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Regionalization of Rural Canadian Emergency Departments: Time for a National Discussion

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The Imperative:
The regionalization of Canadian emergency departments is an inevitable fact of our collective future by default not design.
A collective governmental failure in effective health care planning has led to human resources shortages that continue to impact on our ability to provide universally accessible and timely services to our citizens.
A relative (or is that absolute) shortage of physicians and nurses willing to work in the nation’s emergency departments has let to unfortunate and occasionally unpredictable disruption of emergency service.
The total number of physicians who provide emergency department coverage has decreased over time from 2,525 in 1993 to 1,987 in the year 2000. Almost this entire decline occurred among general practitioners or family physicians without certification in emergency medicine.
The shortage of family physicians providing emergency department coverage has led to regrettable service disruptions.
In Nova Scotia in 2008, there was in excess of two thousand hours of uncovered emergency service; four times greater than the previous year. In Ontario, in 2009 30 of 150 emergency departments were faced service disruptions because of a shortage of staff. In Manitoba in 2009, 16 communities had closed emergency departments because of staffing shortages leading the Premier of the province to apologize to the people of Virden.
There have been repeated media reports of deaths associated with closed or suspended emergency services.
It is simply unacceptable to our specialty, our association and our nation to have an acutely ill or injured Canadian present to an emergency department only to be turned away or met by a “closed” sign on the door.
• Regionalization of rural emergency departments is an inevitable reality as a result of inadequate health care planning
• A shortage of physicians and nurses has led to unpredictable service disruptions in emergency services and has led to a porosity of the health care safety net
• Unpredictable disruptions in emergency service our unacceptable to our specialty and our nation
• The specialty of emergency medicine must commit to the development of policy to guide and assist provincial health authorities in the process of regionalization of emergency services in order to guarantee timely access to quality emergency services for our nation’s citizens

The History:
Regionalization of emergency services has been discussed in Canada for the past twenty years but has never been actually done in the context of larger community rural hospitals.
A number of reports in Ontario in the early 1990’s called for grouping of rural emergency departments within small geographic regions to facilitate emergency service while conserving human resources. Grouping was suggested within a one half hour time frame or within forty kilometers by road.
All of these reports were accepting of the two paradigms of rural “close” and rural “remote” when discussing the location and regionalization of rural health facilities.
Even in Saskatchewan, where 54 small cottage hospitals with emergency rooms were rationalized in the last decade, it was recognized that “planning for the North must reflect their distinct society, geography and health needs”. In short, in a country such as ours with vast distances between communities, there will be geographic imperatives that transcend established parameters for the more densely populated areas of the country.
• Regionalization of emergency facilities must acknowledge and recognize the unique needs of those in northern and remote areas
Recently, in Nova Scotia with the release of the Corpus Sanchez report and in Alberta with the release of the McKinsey report there has been a call for the regionalization of rural emergency services. The imperative in these circumstances is the inability to consistently and continuously staff emergency health facilities.
In Ontario, it has been suggested that the recent closure of emergency departments in the Niagara health region was based on cost containment concerns rather than the potential for service disruption.
• Regionalization should be considered when communities are historically threatened by service disruptions. It should never be a matter of cost containment.
• Regionalization of emergency services in regions chronically under threat of service disruptions and where public access to timely emergency service is in jeopardy should be supported.
• The concept of rationalization of emergency services for cost containment purposes should be rejected
Despite reports calling for the consideration or regionalization of emergency services, it has never actually been done. The Fyke report that led to the rationalization of a number of small “cottage” hospitals in rural Saskatchewan never involved facilities that served large population masses. The regionalization of urban emergency departments in Ontario, under the auspices of the Sinclair report, largely involved small communities with two hospitals with different religious affiliations.
• The regionalization of emergency departments has never been done in Canada. This absence of a history suggests the need for caution as we approach this new era of regionalization.

The CAEP Rural Committee developed a template for the standardization of rural emergency services in 1997. With respect to regionalization the expert panel made the following comment.
“Regionalization offers many opportunities to improve rural emergency health care. Typically, regionalization brings many rural communities under unified management, replacing the fragmented management that occurred when each hospital had its own board and medical staff organization. The advantage of the old system was that each hospital could evolve to meet the individual needs of its own community. A significant disadvantage of the old system was uneven development and poor coordination emergency health care.
An ideal region would link emergency health care services and facilities in a systematic way to ensure adequate patient access, rather than raise further barriers to care such as distance. Regionalization should not artificially cut across traditional cultural, geographic and economic divisions of rural communities.
As regionalization progresses in Canada, different classification schemes for rural health care facilities are emerging. This variation leads to confusion about the roles and standards for facilities.
We avoided the older system of classifying health services into “primary, secondary and tertiary care” because that scheme does not reflect accurately the capabilities of rural health care providers who staff rural facilities. The primary-secondary-tertiary system implies a rigid set of guidelines is possible for defining which patient gets care in a given facility. The reality is that some rural facilities might be sufficiently equipped and staffed with physicians capable of delivering care that traditionally has been considered as “secondary” or even “tertiary” care.”
Another approach to the regionalization of emergency services is through the adoption of either a Centralized or Decentralized model.
The Centralized model calls for the maximum intensity of services to be concentrated on a single lead hospital within a given region. The Decentralized model acknowledges that each hospital within a given geographic region has its own unique strengths that contribute to a whole. Given that rural Canadians bear a disproportionate mortality and morbidity from trauma and the issues of distance, time, weather and geography associated with care delivery in Canada, rural hospitals must be supported and strengthened.
With respect to the more rural and remote communities of our nation, the CAEP rural committee was supportive of a decentralized model.
“While regionalization allows provincial governments to improve health system management by de-centralizing decision-making to local regions, the process also leads to a certain amount of new centralization within regions. “Centralized” or “exclusive” regional organization can weaken the delivery of emergency health care in rural communities that are not supported with sufficient resources to care for patients locally.
For example, an ambulance bypass system that excludes physician groups in some rural communities might prevent them from being able to develop optimum emergency care capability when patients show up there anyway. Bypass decisions usually are made by EMS providers who have less training and experience than physicians, which could lead to inappropriate bypass for patients who might benefit from treatment in the rural facility being bypassed. Furthermore, patients with less critical problems, whose injuries or illness would not qualify them for the bypass protocol, will continue to use excluded emergency facilities anyway. We therefore recommend that managers adopt the “de-centralized” or “inclusive” approach to regionalization. “
In some jurisdictions, with shorter distance and time factors, and less imposing geographical considerations, the centralized model may be an acceptable approach.
• The national emergency physician association,CAEP, favors a decentralized model for the regionalization of emergency health services in remote and isolated communities
• A Centralized model may be an acceptable approach in “rural close” environments. CAEP would expect, however, that in this model traditional geographic and cultural boundaries would be respected and consistently successful emergency services would be supported and maintained.

Considerations for successful regionalization:
Planning for the health needs of a given region is obviously of fundamental importance to understand the requirements for its emergency health service. Population density, age demographics, chronic disease burden, industrial and agricultural concerns and cultural issues all will impact on the requirement for health service.
• Fundamental to the process of regionalization is an understanding of the unique health care needs of a given region
Of particular concern, from the emergency perspective, is the issue of distance and time to access of emergency department service. Previous reports have called for consideration of regionalization when multiple hospitals are grouped within a 40 km radius suggesting acceptable access is defined as one half hour (given 40kms accessible on secondary roads driven at 80km/hour).
Certainly, a number of clinical paradigms (“time is muscle” for cardiac intervention; the “gold hour” of trauma) all suggest the need for timely intervention.
• There must be a national discussion of acceptable time frames for time and distance factors to access emergency department care
The second key issue would be the categorization and standardization of all Canadian emergency facilities to enable an appropriate inventory of regional emergency facilities and appropriate decision making with respect to any planned rationalization.
There are in Canada there is no consistent method of categorization of emergency departments. The original National Health and Welfare standards document recognized four levels of emergency department service in Canada from Academic Health Science Centre to rural hospital. In 1997, the Rural Section of CAEP called for a subdivision of the rural hospital to five distinct levels of emergency health facility. At each level of categorization there were articulated expectations with respect to staffing levels, diagnostic and therapeutic equipment and relationships with other hospitals within a given region.
Furthermore, there remain no articulated minimum performance standards for any emergency department in Canada.
• Basic to the process of regionalization of emergency health facilities is an inventory of the types of emergency health facilities within the region with a common understanding of the anticipated levels of service provision
• There must be a common understanding of the categories of emergency health facility and an articulated performance standard for each category
Regionalization accepts that inter-hospital transfers will be an inherent part of caring for a given patient within a regionalized system. This will require enhanced communications and transport systems to facilitate safe and effective transfers between hospitals. This also means that regional centers of excellence or academic health sciences centers will be required to accept transfers at all times in order for the model of care to succeed.
• Regionalization will require an enhanced level of communications and inter-hospital transfer capability than currently exists in many provinces in Canada
• Regionalization of emergency services will require the ability of lead hospitals in a given health region to accept all transfers from the periphery; this suggests the need for increased bed capacity
Regionalization will require adequate human resources to staff all hospitals within the regional sphere. Human resources continue to be a major concern and this raises a number of interesting questions for emergency medicine. In 2002, the Quebec government attempted to force physicians to staff regional health facilities.
• Will regionalization require that emergency physicians be considered a regional resource, as opposed to an independent contractor at a specific hospital?
A number of reports have called for the use of alternate health care providers in staffing lower levels of facility within a regional hub network.
• What is the role of nurse practitioners, physician assistants and advanced care paramedics in staffing rural emergency health care facilities within a regional model?
These questions are important but remain currently unanswered. Further research, enquiry and national consensus is required to fully understand the health human resources requirements for a regionalized system.

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