Portrait of rural emergency departments in Québec and utilization of the provincial emergency department management Guide: cross sectional survey

To develop a comprehensive portrait of all rural EDs in Québec in 2010, data were collected via telephone, paper, and online surveys with rural ED/hospital staff, from Québec’s Ministry of Health databases, and from Statistics Canada. Briefly, the telephone, paper, and online surveys were used to obtain data concerning (1) hospital center characteristics (e.g., referral centres, availability of local intensive care unit [ICU] beds); (2) availability of health information technology (e.g., Internet and wireless Internet access); (3) knowledge transfer activities (e.g., quality assurance, Journal club); (4) ED variables (e.g., triage level, wait time, average hospital stay, on number of annual visits, number of stretchers and number of transfers between facilities) were gathered in conjunction with MSSS “Direction Nationale des Urgences”, (5) availability of 24/7 diagnostic services (e.g., laboratory, basic radiography, Computerized Tomography (CT) Scanner, Magnetic Resonance Imaging (MRI), ultrasound, portable ultrasound); (6) medical and paramedical staff (e.g., number of emergency doctors, years of experience and level of training, percentage of locum doctors per period, availability of specialists, number and level of training of nurses, presence of other health professionals). Prior to the study, this list of variables was submitted for review to a group of experts in emergency medicine and trauma as well as to decision-makers and leaders of professional associations including clinicians, the heads of professional associations, the Québec college of physicians), policymakers, and the senior management of medical schools [19]. All sociodemographic variables were obtained from Statistics Canada website.

Québec rural EDs receive a significant number of ED visits relative to the size of the local population. In fact, rural EDs in Québec receive, on average more than 40 % more consultations than do rural EDs in other provinces of Canada [14]. These consultations are, for the most part, for lower-acuity conditions. Given the limited access to family doctors in rural communities in Québec, it is possible that patients depend on EDs for their acute care needs [20]. In Québec, 21 % of citizens do not have a family physician (and access to one takes an average wait time of 466 days) [21] compared to 15 % in the rest of Canada [22, 23]. Having a primary care doctor does not guarantee access for emergent consultation. In fact, 45 % of Canadians that have a family doctor cannot obtain same-day consultations [22]. Thus EDs will likely remain a safety net for minor emergencies in rural areas. Considering reasonable wait times reported here this may not be a dramatic outcome [20].

Despite the high volume of consultations, wait times in Québec rural EDs are within or approximate national guidelines that were recently published by CAEP [24]. These guidelines suggest that wait times should be under two hours and total time spent in the ED be less than 8 h [24]. Interestingly, a recent report by the Canadian Institute for Health Information (CIHI) shows that national ED wait times average 9.2 h [25]. CIHI did not report rural versus urban wait times. Noteworthy is that Canada has one of the worst ED wait times in developed countries [22].

EDs are staffed by a combination of family doctors who exclusively practice full-time emergency medicine, and family doctors who also have other duties. A total of 14 % of shifts require locum coverage (back-up doctors). Québec has a back-up system consisting of a list of volunteer physicians that staff EDs as necessary called “mécanisme de dépannage”. This system was established primarily to maintain 24/7 ED coverage in small communities. In 2010, a total of 287 physicians across the province were identified as back-ups, many at the service of the hospitals that participated in this study (240 physicians). One report indicated over 13,000 shifts required locum coverage in 2010. In that year alone, the program cost ten million dollars for physicians’ transportation and lodging [26].

Moreover, in order to improve access to emergency care in rural areas, the Québec government developed a program that favours placement of graduating doctors in non-urban, rural, or regional areas. In their first 3 years of practice, new graduates are encouraged to practice in these areas with various financial incentives that can reach upwards of 40 % more remuneration than urban doctors for the same medical billing code [27]. Also, the regional plans of medical staffing in family medicine authorize, for every administrative region of Québec, a target number for family doctors’ recruitment, which allows a fair distribution of new family physicians. Without these programs, the problem of access to physicians in rural centers could be far worse.

Given this context, our finding that 31 % of doctors working in rural areas have fewer than 5 years of experience is not surprising. However, it is unclear how many young physicians stay in rural communities and for how long. A few studies have examined retention in rural areas and multiple factors affect this aspect [28‐30]. However, no study has examined recruitment and retention in the context of rural emergency practice per se. In light of current and foreseen staffing shortages in emergency medicine, future studies on this aspect are required [31]. A subsequent phase of this study will address this.

The practice of rural emergency medicine is stressful, and may by particularly so for a young physician working with limited consulting and support services. Solutions to the disparity between rural and urban services are complex and multifaceted. Doctors in rural practice become vulnerable to burnout owing to the high workload and low level of collegial and consultant support [28]. Data collected in our pre-study phase suggested that access to resources (e.g., CT scanner) and consultants were among the most important issues for ED physicians [32]. The fact that the vast majority of rural EDs in Québec have 24/7 access to a CT scanner, general surgeon, and an ICU may reflect this need and justify why this is part of the provincial ED management Guide.

Trauma is the 5th leading cause of mortality nationwide [33] and the first cause in patients under the age of 40 [34]. Over the last 40 years, trauma care has improved dramatically and the mortality rate among victims with serious injuries (ISS > 12) fell from 52 % in 1992 to 8,6 % in 2002 in Québec [35]. This dramatic change is believed to be attributable to prevention and the organization of trauma systems. The timely care of patients in level 1 and level 2 trauma centers has also contributed to this excellent result. While 77.5 % of Canadians have access to Level 1 and level 2 trauma centers within a conservative “golden two hours”, marked geographic disparities in access persist [36]. Access to trauma centers is critical because the risk of trauma is three times higher in rural than in urban patients, and the risk of trauma death is twice higher [37]. This study demonstrates that 44 and 48 % of Québec’s rural EDs are respectively, over 300 km from of the level 1 and level 2 trauma centers. Given this distance, it is highly unlikely that trauma patients would reach trauma centers within the recommended time frame. Québec has no helicopter transport and 16 rural hospitals do not have airplane medevac access. Initial management of patients in Québec rural hospitals is therefore highly probable, if not the norm. We are presently conducting a detailed study to specifically address the issue of rural trauma care in Québec. In particular, the study will address the impact of local resources on trauma care.

Inter-facility transfers imply that the local center is not able to provide appropriate care for the specific reason transfer is requested. Despite good access to resources in Québec’s rural EDs in comparison to rural EDs elsewhere in Canada, access to life- and limb-saving consultations remains limited. For example, rural hospitals in Québec do not have access to cardiac catheterization, or to sub-surgical specialties such as orthopedics, neurosurgery and plastics. In our study, fewer than 40 % have access to an internist, 13 % to a pediatrician and 0 % to neurology. Moreover, the present study demonstrated that approximately 294 inter-facility transfers (data not shown) per year are required with 18 % on an urgent basis. This finding is consistent with the only other report on inter-facility transfer requirements in a rural setting in Canada [38]. Rourke et al. showed that 1.6 % of patients require transfer, most commonly for: orthopedic care (24 %), CT scanner (14 %), and pediatric consultation (8,7 %) [38].

Inter-facility transfers lead to reduced ambulance coverage in rural areas posing a risk to communities. Ambulance transfer is in itself a risky high speed transport, with ambulance crashes occurring with greater frequency and severity than crashes involving vehicles of similar size and weight characteristics [39]. Moreover, results indicate that while there is a greater incidence in urban ambulance accidents, the percentage of ambulance crashes with injuries and the severity of the injuries is greater in the rural settings [39‐41]. Future national studies must relate inter-facility transfers to locally available equipment. Québec has a complex EMS system comprising of 50 private companies. This appears to be unique feature where most provinces have provincially managed systems. A subsequent phase of this study will address prehospital care in detail.

Thus providing access to services in rural areas, the province of Québec is a unique and possible forward thinking policy. Future studies are required to evaluate whether this model of care is cost-effective, safe and could favor recruitment and retention of physicians.

The provincial ED management Guide is, to our knowledge, the most recent and concise available document that was designed to make all stakeholders accountable in the process of care of emergency patients. It specifies the services that should be accessible in the province’s EDs based on the number of annual visits to the department and other variables. The Guide also has a section dedicated to rural emergency departments [16].

To our knowledge, Québec is the only Canadian province to have published a comprehensive Guide. For the purpose of the current paper, we focused solely on exploring whether or not participants were aware of the Guide, and whether or not they perceived it to be useful. The large proportion of respondents who were not aware that the Guide existed was a surprise. The provincial ED management Guide is not new, the first version was published in 2000 and a revised version was published in 2006. It is possible that new graduates and employees were not exposed to this tool, and that knowledge transfer concerning the provincial management guide was not sustained over the years. A new version of the guide is presently being developed, and the information in this study may be useful in planning knowledge transfer strategies. An extension of this research will be to conduct a detailed study of the barriers/facilitators to the use of the Guide and better understand its contribution to the level of care and resources offered in rural settings.

In absence of evidence-based standards in care, written policy may serve as a guideline for emergency care. Certainly, the fact that most rural EDs have 24/7 access to a CT scanner, general surgical services and ICU is unique in Canada and could reflect this policy. In absence of standards of care in rural EDs and awaiting data, policy that aims at providing access to services may be a cautious approach to safe care for vulnerable rural populations.

Providing 24/7 surgical, anesthetic and ICU care carries a cost. Decision makers across Canada have centralized these services on the basis of regrouping expertise, facilitating management and obviously reducing costs. The Québec model thus appears dramatically different from elsewhere in Canada, at least with respect to our preliminary data [14]. The salient question remains what system is more cost-efficient and safe? In terms of cost, a recent report by CIHI suggests per capita annual healthcare spending in Québec is one of the lowest [42]. This same report states that Québec provides among the best value per dollar spent among Canadian provinces [42]. Yet, this report does not address issues of quality of emergency care per se. Future studies need to examine the relationship between the level of resources/services locally offered in rural hospitals and emergency specific quality of care indicators.

In Canada, a series of priority emergency care sensitive indicators have been developed by Schull et al., [43] They include: ED Operations, Patient Safety, Main Management, Pediatrics, Cardiac, Respiratory, stroke, Sepsis/Infection [43]. They are currently being validated mainly in urban academic centers. The indicators have not been operationalized for rural settings. Thus, it may be possible that quality of care indicators cannot be easily captured in rural settings with limited computerized data/patients records. A subsequent phase of this study will address this issue. While awaiting results, in the context of preliminary reports from elsewhere in Canada and the US that suggest increased mortality from trauma, stroke, in rural versus urban hospitals, caution must be exercised in service attribution decisions [44‐46].

The present study constitutes a detailed descriptive portrait of rural EDs in Québec. For the purpose of conducting a nationwide study on rural EDs, this work focused on EDs providing 24/7 physician coverage located in “Rural small town” communities in hospitals with acute care hospitalization beds. The study did not examine access to the full scope of emergency services in Québec; it excluded facilities such as Centre Local de Services Communautaires (CLSCs), “Groupe de médecin de famille (GMF)”, nursing stations and private clinics, which provide basic emergency care to thousands of patients per year. However, the vast majority of these facilities provide only daytime services. They have limited resources (ex. CT scanners and specialists) and are unlikely to provide the full scope of emergency care for life or limb threatening disease. Furthermore this study did not report data concerning outcomes and costs associated with level of access to services.

This study did not collect data on rural ED service areas, and only reported local municipality populations. Determining hospital service areas is a complex and unreliable task. Hospitals may provide specific or specialty services such as imaging and dialysis for rural areas. Furthermore, patients may seek emergency treatment at the center of their choice, even if the chosen facility is not the closest one to their home. It is therefore quite likely that rural hospitals serve territories and populations that are considerably larger than the local population figures reported here.