Realistic expectations of our emergency departmentsPublished on February 5, 2013
Published on February 4, 2013
By Desmond Colohan
There is a rumour going around West Prince that Health P.E.I. plans to close the emergency department at Western Hospital. I don’t claim to know whether there is any legitimacy to local residents’ concerns, but I do know that this is an issue that needs to be discussed.
While I currently limit my clinical practice to pain management, for over 30 years I was a full-time emergency physician and was very involved in the development of emergency medicine in Canada and the U.S., including the development of hospital emergency departments, pre-hospital care, ambulance services and specialty certification exams. I have also been an emergency medicine training director and systems administrator and have worked in some of the busiest and best emergency departments in Canada and the U.S. I have watched emergency departments evolve from being out-patient clinics where patients were seen by appointment only, through the brief era when the only patients seen in the emergency department had true life and death emergencies, into the modern era where emergency physicians treat mainly non-urgent primary care problems and the occasional seriously ill patient. The staffing of emergency departments has changed as well. Early on, emergency departments were staffed by nurses and one of the hospital physicians assigned to the out-patient clinic. The 1960s saw the switchover in larger hospitals to full-time emergency physicians. Many of them came from the medical specialties and family practice. Emergency departments started to remain open 24 hours a day. This was initially a big city phenomenon, particularly in university teaching hospitals, which had the luxury of in-house medical trainees. Over the past 30 years, the health-care system has continued to evolve, and emergency departments have had to change as well. Consumer demand for emergency department services skyrocketed in the 1980s-1990s, and continues to increase as more and more people use the emergency department as a health-care one-stop-shopping opportunity. A declining supply of general practitioners, and a sea change in their willingness/preparedness to take on all comers, has drastically changed accessibility to primary health care. As I’ve said before, the likes of Drs. Kent Ellis, Harry Callaghan, Charlie Trainor and other medical workhorses will never be seen again.
In a letter to The Guardian last week, Dr. Alan Drummond, a spokesperson for the Canadian Association of Emergency Physicians, stated emphatically that his organization has not yet endorsed the Nova Scotia model of collaborative emergency care [no doctor on site at night] but that they support fully accredited emergency departments. Accreditation Canada is the primary accrediting agency for health-care institutions in Canada and has established a set of standards that must be met for a health organization like Health P.E.I. to be accredited. What is happening in Alberton and Montague is that Health P.E.I. is, de facto, offering a limited urgent care service because it is unable to consistently provide highly-trained emergency physicians and nurses on-site 24 hours a day. People living in rural communities have always expected that they would have local access to a full-service emergency department, but they don’t, and they never have. This is a situation that inevitably will lead to unrealistic expectations and misunderstandings about the level of emergency service that is deliverable.
It is impractical to expect nurses and physicians working in low-volume rural emergency departments to be skilled at performing sophisticated assessments and interventions such as placing a breathing tube, a pacemaker or a chest tube when they may not have been called upon to use these skills in the past year, if ever, which is often the case. This is not a problem unique to Prince Edward Island, and is not intended as a criticism of the physicians and nurses currently working in these emergency departments. They do the best they can under very difficult circumstances. Elsewhere, the problem has been addressed using various models, all of which invoke the principle of ‘triage, stabilize and transfer’. Patients whose problems exceed local expertise are moved to facilities that can handle them better. In well-defined circumstances, this may involve bypassing the local hospital. The real challenge is to get a good handle on the local level of available expertise.
This is not a challenge that can be solved by throwing money at it. When emergency departments are closed due to physician shortages the usual public reaction is to demand that the government go out and buy more coverage. Yes, this may work in the short term, but it is unsustainable. There aren’t many emergency physicians or GPs with emergency experience prepared to relocate to rural P.E.I. at any price, and many young family physicians are either not comfortable or insufficiently trained to function at the high level expected of full-time emergency physicians. It is a myth that any physician in an emergency is better than no physician at all. We learned that lesson in the 1970s. A better solution would be to optimize local access to primary care and urgent care services, while, at the same time, maximizing local access to highly trained paramedics who have the skills and experience to stabilize and transport critically ill or injured patients to a regional hospital. We have to do everything possible to improve emergency services in West Prince and King’s County, but we need a better model.
Desmond Colohan is a P.E.I. physician with an interest in health systems policies.
No significant disagreement here.
Not every community can expect to have a full service emergency department and some sort of after hours primary care access with ability to stabilize and transfer may be the best people can accept in some small communities. But they are not ERs without doctors and shouldn’t be characterized as such!
Where there is an existing department, efforts should be made to optimize it and develop a regional system.
A warm body in the ER is not good enough but disgree that most life saving skills must be continually relearned.
Accreditation Canada does have ER standards. I helped develop them. The CEC will not be accredited as an ER.
A newer model is required just not so sure its the NS model which after all was pretty much simply made up by John Ross.
Too early in its evolution to call it anything more than an experiment.