distributed between Regina and Saskatoon, the rest of it is spread in roughly 435,000 square kilometres (1); this area is covered by 105 ground ambulance services, air ambulance and STARS.
According to Statistics Canada, The term “urban” was used intuitively for a concentration of population at high density or a population of at least 1,000 and a density of 400 or more people per square kilometre; all areas outside this definition were considered rural. In 2010 StatCan changed the definition and created the term “Population Centre” or POPCTR; a population centre is divided into small, between 1,000 and 29,999 inhabitants; medium, between 30,000 and 99,999; and a large centre is the one with 100,000 and over. (1)
Following the above classification, Saskatoon and Regina are the only two large POPCTR, followed by Lloydminster, Moose Jaw and Prince Albert in the Medium range and another 56 small population centres. However, is that enough to define what a rural location is? In the United States, Colorado EMS services use the definition provided by the Census Bureau, followed by the USDA and, finally, each own service status, i.e. each service can determine by themselves if they are rural or not (2). In Sweden, a rural area was considered an area of about 1 million people because the density of the population was one-third of the urban area. (3) In Ireland, a rural area is defined as a cluster of 1500 or fewer inhabitants. (4) At the same time, in Australia, ambulance services are divided into urban, regional and rural. (5) Washington defines a hospital as rural if it is located in a county of fewer than 200,000 people and is located more than 5 miles from a city of at least 25,000 people. (6)
Each country and region has its definitions of rural and urban areas. Saskatchewan has two cites that fall into the definition of a large POPCTR; Saskatoon is the only city with a dedicated pediatric hospital, and only Regina and Saskatoon have what is defined by the Health Authority as a major hospital. All of the medium POPCTR have a hospital able to take care of all emergencies and, depending on patient needs, consult with the specialist via phone and arrange transport to a higher level of care hospital. In the small POPCTR categories, 54% of them have a hospital on-site, 29% in less than 50 km, 13% in less than 100 km and 5% more than 100 km. Hospital sizes and capabilities in small POPCTR vary and can be from minor emergency care to hospitals with more capacities. (7)
In Saskatchewan, the EMS review committee in 2009 defined the ten largest cities in Saskatchewan as “urban” areas. The report also mentioned remote areas but did not define it. In this group of urban areas, the response time for emergency calls was less than 9 minutes in an average of 88% of the cases (8), considering that all of these services have to cover areas outside the urban agglomeration, the combination of population size and response times seems to be an acceptable way to classify a service into rural or urban.
According to the Saskatchewan College of Paramedics in the province, there are currently 1,728 active paramedics and 371 EMR, (9) not necessarily all of them working in emergency settings; some of them are working industrial only, standbys or a mix of all. Among the 105 ambulance services in Saskatchewan, the 90 BLS services and the 15 ALS providers are not distributed evenly or strategically; some services have to travel more than an hour to reach an emergency and others more than that to the nearest health facility, while others drive no more than a few kilometres out of their base, making the response times variable across the province from 10 to 100 or more minutes (8).
This uneven distribution happens because, at the beginning of the EMS, services were provided by funeral homes or private companies wanting to provide the service, these companies were not regulated, and anyone could start an ambulance service. (10) Nowadays, this distribution reflects in the varying response times while responding to the emergencies, being this the greatest concern among the patients that request an ambulance. In 2008 an average of 88% of the calls in medium and large POPCTR had a response time of fewer than 9 minutes. The statistics did not consider all of the services covered areas outside urban settings. In a 2009 EMS review, a committee recommended that in large urban areas, 90% of the calls should respond within 9 minutes while the standard for rural should be set in a maximum time of 30 minutes. (8)
The extended response and transport times present a challenge for the EMS system in the province; with few ALS services available most of the province relies on BLS responders to provide care. Cardiac arrests, strokes and severe trauma and the effects due to long transport times are the most common situation due to the time factor in the chances of survival. (4) (6) (11) (12) (13) (14) In 2015, Ireland conducted a study and compared the chance of survival of patients in cardiac arrest between rural and urban settings; findings showed that in an urban setting, paramedics achieved recovery of spontaneous circulation (ROSC) double than rural (6% vs 3%), while 26% of the urban patients were discharged alive from hospital versus 11% from rural areas. (4)
Stroke patients are time-sensitive to get a definite treatment and prevent further damage; Saskatchewan has a protocol for EMS for rural services. The ambulance calls a phone centre, where a group of experts, based on patient history, symptoms, findings and location, advise the paramedics to where the patient can be transported; the ambulance will be directed to the stroke unit or might be redirected to a local centre with CAT scan ability to diagnose and perform the initial treatment if indicated. This protocol is from 2019 and relatively new to have statistics to evaluate its effectiveness. (15)
In trauma situations, transport times rural EMS face are hard to compare with the urban setting, since rural severe trauma injuries are most likely to be fatal in rural areas. In a study performed in Minnesota, it was found that the second cause of requesting ALS was a trauma situation in rural areas (6) (13) (14)
In Saskatchewan, an ACP can administer antibiotics in cases of severe sepsis but it is recommended when transport times are greater than 45 minutes. In comparison, medications like norepinephrine or dopamine have to be titrated to effect every 5 minutes; therefore, in an urban setting, a few adjustments have to be made while in longer transport times. The paramedic will perform several adjustments during transport. (16)
Long transports allow the rural provider to not only treat the problem but also be able to see the effectiveness or not of such treatment. Long transports imply that not only the attendant is the one subject of extra moments of stress, but also the driver has a challenge of long hours of driving and, depending on the distance, a non-stop long road trip.
In conclusion, even though some places in Saskatchewan are considered urban areas, all services perform rural calls, either emergencies or scheduled transfers. The uneven distribution of the ambulance services across the province represents advantages for some and disadvantages for others. The Brickberk report in 1985 (10) and the EMS review in 2009 noted these differences, and both recommended to find a solution that will benefit the patient and the ambulance agencies (8). In 1971 a study was conducted in Michigan to find the optimum ambulance location to minimize response times and cost (17); after that, several papers were published dedicated to optimizing ambulance dispatch and location. (3) (18) (18) (19) (20) (21) (22)
However, all of these methods are functional in urban or semi-urban areas, but if we try to apply the models in a territory with the characteristics of Saskatchewan, the optimum ambulance location might fall in the middle of a field. Even if some location improvements can be made, it will be challenging to reach a standard maximum response time across the province; however, maybe a new review should be done to evaluate the results of 2009 and plan for the future of EMS in the province.
- Government of Canada SC. Statistics Canada: Canada’s national statistical agency. [Online].; 2020 [cited 2020 sep 20. Available from: https://www.statcan.gc.ca/eng/start.
- Crampton D. Comparison of PTSD and compassion fatigue between urban and rural paramedics. Anne Arbor:; 2013.
- Brismar B, Dahlgren B-E, Larsson J. Ambulance utilization in Sweden: Analysis of emergency ambulance missions in urban and rural areas. Annals of Emergency Medicine. 1984; 13(11): p. 1037-9.
- Masterson S, Wright P, O’Donnell C, Vellinga A, Murphy A, Hennelly D, et al. Urban and rural differences in out-of-hospital cardiac arrest in Ireland. Resuscitation. 2015; 91: p. 42-7.
- Pyper Z, Paterson JL. Fatigue and mental health in Australian rural and regional ambulance personnel. Emergency Medicine Australasia. 2015; 28(1): p. 62-6.
- Grossman DC, Kim A, Macdonald SC, Klein P, Copass MK, Maier RV. Urban-rural Differences in Prehospital Care of Major Trauma. The Journal of Trauma: Injury, Infection, and Critical Care. 1997; 42(4): p. 723-9.
- Government of Saskatchewan. Find a Hospital. [Online]. [cited 2020 Sep 20. Available from: https://www.saskatchewan.ca/residents/health/emergency-medical-services/find-a-hospital.
- Cummings D. Saskatchewan emergency medical services review: final report. October 2009. Saskatoon: SEMSA; 2010.
- Saskatchewan College of Paramedics. Saskatchewan College of Paramedics. [Online]. [cited 2020 Sep 20. Available from: https://www.collegeofparamedics.sk.ca/.
- SEMSA. The history of Saskatchewan ambulance and emergency medical services Saskatoon: Saskatchewan Emergency Services Association; 2016.
- Leira EC, Hess DC, Torner JC, Adams HP. Rural-Urban Differences in Acute Stroke Management Practices. Archives of Neurology. 2008; 65(7).
- Hansen G, Bal S, Schellenberg KL, Alcock S, Ghrooda E. Prehospital Management of Acute Stroke in Rural versus Urban Responders. Journal of Neurosciences in Rural Practice. 2017; 08(s 01).
- Myers LA, Russi CS, Schultz JL. Paramedic Intercepts with Basic Life Support Ambulance Services in Rural Minnesota. Prehospital and Disaster Medicine. 2010; 25(2): p. 159-63.
- Newgard CD, Fu R, Bulger E, Hedges JR, Mann NC, Wright DA, et al. Evaluation of Rural vs Urban Trauma Patients Served by 9-1-1 Emergency Medical Services. JAMA Surgery. 2017; 152(1): p. 11.
- Government of Saskatchewan. Acute Stroke Pathway. [Online]. [cited 2020 Sep 20. Available from: http://www.sasksurgery.ca/provider/acutestroke.html.
- Saskatchewan College of Paramedics. Protocol Manuals. [Online].; 2020 [cited 2020 sep 20. Available from: https://www.collegeofparamedics.sk.ca/professional-practice/protocol-manuals/.
- Volz R. Optimum Ambulance Location in Semi-Rural Areas. Transportation Science. 1971; 5(2): p. 193-203.
- Berg PLVD, Fiskerstrand P, Aardal K, Einerkjær J, Thoresen T, Røislien J. Improving ambulance coverage in a mixed urban-rural region in Norway using mathematical modelling. Plos One. 2019; 14(4).
- Flynn A. Maximizing resource efficiency in rural prehospital emergency medical services through call frequency analysis. UNED Research Journal. 2013; 5(2): p. 297-301.
- Ingolfsson A, Budge S, Erkut E. Optimal ambulance location with random delays and travel times. Health Care Management Science. 2008; 11(3): p. 262-74.
- Jagtenberg CJ, Bhulai S, Mei RDVD. Optimal Ambulance Dispatching. International Series in Operations Research & Management Science. Markov Decision Processes in Practice. 2017;: p. 269-91.
- Schmid V, Doerner KF. Ambulance location and relocation problems with time-dependent travel times. European Journal of Operational Research. 2010; 207(3): p. 1293-303.
- Gunnarsson B, Svavarsdóttir H, Dúason S, Sim A, Munro A, Mcinnes C, et al. Transport and Services in the Rural Areas of Iceland, Scotland and Sweden. Australasian Journal of Paramedicine. 2015; 5(1).