Regional Emergency Department Study

Transcription

1 ` North West LHIN Regional Emergency Department Study Final Report KPMG LLP 1

2 ExecutiveSummary Thisreport,commissionedbytheNorthWestLHIN,takesacloselook atthesustainabilityofemergencycareinnorthwesternontario. WhiletheProvinceisfocusedonEmergencyDepartmentissues relatedtowaittimesandpatientflow,theissuesconcerning emergencycareinnorthwestlhinaredifferent. Theprovisionofemergencycareinthenorthrequiresacomplexsetof interactionsamonganetworkofprovidersthatcrossjurisdictional boundaries.patientflowformostcriticallyillpatientsinthelhin involvesstabilizationinaruralhospital,andtransportationtoaregional tertiarycentre.issuesofpatientflowareonagranderscaleacrossthe region. EmergencycareintheLHINissupportedbytwelveemergency departmentswithvaryinglevelsofresourcing.theserangefrom ThunderBayRegionalHealthScienceCentre(TBRHSC),fullystaffed 24/7withemergencyspecialists,supportedbyatertiarylevelhospital; Lake-of-the-WoodsDistrictHospitalinKenora,staffedbyamixof emergencyspecialistsandemergency-trainedfamilyphysiciansthat alsoprovideon-callsupportatnight;and,theremaininghospitalsthat arestaffedbyemergency-trainedfamilyphysicianswithon-callstaffing atnight. Thisstudyexaminesthesustainabilityoftheemergencydepartment systemacrossthelhin.severalissueshaveemergedthatthreatento impactthesustainabilityofthesystem.theseincludethefollowing: Ashortageofhealthhumanresourcesthathasthreatenedthe viabilityofsomeemergencydepartments; Transportationandpatientflowissuesacrossthesystem;and, EmergencyDepartmentwaittimesandhospitalalternatelevel ofcaredaysthatimpacttheemergencydepartmentqualityof careandefficiency. Sustainabilityofthesystemforthepurposeofthisstudyisdefinedas theabilityofprovidersacrossthelhintoprovideconsistentquality emergencycarefromend-to-endregardlessofwherethepatientlives inthelhin. Withinthisframeworkthefindingshavebeengroupedintothemesand summarizedbelow: Vision:WithintheNorthWestLHIN,thereisnoagreed-upon VisionregardingthemannerinwhichtheLHIN semergency Departmentsandhospitalsshouldworkasanetworkin ensuringthatpatientswithurgenthealthproblemsreceive i

3 timely,highqualitycare,deliveredinthemostappropriate environment. Governance:Atpresent,eachNorthWestLHINEmergency Departmentfunctionssemi-autonomously;thereisnooverarchinggovernancestructureaccountableforimplementation ofavisionofanintegratedemergencyservicesnetworkin NorthwesternOntario. Administration and Accountability: Thereisnoadministrative structureforthe12emergencydepartmentsinthenorthwest LHIN,nordotheyoperatewithinanexplicitAccountability Framework. Regional Flow: TheNorthWestLHINexistsinalarge geographicareawheremanypatientsliveinruralorremote environments.whenemergenciesarise,patientsgenerally receivehighqualityinitialcare.toenhancelocalcareandto determineifhigherlevelsofcarearerequired,betterusecould bemadeofexistingtelemedicinecapacity.ifhigherlevelsof carearerequired,therolesofvarioushospitalsinthenorth WestLHIN(orelsewhere)inprovidingsuchserviceshavenot beenclarified;hospitalsdonotoperateasatruenetworkandit isattimesdifficulttoaccesshigherlevelsofcareforpatientsin need.furthermore,whentreatmentatahigherlevelofcare hasbeencompleted,arrangingsuitableandtimely transportationofthepatientbacktothereferringhospitalor homeisoftenproblematic. Transportation: Inadditiontopatientrepatriationissues(see above),ahostofissuesconspirestofrequentlyinterferewith theefficient,timelytransportationofemergencypatientsto andfromtbrhsc,(andtoalesserextent,winnipegregional HealthAuthority).Thesetransportationissueshavebeen difficulttoresolve,sincetheyinvolvemultiplejurisdictionswith differentmandatesforservices,someenshrinedinlegislation. Additionally,thereisnosystemintheNorthWestLHINto supportinter-facilitytransferofpatients;substantialems resourcesareusedtoaccomplishthese,butsuchtransfersare outsidethelegislatedmandateofems,arenotapriorityfor EMSandaregenerallyaccomplishedinahighlyinefficientway. Health Human Resources: Whilethereareevident,significant shortagesofphysicians,nursesandotherhealthcare professionalswithinthenorthwestlhin,thereisno contemporaryhealthhumanresourceplans.theapproachto recruitmentandretentionofhealthcareprofessionalsisnot coordinated,noristherecruitment,compensationand ii

4 deploymentoflocumphysicianscentrallyorganized.thereis anunmetneedthroughoutthelhinemergencydepartments relatedtocontinuingprofessionaleducationanddevelopment. ThereisaneedthroughouttheLHINtoimplementalternative modelsofcareprovision.theshortageofhealthhuman resourcesinthelhinislikelythesinglemostimportantissue affectingthesustainabilityoftheemergencydepartment systeminthelhin. Community Supports: ThemandateofCCACsresultsina limitedrangeofservicesbeingprovidedincommunities. Furthermore,thereiswidevariabilityintheLHINinthe availabilityofcommunitysupports(e.g.familyhealthteams, LongTermCare,CommunityCareAccessCentres,Socialand CommunitySupportAgencies,assistedlivingenvironments) thatwouldlessendemandsupontheemergencydepartments. Clinical Quality, Standardization of Patient Care: Thereisno PatientSafetyandClinicalQualityFrameworkforemergency servicesthroughoutthenorthwestlhin.therearefew sharedmedicaldirectivesorotherexamplesofstandardized patientcareinemergencydepartmentsthroughoutthenorth WestLHIN. Information Management: Thereisnostandardizationof informationtechnologysystemsordatadevelopmentand utilizationregardingemergencyservicesthroughoutthenorth WestLHIN. TomovetheEmergencyDepartmentsystemforwardtoaddress issuesofsustainability,thesystemwillneedtoworkdifferentlythanit doestoday.atitscore,thesystemrequiresacommonexplicitvision foremergencycareacrosstheregion.todrivesystemlevel accountabilityforthepatientexperienceacrosstheregion,thereisa needforsystemlevelgovernancesharedamongsttheorganizations thatprovidecareintheregion.flowingoutfromthatistheneedforan accountabilityframeworkwithsupportingadministrativestructures accountableforoperatingtheemergencycaresysteminthelhin. Thesestructurescanthenbuildontheremainingrecommendations (listedbelow)madeinthisreporttoimprovethesustainabilityofthe EmergencyDepartmentsystemintheLHIN.Therecommendationsas describedwillrequireasignificantinvolvementofallprovidersand organizationsthattouchthepatientcarejourneyinthelhin.someof thesecanbeimplementedlocally;themajoritywillrequireinterregionalcoordinationofhospitalsandsupportorganizationssuchasthe LHINorEMSproviders;otherswillrequireinter-jurisdictionalthinking andactiontoresolvelong-standingissuesthatimpactthequalityof emergencypatientcareacrosstheregion. iii

5 Thefullsetofrecommendationsisdescribedinmoredetailinthe Recommendationssectionofthisreport.Thesummarylistof recommendationsisprovidedbelow. Vision Recommendation#1(HighPriority):ThattheNorthWestLHINandits partnerhospitalsdevelopandcommittoaclear,unambiguousvision describingapreferredmodelofcoordinatedemergencyservices deliveryfornorthwesternontario. TheVisionshoulddefinehowtheprovidersinthesystemwouldwork togethertoprovideend-to-endcarethatispatientfocused.key elementsofthevisionshouldincludethefollowing: Patientandfamily-centeredcare; Aunifiednetworkofproviders; Collaborativeuseofresources; Useofbestpractices; Sharedstandards;and, Useofcoordinateddecision-support. Governance Recommendation#2(HighPriority):ThattheLHINanditspartner hospitalscommittothecreationofanorthwestlhinemergency ServicesGovernanceCommittee,anddeterminetheoperating parametersofthisentity.itisenvisionedthatthisbodywouldhave representationfromeachofthehospitalsinthelhin.thiscommittee wouldberesponsibleforrepresentingtheneedsoftheirlocal communitiesandhospitals.thegovernancestructurewouldbe responsiblefordevelopmentandimplementationofhigh-level strategies(e.g.hospitalroleswithinanetworkofhospitals), discussions/negotiationswiththemohltcandhealthcanadaand issueidentificationandresolutionwithotheroutsideagencies(ems, Ornge).Theemergencyservicesadministrativestructures(seebelow) wouldreporttoandbeheldaccountablebythisbody. Administration & Accountability Recommendation#3(HighPriority):ThataNorthWestLHIN EmergencyServicesAdministrativeCommitteeiscreated,ideally evolvingfromthecurrentnorthwestlhinemergencydepartment AdvisoryCommittee.Theresponsibilitiesofthiscommitteeare outlinedindetailintherecommendationssection.thecommitteewill beresponsibleforensuringthat: iv

6 Accessandflowissuesrelatedtoemergencyservicesare addressed; Transportationissuesrelatedtoemergencyservicesare addressed; Asynchronizedapproachisdevelopedtoaddressnonphysicianhealthhumanresourceissuesandopportunities; Communitysupportsdesignedtolessenpressureson EmergencyDepartmentsareoptimized; Apatientsafetyandclinicalqualityframeworkforemergency servicesinthelhinisdeveloped; Datacollectionandinformationmanagementprocesses relatedtoemergencyservicesarecoordinated; Urgentissuesandproblemsrelatedtoprovisionoftimely,high qualityemergencyservicesinthenorthwestlhinare understoodandaddressed; Communicationregardingemergencyservicesamongst partnerorganizationsandstakeholdersisoptimized. Theadministrativestructure smembershipwouldconsistof thefollowing: Administrativeleadersfromeachofthehospitalsinthe LHINwithanEmergencyDepartment; AdministrativeleadershipfromtheCommunityCare AccessCentre;and, NorthWestLHINEmergencyDepartmentLead; Recommendation#4(HighPriority):ThataNorthWestLHIN EmergencyServicesMedicalCouncilbecreated.Thehospitalsinthe LHINshouldreachagreementontheAccountabilityFrameworkforthis council.thecouncilwouldbechairedbytheemergencydepartment Leadandwoulddevelopstrategicgoalsforemergencyservicesfroma physicianperspective(e.g.considerationoflhin-widecredentialing andprivilegingforsomephysicians;developmentofeducationand mentoringprograms,etc.),developacoordinatedapproachtophysician recruitmentandretentionissues,developandimplementastrategic approachtorecruitmentandutilizationoflocumsinthenorthwest LHIN,developamedicalqualityframework,participateinissueand problemresolutionandserveasacommunicationvehicletophysicians inthenorthwestlhinwhoengageinemergencydepartmentwork. TheCouncilshouldhaverepresentationfromeachoftheemergency departmentsinthelhin. v

7 Regional Flow & Access to Higher Levels of Care Recommendation#5(HighPriority):ThattheNorthWestLHIN EmergencyServicesGovernanceCommittee,workingwithpartner hospitalsandthelhin,definespecificemergencyservicerolesfor healthcarefacilitiesinthenorthwest,leadingtothecreationofa formalnetworkoffacilitiesinthenorthwest(healthcanadaremote nursingstations,communityhospitals,districthospitals,atertiary regionalreferralhospital),eachwithdefinedrolesandresponsibilities relativetothecareofemergencypatients. Recommendation#6(HighPriority):ThattheNorthWestLHINtakes theleadinredefiningandclarifyingtheroleoftbrhscasthe regional hospitalinnorthwesternontario.thisroleshouldbedefinedand agreedtoinasignedhospitalserviceaccountabilityagreement defininginexplicittermstbrhsc sresponsibilityasaregionalcentre. TheLHINshouldalsoplayaroleinencouraging/assisting/monitoring TBRHSCasitadvancestheinitiativesthatwillberequiredtopermitit tofillthisrole. Recommendation#7(MediumPriority):ThattheNorthWestLHIN EmergencyServicesAdministrativeCommittee,workingwiththeNorth WestLHINEmergencyServicesMedicalCouncil,identifyopportunities forexpansionoftelemedicineintoemergencydepartments,explore fundingopportunitieswithontariotelemedicinenetwork,and,once fundinghasbeengained,developanemergencydepartment TelemedicineImplementationPlan. Recommendation#8(MediumPriority):Buildingontheexperienceof othercanadiancentres(e.g.fraserhealthinb.c.),thatthenorthwest LHINEmergencyServicesAdministrativeCommitteetaketheleadin developingasetoftransferprotocols(e.g. TertiaryLevelofCare ; MaynotRefuse ; Life,Limb,ThreatenedOrgan )toensuretimely transferofpatientsinneedtohigherlevelsofcareandthatmonthly reportsoftransferdatarelatedtotheseprotocolsbedevelopedand widelycirculated. Recommendation#9(MediumPriority):ThattheNorthWestLHIN EmergencyServicesAdministrativeCommitteetaketheleadin developinganescalationpolicydefiningthechainofindividualswith administrativeresponsibilitytobecontactedshouldintractable difficultiesoruntimelydelaysbeexperiencedinthetransferofa criticallyillpatienttotbrhsc;itisexpectedthatsuchindividuals wouldintercedeadministrativelytoresolveissuesleadingtodelays. vi

8 Recommendation#10(HighPriority):ThattheNorthWestLHIN EmergencyServicesAdministrativeCouncilshouldtaketheleadin developingarepatriationprotocolthatdefinesthemannerinwhich patientsfromtbrhscarerepatriatedinatimelymannertotheir referralhospitalortotheirhome.similarlythepolicyshouldcoverthe repatriationofpatientsfromsiouxlookoutmenoyawinhealthcentre andthewinnipegregionalhealthauthoritytotheirhome communities.thispolicyshouldbeintegratedwiththeinitiativeto improveinter-facilitytransfers(seebelow). Transportation Recommendation#11(HighPriority):TheNorthWestLHIN EmergencyServicesGovernanceCommitteeshouldcreateaninterjurisdictionaltaskforceontransportationwithrepresentationfromthe MOHLTC,theLHIN,partnerhospitals,EMSprovidersandOrnge;and otherstakeholdersasrequired(i.e.healthcanada).thistaskforce wouldbechargedwiththesharedresponsibilityofexaminingoptions foraddressingtransportationissuesasidentifiedinthisreportand detailedintherecommendationssection. Recommendation#12(MediumPriority): TheNorthWestLHIN EmergencyServicesAdministrativeCommitteewillexploreoptionsto addressthenurseescortchallengesinthenorthwestlhin. Health Human Resources Recommendation#13(HighPriority):TheNorthWestLHIN EmergencyServicesAdministrativeCommitteeshouldoverseethe developmentofa10-yearregionalnon-physicianhealthhuman ResourcePlanforNurses,AlliedHealthprofessionalsandotherkey healthcarepersonnelwhoworkinemergencyservices. Recommendation#14(HighPriority):ThattheNorthWestLHIN EmergencyServicesMedicalCouncildevelopa10-yearintegrated RegionalPhysicianHumanResourceNeedsAssessment.This assessmentwillidentifythecurrentandexpectedvacanciesandgaps inphysicianhumanresourcesrelatedtoemergencyservices. Recommendation#15(HighPriority):Whileendorsingcontinued community-basedphysicianrecruitment,thatthenorthwestlhin EmergencyServicesMedicalCouncildevelopsaStrategicPlanfor improvingregionalphysicianrecruitmenttothenorthwestlhin. Elementsofthisplanaredescribedindetailintherecommendations section. Recommendation#16(HighPriority):TBRHSCshouldensurethatthe specialistphysicianrecruitmentprocessattbrhscisnotprimarily vii

9 drivenbyspecialistphysiciansinthesamediscipline,thuseliminating anypotentialconflictofinterest. Recommendation#17(HighPriority):Whilerespectinglong-standing relationshipsandcommunitypractices,chargethenorthwestlhin EmergencyServicesMedicalCouncilwiththetaskofdeveloping acceptableregion-wideapproachestoenhanceproactiverecruitmentof andimprovedeploymentoflocumphysicians,includingthe developmentofalhin-basedpooloflocumresources. Recommendation#18(MediumPriority):TheNorthWestLHIN EmergencyServicesGovernanceCommitteeshouldworkwiththe MedicalCounciltodevelopalistofgovernmentinitiatives/programsin thenorthwestlhinthathavetheunintendedeffectofreducing physiciancommitmenttoemergencydepartmentwork.thislist shouldthenformthebasisofadiscussionwiththemohltcrelatedto modificationofsuchinitiatives/programs;thiswillhelpensurethateach communitywillbeabletocontinuetoprovidemedicalcoveragetotheir EmergencyDepartment. Community Supports Recommendation#19(MediumPriority):TheNorthWestLHINshould workwiththeccac/fht/communityhealthcentreandother providerstodevelopcommunityambulatoryclinicswhereappropriate toclustercareandincreaselevelsofcarethatcanbeprovidedinthe community(e.g.forpatientsrequiringchronicwoundcare). Recommendation#20(MediumPriority):TheNorthWestLHINshould conductaneedsassessmentforsupportivehousing(assistedliving)in itscommunities. Recommendation#21(MediumPriority):TheNorthWestLHINshould continuetosupportthedevelopmentofintegratedchronicdisease ManagementprogramsacrosstheLHINtosupporttheneedsof individualsinthelhinwithchronicmedicalconditions. Patient Safety and Clinical Quality Recommendation#22(HighPriority):TheNorthWestLHIN EmergencyServicesAdministrativeCommitteeandMedicalCouncil shouldworktogethertoconductanenvironmentalscanofcurrent patientsafetyandclinicalqualityinitiativesinthenorthwestlhin s EmergencyDepartmentsand,buildingonthis,developandimplement aplanforalhin-wideemergencyservicespatientsafetyandclinical QualityInitiative.Anincrementalcontinuousimprovementapproach shouldbetaken,buildingoncurrentstrengths. viii

10 Recommendation#23(HighPriority):Asapriority,theEmergency ServicesAdministrativeCommitteeincoordinationwiththeEmergency ServiceMedicalCouncilshoulddevelopamenuofmedicaldirectivesin currentuseinthelhin semergencydepartmentsanddetermine whichofthesecanbestandardizedforusethroughoutthelhin. Recommendation#24(HighPriority):OftheEmergencyDepartments inthelhin,onlytbrhscandkenorahavesecurityfordesignated Form1patients.TheNorthWestLHINEmergencyServices AdministrativeCommitteeshouldexplorestrategiestoaddresssafety issuesfordesignatedform1patients. Information Management Recommendation#25(MediumPriority):Coordinatedmanagementof emergencyservicesthroughoutthenorthwestlhinrequires consistentdata.thenorthwestlhinemergencyservices AdministrativeCommittee,workingwiththeMedicalCouncil,should determinetheinitialdata/informationneedsofan EmergencySystem inthenorthwestlhin.thiscommitteeshouldexploreadditional informationneedsandensuresystemsareinplacetocollectand collateinformationefficientlyfortheongoingadministrationofan EmergencyDepartmentsystemintheLHIN. ix

11 TableofContents Executive Summary i Introduction 2 Methodology 6 Findings 7 Recommendations 29 Implementation 46 Appendix A Interim Report 51 Appendix B Bibliography 52 Disclaimer This proposal is made by KPMG LLP, a Canadian limited liability partnership and a member firm of the KPMG network of independent firms affiliated with KPMG International, a Swiss cooperative, and is in all respects subject to the negotiation, agreement, and signing of a specific engagement letter or contract. KPMG International provides no client services. No member firm has any authority to obligate or bind KPMG International or any other member firm vis-à-vis third parties, nor does KPMG International have any such authority to obligate or bind any member firm. 1

12 Introduction WithintheProvinceofOntario,thereiscurrentlyasignificantfocuson emergencycare.whiletheseeffortsarefocusedonimprovingthe flowofpatientsandaddressingemergencydepartmentwaittimes,the issuesfacedinnorthwesternontarioaredifferent.withtheexception ofthunderbayregionalhealthsciencecentre(tbrhsc),themajority ofhospitalsinthenorthwestlhindonotexperiencelongwaittimes, nordoalternatelevelofcare(alc)daysimpactpatientflow.thekey issueamonghospitalsinthislhinisoneofregionalpatientflowthat requiresahighlycomplexnetworkofprovidersworkingtoservethe emergencycareneedsofpatientsacrossgreatdistances. Emergencycare,asexperiencedbyapatientinnorthernOntario,is differentthantheexperienceintherestoftheprovince.northwest LHINpatientsaresupportedbythirteenhospitals,twelveofwhich haveemergencydepartments.thechartbelowshowstheirrelative sizebyannualvisitvolumesbetween2005and2007. Emergency Department Volumes to PHPDB Number of Visits MGH TMH RLMCMH WMGH AGH NDMH GDH Hospital SLMYWHC RHCF DRHC LWDH TBRHSC Legend (usedthroughoutthereport): Acronym AGH DRHC GDH LWDH MGH TMH Hospital AtikokanGeneralHospital DrydenRegionalHealthCentre GeraldtonDistrictHospital Lake-of-the-WoodsDistrictHospital ManitouwadgeGeneralHospital TheMcCauslandHospital NorthWestLHINRegionalEmergencyDepartmentStudy 2

13 NorthWestLHINRegionalEmergencyDepartmentStudy 3 Acronym Hospital NDMH NipigonDistrictMemorialHospital RLMCMH RedLakeMargaretCochenourMemorialHospital RHCF RiversideHealthCareFacilitiesInc. SLMYWHC SiouxLookoutMenoYaWinHealthCentre TBRHSC ThunderBayRegionalHealthScienceCentre WMGH WilsonMemorialGeneralHospital Withinthesesites,thereisarangeofservicesprovidedtorespondto theemergencycareneedsoftheresidentsofthelhin.these servicescanbecategorizedasfollows: TBRHSCwhichisstaffedentirelybyemergencyspecialists [CCFP(EM)orFRCP(EM)]24/7,andispartofatertiary-level centrethatprovidessupporttotheregion; Lake-of-the-WoodsDistrictHospitalwhichisstaffedbyamix ofemergencyspecialistsandemergency-trainedfamily physiciansthatalsoprovideon-callsupport.thehospitalhasa smallnumberofcriticalcarebedsandarangeofother servicesthatincludesurgeryandaschedule1psychiatric facility. Theremaininghospitalshaveemergencydepartmentsthatare staffedbyemergency-trainedfamilyphysiciansthatprovide coverageduringthedayandon-callsupportatnight.the supportserviceateachsitevarieswitharangeofpermanent andvisitingspecialistcare. Thesesiteseachsupportasmallcommunityandasurrounding populationtypicallyspreadoutoverasignificantdistance.patientsmay berequiredtotravelseveralhourstoaccessservicesinthecenters wheretheyarelocated.theserealitiespresentchallengesfor EmergencyMedicalServices(EMS)providersthatdonotexistinother partsoftheprovince. Emergencydepartmentsinsmallsitesseparatedbyvastdistancesare limitedintheircapacitytotreathighlyacutecases.thesesites,with theexceptionofthunderbayregionalhealthsciencecentre (TBRHSC)andLakeoftheWoodsDistrictHospital(LWDH)inKenora, arestaffedwithoneprimarycarephysicianondutyduringthedayand onlyhaveonephysicianon-callatnight;attimes,thisphysicianmaybe uptoanhouraway.thefactthatthisregionexperiencessignificant weatherandgeographicextremescontributestotherequirementfora systemthatworkswellunderextremecircumstances. Thesesitesarealsohighlyreliantonlocumphysiciancoverageto remainopen.locumphysiciansaretemporaryreplacementphysicians thatprovideshort-termrelief.thedependencyonlocumsresultsina lackofcontinuityofcare.locumphysiciansmaynotbefamiliarwith

14 thesurroundingcommunity,thelinkageswithprimarycare,orthe dependencyontertiarycentresforcriticalemergencycare. Atypicalpatientflowacrossthesystemforapatientwithhighlyacute medicalneedsconsistsofaresponsebylocalems,transportationto thelocalhospital,stabilizationbyphysiciansandnursesatthehospital, transportationtoaregionaltertiarycentre,typicallybyairambulance, andtreatmentattheregionalcentre.notallservicesareprovidedat TBRHSC,sosomewillrequiretransportationtootherpartsofthe province,tomanitoba,ortotheunitedstates.oncetreatedinthe tertiarycentre,transportationbacktothereferringhospitalorpatient s homeisoftenproblematic. Thehospitalsandemergencydepartmentswithinthemalsoservea broaderroleintheruralcommunities.theyhelpsupporttheprimary careneedsofthecommunity,whichcanbeanacceptableuseofthese resourcesinenvironmentswherethereislimitedavailabilityofother primaryhealthcareoptions.themajorityofthesecommunitiesare servedbyaphysiciangrouppracticethatprovidescoverageinthe EmergencyDepartment,socontinuityofpatientcareisachieved irrespectiveofwherethepatientisseen.thechartsbelow demonstratetherangeofacuityofcasesseeninemergency departmentsinthenorthwestlhincomparedtotherestofthe Province.Thereisamuchhigherrelianceontheseemergency departmentsforprimaryhealthcareservices,asshowninthehigh ratesofcanadiantriageacuityscale(ctas)4and5cases. Percent (%) 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Ontario and Thunder Bay Regional - Distribution of CTAS Cases (2007) Source: PHPDB CTAS Level TBRHSC Ontario NorthWestLHINRegionalEmergencyDepartmentStudy 4

15 Percent of Cases (%) 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Ontario and NW LHIN Rural Hospitals - CTAS Distribution (2007) Source: PHPDB CTAS Level NW Rural Hospitals Ontario Asemergencydepartmentsinruralareashelpmeetthebasicmedical careneedsofthecommunity,itisimperativethateachofthe emergencydepartmentsinthenorthwestlhinremainsopenin someshapeorform.manyofthecommunitiesinnorthwestlhin areundergoingsignificantchange.increasesincommoditiespricesare resultingingrowthinsomecommunities,whileothersareindecline duetofallinglumberpricesorthepotential,oractual,closingofmines. Eveninthosecommunitieswherepopulationsaredeclining,poverty ratesarerisingandthehealthstatusisdeclining,contributingtohigher ratesofchronicdiseasesandhigherutilizationofhealthservices. Purpose of the Study Severalprimarycontributingfactorsledtotheinitiationofthestudy, including: Ashortageofhealthhumanresourcesthathasthreatenedthe viabilityofsomeemergencydepartments; Transportationandpatientflowissuesacrossthesystem;and, Emergencydepartmentwaittimesandhospitalalternatelevel ofcaredaysthatimpactqualityofcareandefficiency. Whiletheseprimarycontributingfactorswereexplored,thebroader purposeofthisstudywastoexamineallaspectsofthesystemandto developrecommendationstoimprovequalityofpatientcareand systemsustainability.sustainabilityofthesystemforthepurposeof thisstudyisdefinedasensuringtheabilityofprovidersacrossthe regiontoprovidequalityemergencycareirrespectiveofpatientacuity andregardlessofwherethepatientresides. NorthWestLHINRegionalEmergencyDepartmentStudy 5

16 Methodology Thisstudywasacomprehensivelookatthefunctioningofthe EmergencyDepartmentsysteminNorthwesternOntario.The approachtakenwasbothanalyticalandconsultative.sitevisitsand interviewswereheldwithstakeholdersfromeachhospitalsite, includingadministrativestaff,clinicians,physiciansandarangeofother hospitalstakeholderssuchasrepresentativesfromems,ccac,opp, LTC,socialservices,andothers.Interviewswithprovincial stakeholdersandlhinstakeholderswerealsoconductedtocapture thesystemstrengthsandissues.finally,interviewswereheldwith representativesfromthemohltc,ornge,ontariotelemedicine Network(OTN),HealthForceOntario,CritiCall,andothers. Data Collection and Analysis Site Visits and Interviews Synthesize Current State Analysis Workshop Potential System Solutions Report Writing and Delivery Assessmentof Emergency Departmentand Hospital Indicators Jurisdictional Review/Leading PracticeReview Assess Emergency Department/ HospitalSystem functioning AssessMajor Issuesand Concerns Analyzealldata Createoptions presentation Presentfindingsto EmergencySystem Staffand Administrators Workshopsolutions FinalPresentation tothenorthwest LHIN Tohelpvalidatethefindingsfromtheinterviews,and,todevelopa pictureofthekeystrengthsandissuesinthesystem,datawere collectedfromadministrativedatabases(e.g.phpdb)andstakeholder datasourcesfromacrossthesystem(e.g.ornge,criticall,emsand Dispatch);thesedatawerethencarefullyanalyzed.Tohelpcapture physicianintentionsandquantifythephysicianhealthhumanresource issuesacrossthelhin,aphysiciansurveywascompletedbyeach ChiefofStafforChiefofEmergencyineachofthetwelvehospitals. Anassessmentofpracticesofemergencyandruralmedicinewas conductedonjurisdictionsfromacrosscanada,andinternationally includingbritishcolumbia,alberta,alaska,australia,sweden,the UnitedKingdom,NewZealandandothers.Areasofthereview includedanassessmentofregionalgovernancemodels,healthhuman resourceissuesandpractices,approachestopatienttransportationand otherinnovativepractices. Optionsandpotentialrecommendationstoaddressthekeyissues identifiedbythestudyweredevelopedinaworkshopwitha representationofstakeholdersfromacrossthelhin.theseoptions andpotentialrecommendationswereassessedforfeasibilityand selectedrecommendationsarepresentedinthisreport. NorthWestLHINRegionalEmergencyDepartmentStudy 6

17 Findings ThecompletesetoffindingscanbefoundintheInterimReport,which hasbeenappendedasappendixa.whilethefindingsfocusuponthe sustainabilityoftheemergencydepartmentsinthenorthwestlhin,it isalsoimportanttoreflectontheimpacttheseissueshaveonsafety andqualityandontheexperienceofpatients. ThefollowingthemesemergedintheassessmentoftheEmergency DepartmentsystemintheLHIN: Vision: WithintheNorthWestLHIN,thereisnoagreed-upon VisionregardingthemannerinwhichtheLHIN semergency Departmentsandhospitalsshouldworkasanetworkin ensuringthatpatientswithurgenthealthproblemsreceive timely,highqualitycare,deliveredinthemostappropriate environment. Governance: Atpresent,eachNorthWestLHINEmergency Departmentfunctionssemi-autonomously;thereisnooverarchinggovernancestructureforemergencyservices. Administration & Accountability: Thereisnoadministrative structureforthe12emergencydepartmentsinthenorthwest LHIN,nordotheyoperatewithinanexplicitAccountability Framework. Regional Flow:TheNorthWestLHINexistsinalarge geographicareawheremanypatientsliveinhighlyruralor remoteenvironments.whenemergenciesarise,patients generallyreceivehighqualityinitialcare.toenhancelocalcare andtodetermineifahigherlevelofcareisrequired,betteruse couldbemadeofexistingtelemedicinecapacity. TelemedicineiscurrentlyusedthroughouttheLHINbutit s applicationintheemergencydepartmentislimitedwiththe exceptionofsiouxlookoutmenoyawinhealthcentre.if higherlevelsofcarearerequired,therolesofvarioushospitals inthenorthwestlhin(orelsewhere)inprovidingsuch serviceshavenotbeenclarified;hospitalsdonotalways operateasatruenetworkanditisattimesdifficulttoaccess higherlevelsofcareforpatientsinneed.furthermore,when treatmentatahigherlevelofcarehasbeencompleted, arrangingsuitableandtimelytransportationofthepatientback tothereferringhospitalorhomeisoftenproblematic. Transportation: Inadditiontopatientrepatriationissues(see above),ahostofissuesconspiretofrequentlyinterferewith theefficient,timelytransportationofemergencypatientsto andfromtbrhsc,(andtoalesserextent,winnipegregional NorthWestLHINRegionalEmergencyDepartmentStudy 7

18 HealthAuthority).Thesetransportationissueshavebeen difficulttoresolve,sincetheyinvolvemultiplejurisdictionswith differentmandatesforservices,someenshrinedinlegislation. Additionally,thereisnosystemintheNorthWestLHINto supportinter-facilitytransferofpatients;substantialems resourcesareusedtoaccomplishthese,butsuchtransfersare outsidethelegislatedmandateofems,arenotapriorityfor EMSandaregenerallyaccomplishedinahighlyinefficientway. Health Human Resources:Theshortageofhealthhuman resourcesinthelhinislikelythesinglemostimportantissue affectingthesustainabilityoftheemergencydepartment systeminthelhin.whilethereareevident,significant shortagesofphysicians,nursesandotherhealthcare professionalswithinthenorthwestlhin,thereisno contemporaryhealthhumanresourceplans.theapproachto recruitmentandretentionofhealthcareprofessionalsisnot coordinated,noristherecruitment,compensationand deploymentoflocumphysicians.thereisanunmetneed throughoutthelhinemergencydepartmentsrelatedto continuingprofessionaleducationanddevelopment.thereisa needthroughoutthelhintoimplementalternativemodelsof careprovision. Community Supports: ThemandateoftheCCACresultsina limitedrangeofservicesbeingprovidedincommunities. Furthermore,thereiswidevariabilityintheLHINinthe availabilityofcommunitysupports(e.g.familyhealthteams, LongTermCare,theNorthWestCommunityCareAccess Centre,SocialandCommunitySupportAgencies,assisted livingenvironments)thatwouldlessendemandsuponthe emergencydepartments. Clinical Quality, Standardization of Patient Care: Thereisno PatientSafetyandClinicalQualityFrameworkforemergency servicesthroughoutthenorthwestlhin.therearefew sharedmedicaldirectivesorotherexamplesofstandardized patientcareinemergencydepartmentsthroughoutthenorth WestLHIN. Information Management: Thereisnostandardizationof informationtechnologysystemsordatadevelopmentand utilizationregardingemergencyservicesthroughoutthenorth WestLHIN. Theissuesthatemergefromthesethemesareconnected.Anyone issuecrossesmultipleorallthemes.amulti-facetedapproachwillbe requiredtoaddressthem. NorthWestLHINRegionalEmergencyDepartmentStudy 8

19 Acaseexamplehasbeendevelopedtodemonstratefrequentissues affectingpatientflowacrosstheregion.thiscasedescribesapatient inaruralsetting,whorequirestertiarylevelcareforinvestigationand treatment.whiletheissuesdescribedinthiscasearecommonfora patientrequiringtransportationfromoneoftheruralhospitalstoa tertiarycentre,thiscasedoesnotcapturethefullspectrumofissues documentedinthestudy.thesearedescribedinthesectionsthat follow,organizedaccordingtokeythemes. Asdescribedpreviously,therearevaryinglevelsofhospitalsthat operateinthelhin.tbrhscistheregionalcentrethatprovides tertiary-levelsupporttoresidentsinthelhin.lakeofthewoods DistrictHospital,inKenora,istheonlyotherhospitalemergency departmentstaffedwithccfp(em)orfrcp(em)trainedphysicians. ThishospitalalsoprovidesarangeofservicesthatincludeOrthopaedic surgery,psychiatry,andcriticalcare.siouxlookoutmenoyawin HealthCentreisaregionalcentreservingSiouxLookoutDistrict:many communitiesstretchedacrossnorthernontario,28ofwhichhave nursingstationsthatcollaboratewiththehealthcenterforemergency care.theremaininghospitalsareruralhospitalswithemergency departmentstypicallystaffedbyoneortwoemergency-trainedfamily Physiciansinthedaywithon-callsupportatnight. Thefollowingcasedescribestheflowofapatientfromaruralsetting totbrhscfortertiary-levelcare.thecasehighlightssomeofthekey issuesfoundthroughoutthestudy;thecaseisintendedto demonstratetheexperienceofapatientrequiringthesupportofthe regionforemergencycare. A Story Demonstrating Patient Flow Issues in the North West LHIN Geoffreyisa53year-oldmalewithdiabeteslivinginLonglac.Geoffrey wakesupat3:30a.m.withslightchestpains,shortnessofbreath,and swellinginhishandsandfeet.hewakeshiswifeupcomplainingof hisdiscomfortandsayshethinkstheyshouldgotothehospital.she looksoutsidetoseeblizzardconditions,doesn tthinkshecanmakethe drivetothehospitalingeraldtonandcalls911. Anambulancearrivestwentyminuteslater,delayedbythewhite-out conditions.thedriveintogeraltdondistricthospitalthatwould typicallytake30minutes,takesjustoveranhour.theambulanceis greetedbyanursewhohelpstheemsstaffoff-loadgeoffrey.they aretoldthatthedoctor,anewlocum,hasbeencalledin,butmaybe delayedbecauseofthesnow.inthemeantimesheindicatedshe wouldtakehisvitalsignsanddowhatshecouldforhimtomakehim comfortable.thenursecallsthex-raytechnicianon-call,askingherto comeintoperformachestx-ray.shethendoessomebloodworkand performsacardiogram. NorthWestLHINRegionalEmergencyDepartmentStudy 9

20 Bythetimethephysicianarrives,Geoffreyiscomplainingthathe s findingitmoredifficulttobreathe.thecardiogramshowsananterior myocardialinfarction.geoffreycallsthecardiologiston-callattbrhsc todescribethesituationandrequestthatheacceptthepatient.the cardiologistindicatesthattheydonothavethecapacitytotakeanother patientandcannotacceptthepatient. Thepatientdeterioratesfurtherwithaworseningofhisshortnessof breathandthemddecidestointubatethepatient.thedoctorasksthe nursetocallcriticall(aprovincialservicethathelpsconnectemergency physicianswithspecialistsacrosstheprovinceforconsultationor transport)tohelpthemfindaphysiciantoacceptthepatient.when theconnectionwiththeintensiviston-callattbrhscisestablished, thedoctoringeraldtontakesthephonetoexplainhiscaseagain.the specialistattbrhscisreluctanttotakethepatientasthereisonly1 ICUbedanditisusuallyheldforpatientsinthehospitalwhohavea cardiacarrestorwhomaybecomecriticallyill.thedoctoringeraldton convinceshimtotakethepatientbecauseoftheweatherconditions;if theweatherstaysthesameorgetsworseitmaybemoredifficultto getthepatientout. CritiCallconnectsthenurseinGeraldtonwithOrngetomake arrangementsfortransport.theyhaveafixed-wingvehiclethatcanbe therewithinthehour,butbecauseoftheweather,theydon thavean advancedcareparamedicandwillrequireanurseescort.thenurse thenstartsaroundofcallstofindanursewhocanescortthepatientto TBRHSC.Theonlynursethatcangettherewithinthehouristheone scheduledtocomeoninthemorningshift. Thenursethencallsherlocalambulancecentretoseeiftheyhave receivedthedispatchtogivethemthedetailsoftheemergency transfer.geoffreyandhiswifearetransportedtothunderbayand landsattheairport,awaitingambulancetransporttotbrhsc.dueto thenumberoffirstresponsecallsinthunderbay,thereareno ambulancesimmediatelyavailabletotransferthepatienttotbrhsc. After30minutesonthetarmac,anambulancearrivestotransport GeoffreyandthenursetoTBRHSC.GeoffreyisadmittedtotheICUat TBRHSC. ThenursefromGeraldtonchecksherselfintoahotelroomandthen attemptstoarrangetransportationforherselfbacktogeraldtoninthe morning.geoffrey swifealsochecksherselfintoahotelinthunder Bay.ThenextdaythenursearrangesforGreyhoundtransportationto Nipigon,andasksherhusbandtomakethetwo-hourdrivetopickher upthere.afewdayslatergeoffrey sconditionhasimprovedand arrangementsaremadeforhimtobetransportedbacktogeraldton District.Anambulanceisarrangedthedaybeforebecauseof Geoffrey slowpriority.itarrivessixhoursafterthescheduledtime becauseofarequirementtorespondtoothercriticalemergencies. NorthWestLHINRegionalEmergencyDepartmentStudy 10

21 WhenGeoffreyarrivesattheairport,theaircraftthathadbeenwaiting hasbeendivertedtoanothercall.geoffreyandhiswifewaitanother twohoursfortheaircrafttoarrive.oncetheylandingeraldton,they waitanotherhourbeforetheambulancearrivestotakethemtothe hospitalwheregeoffreywasadmittedanddischargedthenextday. Thiscase,describingtheemergencycareexperiencedbyGeoffrey, highlightssomeofthekeyissuesproviders,administratorsand patientsexperienceonadailybasisinthenorthwestlhin.thecase attemptstohighlightthefollowingkeyissuesparticipantsinthestudy described: Limitedhealthhumanresourcesinruralhospitals; DifficultiesaccessingspecialistcareatTBRHSC; ChallengesinaccessingbedsatTBRHSC; Difficultiesanddelaysarrangingemergencytransportation; Challengesrelatedtoarrangingnursingescortsfortransport; Difficultiesarrangingseamlessinter-facilitytransportfornonurgentpatients;and, Alackofaccountabilityforthepatientexperiencefromend-toend. Astoucheduponinthecase,becauseofphysicianshortages,the regionreliessignificantlyonlocumphysicianstoprovideemergency Departmentcoverage.Thisissueisdescribedinmoredetailinthe HealthHumanResourcesectionbelow.Thereisalsoarangeof findingsthatisnotpresentedinthiscasethatmaybeexclusiveto specifichospitals,ororganizations,orsharedacrosstheregionsuchas acuteshortagesofhealthhumanresources,andalackofestablished transferprotocolsthatmakesitdifficultforlocumphysicianstoworkin differenthospitalsacrosstheregions.thefullrangeofissuesis describedinmoredetailinthesectionsthatfollowandinthecomplete findingsinappendixa. Thefollowingsectionsdescribeasummaryofthefindingsacrossthe systemasgroupedbythecommonthemes. Vision ThepatientcarejourneyforindividualslivinginNorthWestLHINwith criticalemergencycareneedsrequiresthesupportofacomplex networkofproviders.inordertoworkasaneffectivenetworkof providers,workingtowardscollectivegoalsbaseduponacommon understandingoftheneedsofthepatientandhowtheyshouldbemet, theemergencyserviceorganizationsinthenorthwestlhinrequirea commonvision. NorthWestLHINRegionalEmergencyDepartmentStudy 11

22 Currently,thereisnotanagreed-uponVisionregardingthemannerin whichthelhin semergencydepartmentsandhospitalsshouldwork asanetwork,ensuringthatpatientswithurgenthealthproblems receivetimely,highqualitycare,deliveredinthemostappropriate environment. Governance Thecareasdescribedinthecaseabove,fromaregionalcoordination perspective,speakstoalackofsystemorregionaloversight.while thereisalackofanexplicitsharedvisionforemergencyservicesinthe LHIN,thereisalsoabsenceofagovernancestructuretoensure adherencetothatvision. AmodelofregionalemergencycarewillrequireaVisionand supportingstructurestoenablesustainable,qualityemergencypatient care.patientflowshouldbestreamlinedandseamless.tomanage thecomplexitiesthatexistamongthenetworkoforganizationsthat existinthesystem,anoverarchinggovernancestructurewillbe required. Administration and Accountability RelatedtothelackofaVisionandagovernancestructurefor emergencyservicesinthenorthwestlhin,thereisalsothelackof anaccountabilityframeworkwithinwhichprovidersandadministrators wouldfunction.suchaframeworkrequiresanadministrativestructure tosupportsharedaccountabilityandtobeaccountabletothepatient experiencefromaregionalperspective. ItisprobablethatGeoffrey,thepatientinthecasestudy,wouldresist goingtotheemergencydepartmentagain,unlesshereallyfelthis situationwascritical.whileeachprovideralonggeoffrey sjourney mostlikelyactedingoodfaithandprovidedgeoffreywithgoodcare, theconnectionsbetweenthesystemandthequalityofhisoverall experiencewaslacking.thiscanbeattributedinparttoalackof overallsystemaccountabilityforthepatientexperiencefromend-toendacrosstheregion. Thecurrentsystemasitisdescribedbyprovidershasthefollowing characteristics: alackofinterfacesamongtheorganizationsandproviders; alackofcommonprotocolsandstandardizedcareacrossthe system; threeemsprovidersandadistinctairambulanceservice (Ornge); NorthWestLHINRegionalEmergencyDepartmentStudy 12

23 arangeofprovincialservicesandsupportsthatincludes CritiCallandHealthForceOntario;and 12hospitalswith12distinctadministrativestructuresand medicaladvisorycommittees. Thiscomplexnetworkoforganizationsworkstogetheronadailybasis withoutanexplicitcommonvisionforregionalemergencyservices, andwithoutanadministrativestructuretobeaccountableforthe patientjourneyacrosstheregion.thelackofanadministrative structureandanaccountabilityframeworkforemergencycareinthe regionresultsindiscrepanciesinthemannerinwhichcareisprovided forpatientsacrossthesystem.someofthesediscrepanciesare describedinmoredetailinthesectionsthatfollow. Regional Flow Asdescribed,theflowofemergencypatientsintheLHINinvolves manyprovidersandorganizationsworkingacrossthesystemtoprovide care.thekeyfindingsrelatedtothisjourneyincludethefollowing: Approximatelyhalfthepopulationresidesinruralpartsofthe LHINrequiringtransportationviaairandlandambulancefor tertiary-levelemergencycare; TertiarylevelcareisprovidedbyTBRHSC,WinnipegRegional HealthAuthority(WRHA)andelsewhereintheprovinceorUS asneeded; Thesystemworkswellforthosepatientsrequiringhighly criticalcare(e.g.forstroke,duetoaregionalstrokeprotocol thathasbeenadoptedbyallhospitals); AlackoftransferprotocolsacrosstheLHINdelaystransferand careforthosepatientsnotinthemostcriticalneed; PhysiciansintheregionandatTBRHSChavedifficulties accessingspecialistcare; PatientflowduetoALCpatientsamongstotherissuesisan issuewithintbrhscthatimpedesregionalpatientflow;and, Patientsarenotbeingrepatriatedbacktotheirhomehospital assoonasmedicallyappropriate. Eachofthesefindingsisdescribedinmoredetailbelow. ForresidentsintheruralareasoftheLHIN,representingapproximately 50%ofthepopulation,theresponsetoacriticalemergencywill involveairambulancetransportation,oracombinationoflandandair ambulancetransportationtoaregionalcenter(2,034patientarrivals involvingairambulancein2007/08,source:phpdb).therateof arrivalsinvolvingairambulanceismuchhigherthanotherpartsofthe NorthWestLHINRegionalEmergencyDepartmentStudy 13

24 Province.Whiletherearevariationsonthisstorydependingonwhere onelivesandtheservicesthatareavailable,thestoryremainsfairly consistent. Therewere1,441emergencydepartmentinter-facilitytransfersinthe LHINin2007/08:TBRHSCreceived365ofthose(Source:PHPDB).In addition,tbrhscreceivedanother379inpatienttransfers(this excludesthosesentforactscanastheyarenotadmitted).patients inthewesternpartofthelhinmaybetransportedtoahospitalwithin thewinnipegregionalhealthauthority.therearealsoservicesnot availableattbrhsc,resultinginpatientsrequiringtransportationto tertiarycentresacrossontario,manitobaortheus.thechartbelow demonstratessomeofthisactivity. Calls to CritiCall from Hospitals in Northwest LHIN (excluding TBRHSC) Final Destination Total Transferred: 196 April 08 - March % 12.8% 0.5% 13.3% 1.5% 50.0% Southern Ontario LHIN 14 Community Hospital Northeast Duluth Thunder Bay Winnipeg ThechartshowsthefinaldestinationforthosepatientswhereCritiCall wasusedinthelocalanddistricthospitals(outsidethunderbay). CritiCallistheprovincialresourcethatconnectsemergencyphysicians withspecialistsacrosstheprovinceforconsultationorpatientreferral. ItisimportanttonotethatCritiCallsupportsonly33%ofallemergency transfers,withaparticularfocusuponcasesthatareconsideredcritical emergencies(i.e.lifethreatening).criticalldoesnotcoordinatetransfer ofpatientsforpsychiatricemergencies.fornonlifethreatening emergencies,physiciansinthelhinindicatedapreferenceforusing theirpersonalnetworksforarrangingtertiaryemergencycare. Oneaspectofregionalpatientflowthatfunctionswelliswhena patientisinacriticalemergency.theresponsesfromallpartsofthe systemareadequatetomeetthepatient sneeds.agoodexampleof thisisapatientwithsuspectedstroke.protocolsareinplacethat NorthWestLHINRegionalEmergencyDepartmentStudy 14

25 Number of Patients clearlydefinerolesandresponsibilities,anddefineclearaccountability forthepatient scarefromemergencyresponse,stabilizationatthe localordistricthospital,transportationwithinmandatedtimelines, smoothadmittanceandcareattheregionalcentre. Beyondthestrokeprotocol,thereisalackofregionalcare/transfer protocolsforpatientsthatrequirecareforotheremergencies,urgentor non-urgentcare.thistendstoimpactthepatientexperienceforany servicethatisn tacriticalemergency,causingdelaysanddifficultiesfor physiciansandstafftryingtoarrangetransportationandfindaphysician whowillaccepttheirpatientfortertiarycare. PhysiciansathospitalsintheregionandTBRHSCdescribedifficulties accessingspecialistcare.thechartbelowshowsnonacceptanceby LHINhospitalsbyspeciality.Mostnon-acceptancesarefromTBRHSC withsomenon-acceptancefromkenora.criticallonlyhandles33%of emergencycalls,butthechartshowsnon-acceptanceforthosecases wheretherewasacriticalemergency.themostfrequentclinicalareas wherenon-acceptanceoccursarecriticalcare,cardiologyandgeneral Surgery. CritiCall Patients Not Accepted to LHIN 14 Hospitals by Service Fiscal Year 08/09 (Total 111: can be from anywhere in Ontario) ICU Other Cardiology General Surgery Neurosurgery Service Physiciansintheregionreportdifficultiesinaccessingspecialistcare, althoughmanyindicatetheyfeltaccesshasbeenimprovingoverthe pastyear.mostidentifythefollowingspecialtiesasthemostdifficult toaccess:internalmedicine,vascularsurgery,plasticsurgery, PsychiatryandTraumaorCriticalCare.Emergencyphysiciansat TBRHSCindicatetheyalsoexperiencedifficultiesobtaining consultationsfrominternists. WhileworkhasbeenundertakenatTBRHSCtotrytoaddresssomeof theregionaltransferandbedaccessissues,theseinitiativesarenotyet meetingtheneedsofprovidersintheregion.therearegood ENT Perinatal Trauma Hand / Upper Limb NorthWestLHINRegionalEmergencyDepartmentStudy 15

26 Percent Days (%) intentions,butambiguousaccountabilityframeworksandfew mechanismsinplacefortbrbsctoeffectivelyassesswhetherthe initiativesareworking.also,communicationsregardingsuchinitiatives betweentbrhscandtheotherhospitalsintheregiontheyaretrying tohelpareoftennoteffective.asanexample,aprojectwasinitiated tomakeiteasierforbedstobeaccessedbytheregion;however,this initiativedidnotaddresstheprimarybottleneck,acceptanceofpatients byspecialists.suchinitiativeswillbeimportantinaddressingthe sustainabilityoftheemergencydepartmentsystemacrosstheregion, butrequireanaccountabilityframework,evaluationandcontinuous improvement. PatientflowwithinTBRHSCisalsoidentifiedasakeyissue.In ,therewere365emergencydepartmenttransfersintoTBRHSC fromtheregion,representing6.5%ofadmittedpatientsthroughthe TBRHSCEmergencyDepartment.Ambulanceoff-loaddelaysat TBRHSCarealsointermittentlyproblematic.Prolongeddelaystypically indicateemergencyroomover-crowdingandeffectemsresponse ratesinthecommunity.prolongedemergencydepartmentwaittimes aregenerallyareflectionoflackofbedavailabilityduetopatientflow issuesininpatientareas.attbrhsc,occupancyratesinmedicalunits areextremelyhigh(105.0%forq32008/09)andalternatelevelofcare daysareusuallyelevated,althoughtheyhaveimprovedrecently.the chartbelowdemonstratesalcdaysfortbrhscfor2008/09.ascan beseen,rateshavedeclinedsinceahighinaugust2008.therecent lowsshouldbereadwithcaution,asthehospitaldidnotexperiencea usualrespiratoryoutbreakinjanuary/februarythisyear,andalc patientsareexpectedtocontinuetoplacestrainonthesystemintothe future.moreanalysisisrequired,however,tolookatthelongterm effectsovertime. 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% TBRHSC Percent ALC Days (2008/09 FY) Source: TBRHSC Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Month LHIN Target for 2009/10 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% NorthWestLHINRegionalEmergencyDepartmentStudy 16

27 PatientsatTBRHSCcouldalsoberepatriatedbacktotheirhome hospitalssoonerintheregion.physiciansatlocalanddistricthospitals generallybelievemanypatientscouldbedischargedearliertorecover intheirhomehospitalswhiletheystillneedmedicalsupervision.one oftheissuestbrhschaswiththerepatriationofpatientstotheir homehospitalisthetimeandeffortrequiredtocoordinatetransfer back;thereareoftendelaysduetothelowprioritythesepatientshave foremsproviders. Transportation Transportationisdescribedbymanyprovidersinthesystemas problematicacrosstheregion.thekeyissuescanbesummarizedas follows: Theprocesstosecureapatientreferralandtransferfortertiary emergencycareiscomplex; NumerousdifficultiesexistinarrangingandcoordinatinginterfacilitytransfersbetweenOrngeandEMS; TheprocesstosendanursingescortforpatientsrequiringaCT Scanisproblematic;and, Form1(MentalHealth)transfersrequirecoordinationaction fromornge,emsandopp. AsdescribedinGeoffrey scase,arrangingtransportationtoandfrom thetertiarycentreisaprimaryconcerntophysiciansandstaff. Physiciansreportapreferenceforarrangingtransferfirstwithaphone calltophysiciansattbrhsc,followedthenbytheuseofcriticallif theydonothavesuccessinsecuringpatientacceptance.physicians andstaffdescribetheprocessofarrangingemergencytransportation burdensome,especiallyforanemergencydepartmentstaffedbyone physicianandonenursewhoaregenerallyresponsibleformultiple patients. ThecurrentstructureofemergencyresponseintheLHINconsistsof threeemergencymedicalserviceagencies(northwestems Dryden, RainyRiverDistrictEMS DistrictofRainyRiverandSuperiorNorth EMS DistrictofThunderBay)andOrnge,theprovincialairambulance andmedicaltransportservice.thethreeemsagenciesfallunder municipalgovernmentauthorityandreceivefundinginpartfromthe MOHLTC.TheoperationsofEMSfallundertheOntarioAmbulance Act.ThisactrequiresEMStorespondtoemergencysituationswhen called.orngealsofallsundertheambulanceactandthehealth SystemsImprovementAct,2007whichprovidesthemwiththe mandatetocreateanintegratedlandandairambulancesystemforthe transportofcriticallyillpatientsbetweenhospitals. NorthWestLHINRegionalEmergencyDepartmentStudy 17

28 WhileEMSprovidersarequicktorespondtocriticalemergencies,their legislatedmandatedoesnotcovernon-emergentinter-facilitytransfers. Thecurrentvolumeofnon-emergenttransfersbyEMSproviders representsapproximately53%oftheirtotaltransfervolume.the transferofpatientsacrosswidedistancesrepresentsalargeproportion ofemergencycasesintheregioncomparedtowhatonewouldseein therestoftheprovince.onceapatientisstable,orsimplyrequires urgentdiagnosticsintheregionalcentre,theirprioritystatusis reduced,andambulancesarethenreroutedtocovermorecritical cases.whilethisisexpected,theimpactonthepatientcanbesimilar orworsethanthatdescribedingeoffrey scase.thisisthecase,for example,forpatientscomingfromtheregionwhorequireactscan. ProvidersdescribedfrequentdelaysinthecoordinationofOrngeand EMSservices.Apatientmaywaitontheairporttarmacforextended periodsoftimewaitingforemspick-upandtransporttotbrhsc, sometimesmissingscheduledappointmentsfordiagnosticservices. ThisislargelyduetothereroutingofEMStocovermorecriticallyill patientsinthunderbay. Nurseescortsarerequiredforseveralreasonsthatincludethe following: ApatientiscriticallyillandEMSand/orOrngearenot equippedwithadvancedcareparamedics;or ApatientisbeingsentforaCTSanatTBRHSCorWRHAand thesesitesrequirethatpatientsupervisionbeprovided. Hospitalsareoftenrequiredtosendanurseescort.Thisrequirement oftenleadstodifficultiesarrangingshiftcoverageatruralhospitalswith limitedstaffing.inaddition,paymentforovertimeandadditionalshift coverageleadstohighercostsforthesehospitals. Thedelaysmakeitdifficultforhospitalsintheregiontoassess whetheranescortshouldbesent.generally,emsrequiresthatnonemergenttransfersarecompletedbefore7o clockintheevening. TBRHSChasimplementedanursingpositionintheDiagnosticImaging Departmenttotrytoalleviatetherequirementbyhospitalsintheregion tosendanursingescortfordiagnostics.theyhavealsoimplemented apolicytoleaveearlymorningappointmentsavailableforpatientsfrom theregion.delaysandlackofcoordinationbetweenorngeandems oftenresultinmissedappointments.hospitalsalsoendupsendingan escortasaprecautionarymeasure.itcanbedifficulttoassess whethertheywillreturnbefore7pm,whichisthecut-offforpick-up whenemsprovidersinthecommunitiesgooff-dutyfornon-emergent calls.theprogramsinplaceattbrhschavebeenmoresuitedtononurgentorplannedcarewhentherearefewerunknownsandschedules canbearranged. NorthWestLHINRegionalEmergencyDepartmentStudy 18