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Variability in Rural Emergency Care

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If you’re in a rural area and in need of emergency care, you’re better off in Quebec than Ontario or B.C.: study

Tom Blackwell | May 4, 2015 4:04 PM ETNational Post

File: A girl's hand is bandaged at Perth Great War Memorial and Smith Falls District hospital in Perth, Ontario.

Lars Hagberg for National PostFile: A girl’s hand is bandaged at Perth Great War Memorial and Smith Falls District hospital in Perth, Ontario.

Rural emergency departments in Ontario have dramatically fewer CT scans, specialists and nearby intensive-care units than those in Quebec, suggests a new study that adds to evidence of wide quality gaps in Canada’s emergency health care.

The findings parallel a similar disparity the researchers discovered earlier between rural ERs in British Columbia and Quebec.

They are now studying whether that lack of specialists and equipment affects the number of non-urban Canadians who die from trauma, stroke, heart attack and severe infection. The early results are “concerning,” said Richard Fleet, a Laval University emergency-medicine professor who co-authored the newest research.

“In a rural emergency department, people actually save lives by working as teams,” said Dr. Fleet, who practiced in a small-town B.C. emergency department before heading to Quebec. “For emergencies … it’s really good to have these backup systems in house.”

One prominent rural ER physician in Ontario rejected the notion that his province’s departments are inferior, saying the focus is more on sending the sickest patients to big trauma centres.

It’s a crap shoot, when you go to any hospital in this country, in terms of what you’re going to get in the type and quality of care

Across the country, however, wide variations in emergency-department standards definitely do exit, said Alan Drummond, a spokesman for the Canadian Association of Emergency Physicians.

“It’s a crap shoot, when you go to any hospital in this country, in terms of what you’re going to get in the type and quality of care,” he said. “We have national variability and for 23% of Canadians [who live outside cities], that’s unacceptable.”

Lars Hagberg for National Post

Lars Hagberg for National PostDr. Alan Drummond, seen in a 2009 file photo.

About 6 million Canadians live in rural areas, tend to be older on average, have greater health needs, and are more likely to suffer traumatic injury, partly due to the prominence of dangerous professions like farming and logging.

Dr. Fleet became interested in the relative quality of emergency service after government cutbacks meant his former hospital in Nelson, B.C., could offer only “bare-bones services to a high-risk population.” He lobbied for additional funding, but realized there were no published data comparing different Canadian emergency departments.

In the most recent study, just published in the journal PlosOne, he and colleagues looked at rural departments with 24/7 service and an ability to admit patients to acute-care beds in their hospitals – 26 facilities in Quebec and 62 in Ontario.

If anything, the Ontario ERs appeared more isolated on average, with a greater percentage of them being at least 300 kilometres from a trauma centre.

Yet 92% of the Quebec emergency departments had a local intensive-care unit, compared to 31% of the Ontario ones. Just over 80% of the Quebec ERs had a general surgeon available on call, versus a third of the Ontario emergency departments.

And while 77% of the Quebec departments had 24/7 access to a CT scanner, only 15% of their Ontario counterparts did.

Similar differences exist between B.C. and Quebec emergency departments, the same researchers concluded in a study published last year in the Canadian Journal of Emergency Medicine.

Dr. Fleet said he is not sure why Quebec’s rural ERs are better equipped, given the provinces’ spending on health care is similar per capita. It may relate to the fact its rural hospitals have fewer foreign-trained doctors, who may feel less empowered to demand better facilities.

Lars Hagberg for National Post

Lars Hagberg for National Post

But Dr. Drummond said Ontario has a different protocol that ensures rural ER physicians are well-trained to provide basic emergency services – such as treating shock and blocked airways – and emphasizes funneling critically ill patients to trauma centres in larger cities. The province’s CritiCall system helps rural hospitals find facilities that can take their patients. That means, for instance, that a surgeon would not need to be on call in a small, rural hospital, he said.

However, he agreed that having a CT scanner is now crucial to emergency departments anywhere making accurate diagnoses; the one his hospital in Perth, Ont., acquired five years ago “changed the way we practice.”

Just nine of 62 full-time rural Ontario departments had a CT scanner, according to the new study.

Dr. Fleet said it is possible that better air-ambulance and other patient-transfer systems outside Quebec could offset some of the shortfalls in local hospitals’ equipment and personnel, but that’s not backed up by any peer-reviewed, published evidence.

National Post

tblackwell@nationalpost.com

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