Collaborative Emergency Centres: Improving Access to Primary and Emergency Care in Rural Nova Scotia Jake Yorke Dalhousie University Abstract In 2010 Dr. John Ross, Nova Scotia s first provincial advisor on emergency care, released a report detailing aspects of emergency care which were sub-standard in Nova Scotia, including frequent ER closures and, in rural settings, exceedingly long wait times for primary care appointments. To address these issues, Nova Scotia introduced Collaborative Emergency Centres with the goal of increasing access to quality health care in rural communities. Collaborative Emergency Centres reduce the role of the rural family physician in overnight emergency care and more fully utilize the existing expertise of nurses and paramedics, with the oversight of an experienced ER physician available for remote consultation. This helps to ensure that ERs in rural areas can stay open 24/7, while also increasing access to primary care providers, as rural physicians no longer are needed for overnight emergency duty and can keep clinics open. Since their introduction, Collaborative Emergency Centres have had a dramatic impact on access to care in rural Nova Scotia. In one centre, ER closures in one four month period were reduced 98.5%, and primary care appointments can be obtained for same or next day. The success of these innovative centres have gained national attention, and these centres provide an excellent blueprint for improving access to both primary and emergency care in rural Canada.
Need Many Canadians have come to accept that a visit to the emergency room means a long wait in an overcrowded reception area: this is one of the prices we pay for Universal Health Care. Patients and physicians alike are dissatisfied with the prolonged wait times in emergency rooms 1,2, and in one study 91% patients who leave the ER without being seen cite the wait time as the primary reason for leaving 3. While increasing wait times and emergency room overcrowding are major health care concerns across Canada, in rural Nova Scotia, where the local family physicians often serve in the emergency room as well, prolonged wait times in the ER also result in decreased access to primary care, as tired family physicians have fewer available days for appointments. Not only does access to primary care suffer in rural areas, many small communities face unplanned emergency room closures if the physicians staffing them take vacations or become ill. For example, the emergency room in Parrsboro, NS, was closed for almost 1300 hours from April 1, 2009 to March 31, 2010 4, meaning that the ER in this small community was closed 14.5% of the time. These increased job pressures on rural physicians make it difficult for rural areas to attract and retain physicians. The 2009 appointment of veteran emergency room physician Dr. John Ross as Nova Scotia s first provincial advisor on emergency care allowed for an in-depth analysis of the problems facing emergency care in Nova Scotia. The resulting report 5 outlined several potential improvements to emergency care, including laying the foundations of an innovative solution to many of the issues plaguing rural emergency care: Collaborative Emergency Centres. Audience Following many of the recommendations made by Dr. Ross, Nova Scotia aimed to address the shortcomings in emergency care across the province with the Better Care Sooner initiative, introduced in December 2010. Though the program aims to address the emergency health care needs of all Nova Scotians, the most innovative solution, Collaborative Emergency Centres (CECs), specifically address the most pressing concerns in rural emergency care; frequent ER closures and decreased access to primary care. The primary audience of the CECs are patients in rural communities, who must struggle with unreliable access to emergency rooms which may be unexpectedly closed and for whom an appointment to see a primary care physician could take one-six weeks. By decreasing the role of rural family physicians in providing overnight emergency care, physician clinics can remain open during the day, providing access to same or next day appointments with a family physician. Similarly, reducing the role of physicians in the overnight emergency care also leaves the ERs less venerable to unexpected closures as there is a much larger pool of people from
which essential staff is drawn. This change ensures rural patients have access to the most appropriate care, 24/7. Not only do patients benefit from more reliable access to emergency care, studies have shown that collaborative care settings can increase positive patient outcomes as well as satisfaction with their health care experience 6-8. Secondary to patients, health care workers are also a target audience of the CEC model. They benefit from reduced working hours during times when few patients require their services and increased interprofessional collaboration, an aspect of the working environment which has been shown to increase job satisfaction amongst health care workers 9,10. CECs may also improve physician retention in rural areas, as they aim to reduce physician burn-out by limiting the overnight emergency care burden of local primary practitioners. In addition, the CECs provide a versatile blueprint for adaptation in other areas of the country. Goals and Objectives The aim of the Better Care Sooner program is all in the name: give patients quicker access to the most appropriate care. Specifically, the Collaborative Emergency Centres share these goals, with increased focus on reducing ER closures and decreasing the wait times to obtain a primary care appointment. This patient-centred approach to emergency care focuses on a more collaborative ER which fully utilizes the skills and availability of physicians, nurses, nurse practitioners, paramedics and other health professionals. Objectively, the successes of this program are measured by analysing the amount of time ERs are closed unexpectedly and the availability of appointments with primary care physicians within the same or next day. A secondary goal of the Collaborative Emergency Centres is to reduce the financial burden of rural emergency care on taxpayers. For small hospitals, having a physician on overnight emergency call is also very expensive, costing $350,000 to $700,000 per site per year 5. Given that the vast majority of patients presenting to the emergency room have minor or less-urgent injuries 5 it is significantly more cost efficient for CECs to be staffed by nurses and paramedics, who are ably trained to deal with such situations. Solution Overview The primary care providers at Collaborate Emergency Centre are not physicians. Rather, the CECs utilize the emergency medicine skills of nurses and paramedics to provide immediate care, with an ER physician available remotely for oversight and consultation. Each patient who arrives at a CEC is triaged by the team of nurses, paramedics and the online physician, a highly experienced ER physician. This is an extension of the type of system in place with Nova Scotia s highly regarded EHS system, providing patients with the 24/7 access to emergency care provided by those health care workers most familiar with these situations.
Not only do these centres provide consistent access to care, but they also allow rural physicians to focus on primary practice, rather than ER care. This means that for urgent needs, an appointment with a family physician is available on the same or next day, greatly reducing the waiting time not only for ER visits, but also for access to primary care. Collaborative Emergency Centres are not necessarily the correct option for addressing emergency health requirements in every community and careful consideration is given to determine which sites would benefit from the care model. Dr. Ross identified fourteen such sites in Nova Scotia and inclusion was determined by examining the number of patients presenting to the ER with minor or less urgent complaints (Canadian Triage and Acuity Scale [CTAS] level 4-5) compared to more urgent or severe complaints (CTAS level 1-3), as well as the distances and travel times to the nearest regional hospital 5. It is important to note that the utility of this model is not limited to only these fourteen communities, merely that these areas could most immediately benefit from the adoption of the collaborative approach. One of the strengths of this model is that it is readily adaptable and can be tailored to meet the specific needs of communities. The Nova Scotia Nurses Union (NSNU) 11 and College of Registered Nurses of Nova Scotia (CRNNS) have fully supported the introduction of CECs as a means to improve rural health care, with CRNNS Executive Director Donna Denney saying It is encouraging to see the success of the CECs introduced to date. They represent just one example of new ways in which RNs and other health-care professionals can combine their respective knowledge, skills and expertise to deliver quality health care and, with specific reference to the CECs, effectively and efficiently meet the unique health needs of rural communities 12. There have, however, been some concerns raised by the NSNU with respect to staffing levels and staff safety 11,13. Indeed, nursing shortages in Annapolis Royal lead to a brief closure of the CEC in that area, demonstrating that while the CEC model effectively addresses a primary reason for ER closure (Physician shortage), they are not totally prevented and the CECs are more venerable to other health care staff supply issues. While the majority of patients presenting to rural ERs have less urgent or minor injuries, major health emergencies do occur in rural Nova Scotia. The CEC is not a replacement for normal 911 and EHS ambulance services, which are still required in major health emergencies. However, the CECs are excellently equipped to facilitate transfer to major centres for situations exceeding the capabilities of the CEC. Evaluations of Outcomes Since their adoption in May 2011, seven Collaborative Emergency Centres have been opened, with seven more planned for the near future. All communities where Collaborative Emergency Centres have opened have benefited dramatically from the more reliable access to emergency care 14. Perhaps the most striking example comes from the Lillian Fraser Memorial
Hospital in Tatamagouche, where the introduction of the CEC brought ER closures down from 856 hours from July 10 to Oct 31 2011, to only 13 hours over the same period in 2012 14,15 : a 98.5% reduction. Though the reports of significant reduction of ER closures and increased access to primary care are an excellent demonstration of the impact these innovative care centres have for small communities, perhaps the best evaluation of the outcome of this program is the patient experience. I used to have to wait over a week to get an appointment with the doctor, which often meant a trip to the ER to wait and get things checked out. Now, if I need to I can book an appointment usually for the same day, and it s taken off a lot of stress. It s been such an improvement. As my disease progresses and I am requiring more urgent medical help, I feel very confident with my care. Speaking with this resident of Parrsboro, who has a chronic illness and frequently requires both urgent appointments with a family physician and emergency care, the success of the CECs become even more apparent. The increased access to primary care and reliable access to overnight emergency care provide stability rural health care that has been lacking in the past. While there has been clear improvement in the primary goals of the Collaborative Emergency Centres, evaluation of any budgetary improvements upon adopting the model are as yet unknown. Indeed, the Nova Scotia Health Research Foundation Short Report on the Collaborative Emergency Centres recognized the general lack of studies outlining the costeffectiveness of collaborative-type care models, though further work could clarify the cost savings, if any 16. In depth studies relating to patient and provider satisfaction with the Collaborative Emergency Centres are also yet to be released, though preliminary studies and surveys are underway 17. National Adoption The early success of the Collaborative Emergency Centres in improving rural emergency care gained attention from the government of Saskatchewan. The Honourable Randy Weekes, Minister of Rural and Remote Health for Saskatchewan visited the CEC in Parrsboro on July 26 th, 2012, and the provinces participated in a knowledge exchange day in September of this year. Saskatchewan Minister of Agriculture Lyle Stewart has praised the Collaborative Emergency Centres, saying We see the Nova Scotia model as an innovative way to meet the needs of rural and remote communities by improving access to services, reducing wait times and same or next day appointments 18.
While Saskatchewan has announced that it will be adopting this versatile model, Prince Edward Island is also exploring the adoption of this model as a means of addressing the emergency needs of rural citizens. The versatility of the model and the ability to be tailored to target an individual community s specific needs makes the Collaborative Emergency Centre an exciting innovation to improve rural health care. Conclusions The Collaborative Emergency Care Centres are an innovative solution to the problems plaguing emergency care in rural Nova Scotia, such as frequent ER closures and reduced availability of primary care appointments. Providing a versatile blueprint which can be tailored to meet individual community s specific needs, CECs deliver reliable access to teambased emergency care, decreased wait times for both emergency and primary care, including same or next day appointments with family physicians. Disclaimer I hereby acknowledge that all research materials and quoted statements contained herein are properly referenced and that I am permitted to disclose the material submitted. References 1 Shefrin AE, Milner R, Goldman RD. Adolescent Satisfaction in an Urban Pediatric Emergency Department. Pediatric Emergency Care. 2012;28(7). 2 Locke R, Stefano M, Koster A, Taylor B, Greenspan J. Optimizing Patient/Caregiver Satisfaction Through Quality of Communication in the Pediatric Emergency Department. Pediatric Emergency Care. 2011;27(11). 3 Varney SM, Vargas TE, Pitotti RL, Bebarta VS. Reasons Military Patients With Primary Care Access Leave an Emergency Department Waiting Room Before Seeing a Provider. Southern Medical Journal. 2012;105(10). 4 Nova Scotia Department of Health and Wellness. Annual Accountability Report on Emergency Departments 2009-2010. Retrieved from http://novascotia.ca/dhw/publications/annual-accountability-report-emergencydepartments-2009-2010.pdf 5 Ross, J. (2010) The Patient Journey Through Emergency Care in Nova Scotia: A Perscription for New Medicine. Retrieved from http://www.gov.ns.ca/dhw/publications/dr-ross-the-patient-journey-through-emergency- Care-in-Nova-Scotia.pdf 6 Nielsen PE, Munroe M, Foglia L, Piecek RI, Backman MP, Cypher R, et al. Collaborative Practice Model: Madigan Army Medical Center. Obstetrics and Gynecology Clinics of North America. 2012;39(3):399-410.
7 Kuo DZ, Sisterhen LL, Sigrest TE, Biazo JM, Aitken ME, Smith CE. Family Experiences and Pediatric Health Services Use Associated With Family-Centered Rounds. Pediatrics. 2012;130(2):299-305. 8 Baumeister H, Hutter N. Collaborative care for depression in medically ill patients. Current Opinion in Psychiatry. 2012;25(5). 9 Papathanassoglou EDE, Karanikola MNK, Kalafati M, Giannakopoulou M, Lemonidou C, Albarran JW. Professional Autonomy, Collaboration With Physicians, and Moral Distress Among European Intensive Care Nurses. American Journal of Critical Care. 2012;21(2):e41-e52. 10 Johnson PA, Bookman A, Bailyn L, Harrington M, Orton P. Innovation in Ambulatory Care: A Collaborative Approach to Redesigning the Health Care Workplace. Academic Medicine. 2011;86(2). 11 Nova Scotia Nurses Union. NEWS RELEASE - Nurses Union says new Collaborative Emergency Centre breaches safe staffing standards. 2012. Retrieved from http://nsnu.ca/files/files/news%20releases/cecs%20breach%20safe%20staffing%20standar ds%20may%202012.pdf 12 Canadian Nurses Association. NEWS RELEASE - Canada s registered nurses join with Council of the Federation to drive health-care transformation. 2012. Retrieved from http://www.cna-aiic.ca/en/canadas-registered-nurses-join-with-council-of-the-federation-todrive-health-care-transformation/ 13 Jackson, D. Annapolis Royal emergency centre closes due to shortage of nurses. The Chronicle Herald. 2012 Nov 2. Retrieved from http://thechronicleherald.ca/novascotia/159852-annapolis-royal-emergency-centre-closesdue-to-shortage-of-nurses 14 Nova Scotia Department of Health and Wellness. Annual Accountability Report on Emergency Departments 2011-2012. 2012. Retrieved from http://novascotia.ca/dhw/publications/annual-accountability-report-emergencydepartments-2011-2012.pdf 15 Nova Scotia Department of Health and Wellness. Annual Accountability Report on Emergency Departments 2010-2011. 2011. Retrieved from http://www.gov.ns.ca/health/reports/pubs/accountability-report-on-emergency- Department.pdf 16 Hayden J, Babineau J, Killian L, Martin Misener R, Carter A, Jensen J, Zygmunt A. Collaborative emergency centres: Rapid knowledge synthesis. Short report. Halifax, Nova Scotia: Nova Scotia Cochrane Resource Centre. 2012. Retrieved from http://www.nshrf.ca/sites/default/files/cec_rapid_knowledge_synthesis_short_report_2012.pd f
17 Nova Scotia Department of Health and Wellness and Saskatchewan Ministry of Health. Collaborative Emergency Care Centres: Knowledge Exchange Day. 2012 Sept 18. Retrieved from http://www.health.gov.sk.ca/adx/aspx/adxgetmedia.aspx?docid=e46979a9-9111-4d84-8a3e-71364fd32385&mediaid=6646&filename=knowledge-exchange-daysept2010-presentation.pdf&l=english 19 Stewart, L. Legislative Report. 2012, September 20. Retrieved from http://www.lylestewart.ca/index.php?docid=539