Regional Emergency Department Study

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

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

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

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

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

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

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

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

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

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

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

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 2005 -to- 2008 PHPDB Number of Visits 120000 100000 80000 60000 40000 2005 2006 2007 2008 20000 0 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

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

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 1 2 3 4 5 CTAS Level TBRHSC Ontario NorthWestLHINRegionalEmergencyDepartmentStudy 4

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 1 2 3 4 5 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

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

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

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

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

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

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

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

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

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 09 21.9% 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

Number of Patients 35 30 25 20 15 10 5 0 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

Percent Days (%) intentions,butambiguousaccountabilityframeworksandfew mechanismsinplacefortbrbsctoeffectivelyassesswhetherthe initiativesareworking.also,communicationsregardingsuchinitiatives betweentbrhscandtheotherhospitalsintheregiontheyaretrying tohelpareoftennoteffective.asanexample,aprojectwasinitiated tomakeiteasierforbedstobeaccessedbytheregion;however,this initiativedidnotaddresstheprimarybottleneck,acceptanceofpatients byspecialists.suchinitiativeswillbeimportantinaddressingthe sustainabilityoftheemergencydepartmentsystemacrosstheregion, butrequireanaccountabilityframework,evaluationandcontinuous improvement. PatientflowwithinTBRHSCisalsoidentifiedasakeyissue.In2008-09,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

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

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

IncaseswhereCritiCallhasbeenengaged,CritiCallwillarrangefor transportationtorepatriatepatients;thiswillonlyhappenforthose patientswhoarebroughtbacktotheirhomehospitalsforrecovery. Anyotherpatientdischargedfromthetertiarycentremustfindtheir owntransportationhome.forapatientrequiringemergencycarewho istransferredtowrhafromsiouxlookout,forexample,thejourney homecanrequireaplanetripbacktotheirhomecommunity,whereas acomparablepatientinacityinsouthernontariowouldlikelyreceive careinthecitywheretheyreside,orbecapableorrelyingonpublic transportationnetworkstogetthemhomeupondischarge.optionsfor usingpublictransportationinnorthwesternontarioarelimited. Thefinaltransportationissueconcernsthetransferofpatientsputona Form1.ApatientisdeemedForm1,orPsychiatricAssessment,when aphysicianbelievesapatientisatharmtothemselvesoranother person.theymustremaininahospitalorpsychiatricwardfor72hours forassessment.whenapatientisdeemedform1,thehospitaloften hastocallinopptoprovidesecurityforstaffandpatientssincesecure roomsgenerallyarenotavailable.physiciansandstaffreportfindingit difficulttofindapsychiatristwhoiswillingtoacceptapatientfor transfer.whenoneisfinallyfound,theyreportthetransferprocessis burdensomesincethepatientisnotdeemedcriticalbyemsandthe transferhastotakeplaceupontheavailabilityofoppstaff.two officersarerequired,onetotravelintheambulanceandtheotherto drivebehindtoprovidethereturntripfortheofficer.therequirement tosendoppofficersasescortsresultsinadditionalcostsforthose hospitals.hospitalsarerequiredtopayfortheservicesoftheopp duringthistrip,whichcantakeuptotenhours. Health Human Resources Healthhumanresourcesarevitaltothesustainabilityoftheemergency departmentsysteminnorthwesternontario.thefollowinghealth humanresourceissueshavebeenidentifiedthatcouldimpactsystem sustainability: Ashortageofhealthhumanresourcesacrossprofessions, includingthefollowing: o o o o Physiciansandspecialists; Nursingstaff; Alliedhealth(e.g.Physiotherapists,SocialWorkers etc); Lab&DiagnosticImagingtechnicians. Difficultiesrecruitingandretainingprofessionals,witheach community/hospitaladministeringtheirownprograms; NorthWestLHINRegionalEmergencyDepartmentStudy 19

Hospitalsarehighlydependentonlocumcoveragetocover EmergencyDepartmentshifts;and, Difficultiesorganizingtraininganddevelopmentwithout adequateshiftcoverage. Physician Resources Thereareseveralmodelsofemergencydepartmentphysicianstaffing inthelhin,asfollows: TBRHSC:fullystaffed,manywithCCFP(EM)orFRCP(EM) training. Lake-of-the-WoodsDistrictHospital:staffedbyemergency specialistsandemergency-trainedfamilyphysicians,relying onfamilyphysiciansforon-callsupport;and, Theremaininghospitalswhicharestaffedbyemergencytrainedfamilyphysicians. Allofthesesitesaredependentonlocumcoverage,whosetrainingis variable.themajorityofthesehospitalsstrugglewithhighphysician vacancyrates.whilenotcriticalineverycommunity,vacancies threatentoclosesomeemergenciesduetoalackofadequate physiciancoverage.thisfluctuatesandcommunitiesgoinandoutof crisis.asmentionedpreviously,accesstospecialistcareisanissue raisedbyphysiciansintheregionandemergencyphysiciansat TBRHSC.PartofthereasonforthisisthedifficultyTBRHSChashadin recruitingandretainingspecialiststaff.whileashortageofphysicians doesnotthreatentheclosureoftbrhscemergency,itimpacts physicianworkloadsignificantlywhichimpactstheabilitytoretainand recruitphysicians. AsurveywasdistributedtotheChiefsofStaff/ChiefsofEmergencyto assessthesizeandscopeofthephysicianhumanresourceissues. ThefulldetailsoftheanalysiscanbefoundinAppendixA.Each communityconductsitsownrecruitmentandretentionprocesses includingtherecruitmentandretentionoflocums,temporaryshorttermreplacementphysicianswhotypicallypracticepermanentlyin anotherlocation.someofthecommunitiestookadvantageof HealthForceOntario scommunitypartnershipsprogramtohelpthem designincentivepackagesandmarkettohealthcareprofessionals. HealthForceOntarioistheprovincialagencycreatedtohelphealthcare organizationsaddresshealthhumanresourceneedsthrough recruitmentandretentionassistanceandthefundingthelocum positions.locumsaretemporaryshort-termreplacementphysicians thattypicallypracticepermanentlyinanotherlocation.locumsinthe LHINprimarilycomefromacrossOntario.Somehowevercomefrom acrosscanada. NorthWestLHINRegionalEmergencyDepartmentStudy 20

Mosthospitalsarehighlyreliantonlocumcoveragetokeeptheir emergencydepartmentsfunctioning.thosewithhigherlocum dependenciesincluderedlake,kenora,drydenandfortfrances, GeraldtonandTBRHSC.Otherhospitalsrelyonlocumstoprovide muchneededcoverageprimarilyforvacationschedulesand professionaldevelopment.thetransiencyoflocumsmakesitdifficult toschedulefirmvacationtimesandprofessionaldevelopmentfor physiciansinthelhin.aphysicianwhoisinterestedinattendinga weeklongconferenceoutsidethelhinmayregisterforthe conference,onlytolearnthatthereisnolocumcoverageandthat he/shecannotattend. Inthosecommunitiesthataredependentonlocumcoverage,the activitiesofrecruitmentandretentionandtheadministrationoflocums takesasignificantamountoftimeandeffort.slightlymorethan50% ofrespondentsinthephysiciansurveyreportedengaging HealthForceOntariotoassistinlocumadministration,eitherthroughthe EmergencyDepartmentCoverageDemonstrationProject(for emergencyspecialists)ortheruralfamilymedicinelocumprogram. Additionally33%ofhospitalsreporttoppingupincentivestoattract locumsinadifficultcompetitiveenvironment. Historically,significantcommunitysupportforphysicianrecruitment hasbeenprovidedbylocalindustries;astheeconomiesof communitieschange,thesesupportsarevanishing.thereisalsono coordinationofrecruitment,andinfact,thereiscompetitionbetween communitiesforphysicianresources.thispermitstheavailable physicianstopickandchoose,oftenchoosingtheeasiestrotations. Locumcoverage,whileappreciatedbyphysiciansintheLHIN,isnot alwayscomparabletotheservicesprovidedbyapermanentphysician. Locumsmaybeunfamiliarwithresourcesinthecommunityorwith standardprotocolsormaynotbeabletoprovidethesamecontinuityof careapermanentphysiciancanprovide.inaddition,locumsmaybe lesswell-trainedandcanrefusetoprovideafullscopeofservice typicallyrequiredinaruralsettingthatcanincludeobstetrics,clinic, inpatientandemergencycoverage. Theresultsofthephysiciansurveydemonstratetheextenttowhich physicianresourcingisanissueandthedependencyonlocumstokeep theemergencydepartmentsopen.thetablebelowdemonstratesa significantdependencyonlocumsforthehospitalsacrosstheregion. Fivehospitals,includingRedLake,Atikokan,Dryden,Geraldtonand Lake-of-the-Woodsallreportadependencythatisgreaterthan25%of allemergencydepartmentshifts. NorthWestLHINRegionalEmergencyDepartmentStudy 21

Percent of ED Shifts in NW LHIN Covered using Locums (Reporting Hospitals - 2009 Physician Survey) Sioux Lookout Meno Ya Win Red Lake Margaret Cochenour Memorial Atikokan General Nipigon District M emorial M ccausland Dryden Regional Health Centre TBRHSC Geraldton District Lake-of-the-Woods District Wilson M emorial General Manitouwadge General Riverside Health Care Facilities Inc. 0% 10% 20% 30% 40% 50% 60% Percent of shifts / time covered between April 08 and March 09 Whilethereareareported24physicianvacanciesacrosstheLHINas ofmay2009,thereisanevengreaternumberofphysiciansthatis requiredtohelptakesomeoftheloadforcoveringon-callshifts.the followingtablesdemonstratetheproportionofpositionsinthe emergencydepartmentsacrossthelhinthatarevacantandthe numberofphysiciansthisrepresents. Vacancies as a Proportion of ED Full Staff Complement (NW LHIN 2009 Physician Survey) Sioux Lookout M eno Ya Win Red Lake M argaret Cochenour M emorial 30% 64% Atikokan General Nipigon District M emorial M ccausland 0% 25% 33% Dryden Regional Health Centre TBRHSC Geraldton District 29% 25% 43% Lake-of-the-Woods District 9% Wilson M emorial General M anitouwadge General Riverside Health Care Facilities Inc. 0% 0% 38% 0% 10% 20% 30% 40% 50% 60% 70% Percent NorthWestLHINRegionalEmergencyDepartmentStudy 22

Number of Current Physician Vacancies in NW LHIN (Reporting Hospitals - 2009 Physician Survey) Sioux Lookout M eno Ya Win Red Lake M argaret Cochenour M emorial Atikokan General Nipigon District M emorial M ccausland Dryden Regional Health Centre TBRHSC Geraldton District Lake-of-the-Woods District Wilson M emorial General M anitouwadge General Riverside Health Care Facilities Inc. 0 0 0 1 1 ThehospitalswiththelargestproportionofvacanciesincludeRed Lake,GeraldtonandRainyRiver.Attheselevels,thesehospitalsare undercontinualstraintofillvacantshiftswithlocums.moreover, currentmohltcfundingforlocumsdoesnotcoverlocumshiftsfor vacantpositionsforallhospitals,dependingonthecontract,placing additionalstrainonthesesites.atsmallruralhospitalsthelossofone physicianhasasignificantimpact.hospitalsareleftscramblingto covershiftswithexistingstafforlocums. Inadditionthereareanestimated15physicianswithintentionsto leavetheirrespectivecommunitiesoverthenext1to5yearsandan additional6.5physicianswithplanstoretire,placingadditionalstrainon thesystem.solutionswillberequiredthatwillleveragetheuseof existingresourcesasdemandisnotlikelytolesseninthecoming years,whileprojectionsfordemandinserviceshowasteadyvolumeto slightincreaseinemergencydepartmentvolumes. TheLHINhasseenthegrowthofproviderpracticeagreementsmany thatincludefamilyhealthteams.thereisarangeofphysician agreementsinthelhin,allofthemfocusedonteam-basedpractices. TheagreementsinplacearesignedwiththeMOHLTCandnotall requirephysicianstoprovideemergencydepartmentcoverageinthe communitieswheretheylive.somefamilyhealthteamagreements allowforphysicianstoprovideotherhospitalservices(i.e.anaesthesia, obstetrics,medicineetc.)thanemergencycare.theseagreements havealsohadtheunintendedconsequenceofmakingitmorelucrative todofamilymedicinewithoutprovidingcoveragetotheemergency Department.Thishascontributed,inafewcommunitiesintheLHIN, 2 2.5 3 3 4.5 0 1 2 3 4 5 6 7 8 9 Units 7 8 NorthWestLHINRegionalEmergencyDepartmentStudy 23

toemergencydepartmentcoverageshortageswherethereotherwise isanadequatesupplyofphysicians.asdescribedbyproviders,the presenceofafulltimeemergencyphysicianintheemergency DepartmentinKenorahasalsocreatedsentimentbysomefamily physiciansinthecommunitythattheyarenolongerrequiredtosupport theemergencydepartment. Therecruitmentandretentionofphysicianspecialistsisalsoanissue identifiedattbrhsc.currently,specialistphysiciansplayamajorrole intherecruitmentofotherspecialistsintheirarea,resultinginaconflict ofinterest.asaresultofthis,therecontinuetobespecialistshortages inkeyareas,resultinginaccess-to-careissuesforpatientsrequiring specialistservices. Theuncertaintyofemergencyphysiciansupplythreatensthe sustainabilityoftheemergencydepartmentsystem,whichissetupto behighlyreliantonphysicians.alternativemodelsexistthatusenonphysicianhealthcareprofessionalstoprovidesomeemergency services,thusleveragingphysicianresources.unfortunately,someof thesealternativeprovidersarealsoinshortsupply,asdiscussedinthe nextsection. Non-Physician Resources Hospitalsalsodescribedifficultiesintherecruitmentandretentionof nursingandalliedheathstaff,asdocommunityandhomecare providers. Hospitalsfinditparticularlydifficulttoattractnursestoparttime positions.jobsharingacrossmultiplesitesisnotalwayseasybecause ofthedistancesbetweenthehospitals.typicallytherecruitmentof healthcareprofessionalsrequiresemploymentforthatprofessional s partner.thiscanbedifficultinsomeofthecommunitiesinthelhin whereunemploymentisgrowingduetomillandmineclosures. Providersalsodescribedifficultyrecruitingnursepractitioners.The growthoffamilyhealthteamsacrossthelhinhasresultedinan increaseinthenumberofavailablepositionsfornursepractitioners. Someofthesepositionshavebeenfilledfromnursingresourcesinthe hospitals.additionally,orngeiscurrentlyexperiencingashortageof advancedcareparamedics.asdescribedinthecase,thiscanplace addedburdenonhospitalsthatarerequiredtosendnursingescorts whenotherpersonnelareunavailable.additionally,ashortageof nursing,andalliedhealthprofessionalslimitstheirusageasalternatives tophysicianresources. Withshort-staffedhospitals,itisdifficulttosendstafftotrainingand developmentopportunities.findingreplacementstaffforthoseon trainingisadifficulttask. NorthWestLHINRegionalEmergencyDepartmentStudy 24

Community Supports and integration Theroleofaruralcommunityhospitalisdifferentthanoneinanurban setting.fewerprimaryhealthcareresourcesareavailableinsuch communities,andresidentsarelefttorelyontheemergency Departmenttoprovideprimaryhealthcaresupport.Utilizationofthe EmergencyDepartmentinthesecommunitiesishigherthantherestof theprovince,asshowninthechartbelow.itshouldbenotedthat NorthWestLHINhasahigherproportionofAboriginalpeoplelivingin thelhinthanotherlhins.dataonaboriginalslivingonreserveare notalwayscollectedinthecensus,andmaymakethenumberofvisits lookdisproportionatelylarger. Ontario Emergency Department Cases per 1,000 Population by LHIN FY 2006/2007 (Data Source: PHPDB) 1400 1200 visits/1000 pop 1000 800 600 400 200 0 1. Erie St. Clair 2. South West 3. Waterloo Wellington 4. Hamilton Niagara Haldimand Brant 5. Central West 6. Mississauga Halton 7. Toronto Central 8. Central LHIN 9. Central East 10. South East 11. Champlain 12. North Simcoe Muskoka 13. North East 14. North West Province ThereisgreaterusageoftheEmergencyDepartmentinruralsettings forprimaryhealthcare.thechartbelowdemonstratesanindicator termed EmergencyDepartmentVisitsthatcouldhavebeenManaged Elsewhere. A g e -A d j u s te d R a te p e r 1, 0 0 0 P e o p l e 160.0 140.0 120.0 100.0 80.0 60.0 40.0 20.0 0.0 Emergency Department Visits that Coulf Have Been Managed Elsewhere 2007/09 PHPDB Kenora Rainy River Thunder Bay District Thunder Bay City 160 140 120 100 80 60 40 20 0 Sub-LHIN Area NorthWestLHINRegionalEmergencyDepartmentStudy 25

ThesevisitsincludeCanadianTriageAcuityScale(CTAS)IVandV(low acuity)visitsforthefollowingconditions:otitismedia,cystitis, conjunctivitis,andupperrespiratoryinfections(e.g.commoncold, acuteorchronicsinusitisandtonsillitis,acutepharyngitis,laryngitisor tracheitis,andotherupperrespiratoryinfections).theseexcludeany visitsforanyoneundertheageof1orolderthan74yearsofage.this indicatortracksvisitsthatwouldbebestmanagedinthecommunityif resourcesareavailable.asthegraphindicates,thereisamuchhigher relianceontheemergencydepartmentsintheregion,outsidethunder Bay,forthesetypesofvisits.Inasmallcommunityitmaybe appropriateandeffectiveforahigherdegreeofprimaryhealthcareto becentredatthehospital. ThenumberofFamilyHealthTeams(FHTs)intheLHINhasgrown,and 58.4%ofthepopulationintheLHINisnowrosteredinsomeformof physiciangrouppractice.someoftheseteamshaveurgentcare clinics,orreservetimeforurgentcases,howevermostteamsarenot focusedonreducingcommunityrelianceontheemergency Department.InsomecommunitiestheFamilyHealthTeamdoesnot supporttheemergencydepartment;othershavehirednurse PractitionerstodivertcasesfromtheEmergencyDepartment. Anagingpopulationwithanincreasingprevalenceofchronicdiseases andtheirriskfactorspointstoacontinuedgrowthindemandfor emergencyservices.thefollowingchartsshowprevalenceratesof diabetesthatarehigheramongthetotalpopulationthantheontario rateswithsignificantlyhigherratesamongthoseaged65andolder. Similarly,ratesofsmokingintheLHINaresignificantlyhigherthanthe provincialrate.smokingislinkedtomultiplechronicconditions. cancers. Diabetes Prevalence 2007 StatsCan 2007 25.0 20.0 Percent (%) 15.0 10.0 NW LHIN ONT 5.0 0.0 Total, 12 years and over 45 to 64 years 65 years and over Age Category NorthWestLHINRegionalEmergencyDepartmentStudy 26

Smoking Rates StatsCan 2007 Percent (%) 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Total, 12 20 to 34 years years and over 35 to 44 years 45 to 64 years 65 years and over NW LHIN ONT Age Category Alloftheabovesuggestsaneedforanintegratedcommunitysolution toemergencyservicesthatincludesanassessmentoffuturedemand andprovisionofsupportsinthecommunitythatcanserveas alternativestoemergencydepartmentvisits.amodelforsustaining emergencyservicesinthenorthwestlhinneedstoincludean understandingofhowprimarycareandchronicdiseasemanagement shouldbestbedeliveredwithinthecommunity. Clinical Quality, Standardization of Patient Care Acrossthesystem,hospitalsandtheiremergencydepartments,forthe mostpart,workinisolationindevelopingqualityandsafetypractices. Thelackofsharedpatientcareprotocolsacrosstheregionmakesit difficultforlocumsworkingindifferenthospitals.thelackofshared protocolsalsocreatesdifficultiesfororganizationssuchasorngeand EMSthatinteractwithmultipleemergencydepartments. Thereisalsoalackofregionalmedicaldirectivesthatwouldprovide theopportunityfornursestoworktoabroaderscopeofpractice,thus leveragingphysicianresources.whiletheseareinplaceinsomesites, theyarenotconsistentlysharedacrosstheregion.amodelfor increasedsustainabilityshouldtakeadvantageofefficienciesgainedby utilizationofstandardizedpracticesandcommonmedicaldirectives. Information Management Informationmanagementisessentialinknowledge-driven environments.informationisrequiredfortheaccuratediagnosisand evidence-basedcareofcriticallyillpatients.currently,notallhospitals inthenorthwestlhinemploythesameinformationsystem.this createsdifficultieswhenpatientsrequirecareonmultiplesites,a commonoccurrenceinnorthwesternontario. Providersacrossthesystemdonotcollectthesamedataorcollect datainconsistently.thisinconsistencymakesitdifficulttoprovideone viewofthesystemthatdescribeswithaccuracytheongoingissuesin NorthWestLHINRegionalEmergencyDepartmentStudy 27

patientcare.thislackofdataalsomakesitdifficulttomanagethe systemfromaregionalperspective. ItisessentialthataQualityFrameworkbedevelopedforemergency servicesinthenorthwestlhin.developmentandutilizationofa QualityFrameworkrequiresavailabilityofdataandinformation.Data andinformationarerequiredtocreatequalityreports,toidentifyqualityrelatedconcernsandtoprovideevidencethatcorrectiveactionshave resultedinperformanceimprovement. Insummary,aNorthWestLHIN-widesystemofdataandinformation management,supportedbycompatibleinformationtechnology platforms,isessentialforpatientcare,forsystemadministrationand forqualityassurance. NorthWestLHINRegionalEmergencyDepartmentStudy 28

Recommendations Therecommendationsprovidedbelow,ifimplemented,willaddress thekeyissuesconfrontingemergencycarethroughoutthegeographic areaofthenorthwestlhin.theyarebaseduponareviewofdata pertainingtoemergencyservicesinthelhin,uponinterviewswith providersineachofthelhin semergencydepartmentsandupon commentsandsuggestionsofferedinaworkshopthatinvolvedallkey emergencyservicestakeholders.theserecommendationsbuildonthe strengthsinthecurrentsystemandareinformedbyleading emergencyservicespracticesincanadaandelsewhere. Therecommendationsasoutlinedbelowareidentifiedashighor mediumpriority.thispriorityrankingisameasureofthe recommendation sabilitytoimpactthesustainabilityoftheemergency departmentsystem.therecommendationsrankedashighhavea immediate,significantabilitytoimpactthesustainabilityofthesystem. Thoserankedmediumstillimpactthesustainabilityofthesystem,but toalesserdegree. Inthecourseofinterviewingemergencyhealthcareprovidersand otherkeystakeholdersthroughoutthenorthwestlhin,itbecame apparentthattheissueshealthcareprovidersconfrontastheyattempt toensurethattheirpatientsreceiveefficientandeffectivecarefor emergencymedicalproblemscanbegroupedaccordingtothe followingthemes: Vision Governance Administration & Accountability Regional Flow and Access to Higher Levels of Care Transportation Health Human Resources Community Supports Clinical Quality, Standardization of Patient Care Information Management TheRecommendationsoftheConsultantsrelatedtotheimprovement indeliveryofemergencyservicesthroughoutthenorthwestlhin havebeenorganizedaccordingtheabove-listedthemes. Vision Summary of Findings:WithintheNorthWestLHIN,thereisnoagreeduponVisionregardingthemannerinwhichtheLHIN semergency NorthWestLHINRegionalEmergencyDepartmentStudy 29

Departmentsandhospitalsshouldworkasanetworkinensuringthat patientswithurgenthealthproblemsreceivetimely,highqualitycare, deliveredinthemostappropriateenvironment. Recommendation#1(HighPriority):ThattheNorthWestLHINandits partnerhospitalsdevelopandcommittoaclear,unambiguousvision describingapreferredmodelofcoordinatedemergencyservices deliveryfornorthwesternontario. TheVisionshoulddefinehowtheprovidersinthesystemwouldwork togethertoprovideend-to-endcarethatispatientfocused.key elementsofthevisionshouldincludethefollowing: PatientandFamily-centeredcare; Aunifiednetworkofproviders; Collaborativeuseofresources; Useofbestpractices; Sharedstandards;and, Useofcoordinateddecision-support. Outcome measure: 1. Presence ofa Vision for an emergency service delivery system throughout the North West LHIN 2. Commitment to this Vision by all partners. Governance Summary of Findings:Atpresent,eachNorthWestLHINEmergency Departmentfunctionssemi-autonomously;thereisnoover-arching governancestructureaccountableforimplementationofavisionofan integratedemergencyservicesnetworkinnorthwesternontario. Recommendation#2(HighPriority):ThattheLHINanditspartner hospitalscommittothecreationofanorthwestlhinemergency ServicesGovernanceCommittee,anddeterminetheoperating parametersofthisentity.itisenvisionedthatthisbodywouldhave representationfromeachofthehospitalsinthelhin.these representativeswouldberesponsibleforrepresentingtheneedsof theirlocalcommunitiesandhospitals.thegovernancestructurewould beresponsiblefordevelopmentandimplementationofhigh-level strategies(e.g.hospitalroleswithinanetworkofhospitals), discussions/negotiationswiththemohltcandhealthcanadaand issueidentificationandresolutionwithotheroutsideagencies(ems, Ornge).Theemergencyservicesadministrativestructures(seebelow) NorthWestLHINRegionalEmergencyDepartmentStudy 30

wouldreporttoandbeheldaccountablebythisbody.other recommendedfunctionsforthisbodyarefoundinthe Recommendationsbelow. Outcome Measures: 1. North West LHIN Emergency Services Governance Committee created; 2. Terms of Reference developed and approved; 3. Chair and members appointed; 4. Administrative structures (see below) created; 5. Initial Workplan developed and approved. Administration & Accountability Summary of Findings: Thereisnoadministrativestructureforthe12 EmergencyDepartmentsintheNorthWestLHIN,nordotheyoperate withinanexplicitaccountabilityframework. Recommendation#3(HighPriority):ThataNorthWestLHIN EmergencyServicesAdministrativeCommitteeiscreated,ideally evolvingfromthecurrentnorthwestlhinemergencydepartment AdvisoryCommittee.Thiscommitteewillberesponsibleforensuring that: Accessandflowissuesrelatedtoemergencyservicesare addressed; Transportationissuesrelatedtoemergencyservicesare addressed; Asynchronizedapproachisdevelopedtoaddressnonphysicianhealthhumanresourceissuesandopportunities; Communitysupportsdesignedtolessenpressureson EmergencyDepartmentsareoptimized; Apatientsafetyandclinicalqualityframeworkforemergency servicesinthelhinisdeveloped; Datacollectionandinformationmanagementprocesses relatedtoemergencyservicesarecoordinated; Urgentissuesandproblemsrelatedtoprovisionoftimely,high qualityemergencyservicesinthenorthwestlhinare understoodandaddressed; Communicationregardingemergencyservicesamongst partnerorganizationsandstakeholdersisoptimized. NorthWestLHINRegionalEmergencyDepartmentStudy 31

Theadministrativestructure smembershipwouldconsistof thefollowing: Administrativeleadersfromeachofthehospitalsinthe LHINwithanEmergencyDepartment; AdministrativeleadershipfromtheCommunityCare AccessCentre;and, NorthWestLHINEmergencyDepartmentLead; Asmallsecretariatwillberequiredtosupporttheworkofthis committee.whilewidespreadcommunicationfromthecommitteeto abroadnetofstakeholderswillbeessential,theprimaryreportingline ofthiscommitteewillbetothenorthwestlhinemergencyservices GovernanceCommittee,towhichthiscommitteewouldbe accountable. Outcome Measures: 1. Terms of reference developed for an Emergency Services Administrative Committee; 2. The reporting line for this committee confirmed; 3. The Accountability Framework for this committee confirmed; 4. A Role Description for the Committee Chair developed; 5. Membership on the committee defined; 6. Chair and members appointed; 7. Initial Workplan developed and approved. Summary of Findings: Thereisnocommitteecomprisedofphysician leadersinemergencymedicinefromthenorthwestlhin. Recommendation#4(HighPriority):ThataNorthWestLHIN EmergencyServicesMedicalCouncilbecreated.Thehospitalsinthe LHINshouldreachagreementontheAccountabilityFrameworkforthis council.thecouncilwouldbechairedbythenorthwestlhin EmergencyDepartmentLeadandwoulddevelopstrategicgoalsfor emergencyservicesfromaphysicianperspective(e.g.considerationof LHIN-widecredentialingandprivilegingforsomephysicians; developmentofeducationandmentoringprograms,etc.),developa coordinatedapproachtophysicianrecruitmentandretentionissues, developandimplementastrategicapproachtorecruitmentand utilizationoflocumsinthenorthwestlhin,developamedicalquality framework,participateinissueandproblemresolutionandserveasa communicationvehicletophysiciansinthenorthwestlhinwho engageinemergencydepartmentwork.thecouncilshouldhave representationfromeachoftheemergencydepartmentsinthelhin. NorthWestLHINRegionalEmergencyDepartmentStudy 32

ItwillbeimportantthattheLHINhospitalsdevelopanunambiguous reportinglineandaclearaccountabilityframeworkforthecouncil. Muchthoughtmustbegiventothesematters,sincetheLHINandits hospitalswillwanttosupportlocalphysicianautonomy,asappropriate, whileimplementingastructurethatsupportsaregionalmodelofcare. Outcome Measures: 1. Terms of reference for a Regional Emergency Medical Council developed; 2. The reporting line for the Council defined; 3. The Accountability Framework for the Council determined; 4. A Role Description for the Chair developed; 5. Council membership agreed upon; 6. Chair and members appointed; 7. Initial Workplan developed and approved. Regional Flow & Access to Higher Levels of Care Summary of Findings: TheNorthWestLHINexistsinalarge geographicareawheremanypatientsliveinruralorremote environments.whenemergenciesarise,patientsgenerallyreceivehigh qualityinitialcare.toenhancelocalcareandtodetermineifhigher levelsofcarearerequired,betterusecouldbemadeofexisting Telemedicinecapacity.Ifhigherlevelsofcarearerequired,therolesof varioushospitalsinthenorthwestlhin(orelsewhere)inproviding suchserviceshavenotbeenclarified;hospitalsdonotoperateasatrue networkanditisattimesdifficulttoaccesshigherlevelsofcarefor patientsinneed.furthermore,whentreatmentatahigherlevelofcare hasbeencompleted,arrangingsuitableandtimelytransportationofthe patientbacktothereferringhospitalorhomeisoftenproblematic.the followingseriesofrecommendations,ifacceptedandenacted,will improveregionalpatientflowissuesandissuesrelatedtoaccessto higherlevelsofcare: Recommendation#5(HighPriority):ThattheNorthWestLHIN EmergencyServicesGovernanceCommittee,workingwithpartner hospitalsandthelhin,definespecificemergencyservicerolesfor healthcarefacilitiesinthenorthwest,leadingtothecreationofa formalnetworkoffacilitiesinthenorthwest(healthcanadaremote nursingstations,communityhospitals,districthospitals,atertiary regionalreferralhospital),eachwithdefinedrolesandresponsibilities relativetothecareofemergencypatients. NorthWestLHINRegionalEmergencyDepartmentStudy 33

Thesedefinedrolesshouldbeaccompaniedbyaserviceplanthat describestheflowofpatientcareacrosshospitalsinthelhinfor definedservices.thismayincludethedevelopmentofregional specialtyservicesamongahospitalorgroupofhospitals.thedefinition ofroleswillleadtoestablishmentofnetworksofcareandreducethe system srelianceontbrhscforemergencycare. Outcome Measures: 1. Roles and responsibilities of all health care facilities in North West defined, in regard to emergency services; 2. Lines of referral between hospitals clarified; 3. Over time, personnel and equipment upgraded, as required. Recommendation#6(HighPriority):ThattheNorthWestLHINtakes theleadinredefiningandclarifyingtheroleoftbrhscasthe regional hospitalinnorthwesternontario.thisroleshouldbedefinedand agreedtoinasignedhospitalserviceaccountabilityagreement defininginexplicittermstbrhsc sresponsibilityasaregionalcentre. TheLHINshouldalsoplayaroleinencouraging/assisting/monitoring TBRHSCasitadvancestheinitiativesthatwillberequiredtopermitit tofillthisrole.thesewillinclude: EmbracingtheNorthWestLHINEmergencyTransferPolicies (seebelow); Ensuringadequatespecialistphysicianavailability;thiswill requireachangeinphysicianrecruitmentstrategyattbrhsc (seebelow)andfullimplementationoftbrhsc smost ResponsiblePhysician(MRP)policy; Improvingbedavailabilitythroughdevelopmentand implementationofanaggressivebedutilizationmanagement strategy; Supporting/expandingacurrentinitiativetoidentifyanavailable bedforpatientsrequiringemergencytransfer,potentially permittingdirectadmissiontothosebeds; Ongoingevaluationofitsroleasaregionalcentreand performancetherein. Outcome Measures: 1. Unambiguous acceptance by TBRHSC of a role as the tertiary referral hospital for Northwestern Ontario; 2. TBRHSC rarely refuses a transfer from region; NorthWestLHINRegionalEmergencyDepartmentStudy 34

3. Altered physician recruitment strategy leading to enhanced recruitment of specialists; 4. Increased bed availability through improved patient throughput; 5. Increase in direct admissions of emergency patients to preassigned beds. Recommendation#7(MediumPriority):ThattheNorthWestLHIN EmergencyServicesAdministrativeCommittee,workingwiththeNorth WestLHINEmergencyServicesMedicalCouncil,identifyopportunities forexpansionoftelemedicineintoemergencydepartments,explore fundingopportunitieswithontariotelemedicinenetwork,and,once fundinghasbeengained,developanemergencydepartment TelemedicineImplementationPlan. Outcome Measures: 1. Emergency Department Telemedicine opportunities identified; 2. Funding opportunities identified with Ontario Telemedicine Network and initial funding gained; 3. Implementation plan developed and approved. Recommendation#8(MediumPriority):Buildingontheexperienceof othercanadiancentres(e.g.fraserhealthinb.c.),thatthenorthwest LHINEmergencyServicesAdministrativeCommitteetaketheleadin developingasetoftransferprotocols(e.g. TertiaryLevelofCare ; MaynotRefuse ; Life,Limb,ThreatenedOrgan )toensuretimely transferofpatientsinneedtohigherlevelsofcareandthatmonthly reportsoftransferdatarelatedtotheseprotocolsbedevelopedand widelycirculated. Thesetransferprotocolsshoulddefineasetofstepscliniciansshould followtotransferpatients,includinguseofcriticallandstepstofollow whenservicesarenotreadilyavailable.thesetransferprotocols shouldalsodefinewhentoengagetheservicesoftbrhsc,wrha, hospitalsintheusandhospitalselsewhereinontario. Outcome Measures: 1. Transfer protocols developed and implemented; 2. Role of CritiCall clarified; 3. Monthly data re: transfers according to these protocols developed and circulated. NorthWestLHINRegionalEmergencyDepartmentStudy 35

Recommendation#9(MediumPriority):ThattheNorthWestLHIN EmergencyServicesAdministrativeCommitteetaketheleadin developinganescalationpolicydefiningthechainofindividualswith administrativeresponsibilitytobecontactedshouldintractable difficultiesoruntimelydelaysbeexperiencedinthetransferofa criticallyillpatienttotbrhsc;itisexpectedthatsuchindividuals wouldintercedeadministrativelytoresolveissuesleadingtodelays. Theescalationpolicywouldcoverthetransferofpatientsfromlocal anddistricthospitalstotbrhsc.ifforexampledelayswere encounteredaccessingabedorspecialistcare,achainofcommand wouldbeinitiatedwithsettimelinesassociatedwithexpected responsetimesandtheelapsedtimeforproviderstoescalatethenext pointinthechain. Outcome Measure: 1. Escalation Policy developed and implemented. Recommendation#10(HighPriority):ThattheNorthWestLHIN EmergencyServicesAdministrativeCouncilshouldtaketheleadin developingarepatriationprotocolthatdefinesthemannerinwhich patientsfromtbrhscarerepatriatedinatimelymannertotheir referralhospitalortotheirhome.similarlythepolicyshouldcoverthe repatriationofpatientsfromsiouxlookoutmenoyawinhealthcentre inpartnershipwithhealthcanada,andthewinnipegregionalhealth Authoritytotheirhomecommunities.Thispolicyshouldbeintegrated withtheinitiativetoimproveinter-facilitytransfers(seebelow).note: patientstransferredthroughcriticallareprovidedtransportationbackto theirhomehospital anotherreasontosupportwideruseofcriticall. Outcome Measure: 1. Repatriation Policy developed for patients not covered by CritiCall policy; this policy should be integrated with initiatives to improve inter-facility transfers (see below); 2. Repatriation Policy approved and implemented; 3. Data on repatriation of patients collected and widely communicated. Transportation Summary of Findings: Inadditiontopatientrepatriationissues(see above),ahostofissuesconspirestofrequentlyinterferewiththe efficient,timelytransportationofemergencypatientstoandfrom TBRHSC,(andtoalesserextent,WinnipegRegionalHealthAuthority). Thesetransportationissueshavebeendifficulttoresolve,sincethey involvemultiplejurisdictionswithdifferentmandatesforservices, NorthWestLHINRegionalEmergencyDepartmentStudy 36

someenshrinedinlegislation.additionally,thereisnosysteminthe NorthWestLHINtosupportinter-facilitytransferofpatients; substantialemsresourcesareusedtoaccomplishthese,butsuch transfersareoutsidethelegislatedmandateofems,arenotapriority foremsandaregenerallyaccomplishedinahighlyinefficientway.the followingrecommendations,ifacceptedandimplemented,will facilitateresolutionoftheseissues. Recommendation#11(HighPriority):TheNorthWestLHIN EmergencyServicesGovernanceCommitteeshouldestablisha processtoengagestakeholderstocreateaninter-jurisdictionaltask forceontransportationwithrepresentationfromthemohltc,the LHIN,partnerhospitals,EMSprovidersandOrnge,andother stakeholdersasrequired(e.g.healthcanada).thistaskforcewouldbe chargedwiththesharedresponsibilityofthefollowing: Developingacomprehensivelistofcurrentissuesthatinterfere withsmooth,timely,efficienttransferofpatientstoandfrom TBRHSCanddevelopingandimplementingresolvingactions. Thelistofissueswouldinclude,butnotbelimitedto: Coordinationofpatient hand-offs betweenemsand Ornge; CommunicationprocessesbetweenOrngeandEmergency Departments,leadingtoprolongedpatientpick-uptimes; Improvedcompatibilityofresuscitationequipment betweenornge,emsandemergencydepartments. Consideroptionstoaddressnon-urgentinter-facilitypatient transferneeds. Outcome Measures: 1. Issues confronting effective transfer of patients to and from TBRHSC tabulated and addressed; 2. An initiative developed to address inter-facility patient transfer needs in the North West LHIN. Recommendation#12(MediumPriority):TheNorthWestLHIN EmergencyServicesAdministrativeCommitteewillexploreoptionsto addressnurseescortchallenges. Outcome Measures: 1. Identification of options to reduce or eliminate need for nurse escorts 2. Agreement achieved on ability of nurses to provide nursing care to patients in transit (when necessary). NorthWestLHINRegionalEmergencyDepartmentStudy 37

Health Human Resources Summary of Findings:Whilethereareevident,significantshortagesof physicians,nursesandotherhealthcareprofessionalswithinthenorth WestLHIN,thereisnocontemporaryhealthhumanresourceplans. Theapproachtorecruitmentandretentionofhealthcareprofessionals isnotcoordinated,noristherecruitment,compensationand deploymentoflocumphysicianscentrallyorganized.thereisanunmet needthroughoutthelhinemergencydepartmentsrelatedto continuingprofessionaleducationanddevelopment.thereisaneed throughoutthelhintoimplementalternativemodelsofcareprovision. TheshortageofhealthhumanresourcesintheLHINislikelythesingle mostimportantissueaffectingthesustainabilityoftheemergency DepartmentsystemintheLHIN.TheRecommendationslistedbelow, ifacceptedandimplemented,willfacilitateresolutionofhealthhuman resourceissues. Recommendation#13(HighPriority):TheNorthWestLHIN EmergencyServicesAdministrativeCommitteeshouldoverseethe developmentofa10-yearregionalnon-physicianhealthhuman ResourcePlanforNurses,AlliedHealthprofessionalsandotherkey healthcarepersonnelwhoworkinemergencyservices.thisplan shouldalsoincludeoptionstoleverageexistingresourcesthrough contemporaryutilizationofcareproviderssuchasnursepractitioners, highlytrainedemspersonnelandphysicianassistants.these resourceshavedemonstratedbenefitinemergencyservicesinrural Australia.AdministratorstherehaveemployedNursePractitionersin emergencydepartments,linkedviatelemedicinetoemergency physiciansandexpandedthescopeofpracticeemspersonnel,who providesupportbothintheemergencydepartmentsandthe community.theplanshouldalsorecognizeandmakeuseofthe resourcesavailablethroughthenursingsecretariatand HealthForceOntariothatincludetheNursingRetentionFund,Grow YourOwnNursePractitionerProgram,TuitionSupportandother programs. Planningandimplementationshouldconsiderameasuredapproach, startingwithafewpilotprojects,tointroducetheconceptofalternate providersinemergencydepartments.aniterativeapproachbuildingon theexperiencesofeachcommunitywillhelpgainacceptanceforthe effectiveuseoftheseproviders. Additionally,hospitalsintheLHINshouldconsideraregionalapproach toimplementingtheplanandregionalcoordinationofprofessional developmentactivities.thiscouldbeachievedthroughthe establishingaregionalcommitteetooverseeandcoordinatethese activities. NorthWestLHINRegionalEmergencyDepartmentStudy 38

Outcome Measures: 1. Development of a Regional Non-Physician Health Human Resource Plan; 2. Innovative use of Advanced Nurse Practitioners, highly-trained EMS personnel and physician assistants in Emergency Departments; 3. Regional coordination of professional development and training. Recommendation#14(HighPriority):ThattheNorthWestLHIN EmergencyServicesMedicalCouncildevelopa10-yearintegrated RegionalPhysicianHumanResourceNeedsAssessment.This assessmentwillidentifythecurrentandexpectedvacanciesandgaps inphysicianhumanresourcesrelatedtoemergencyservices. Outcome Measures: 1. 10-year North West LHIN Physician Resource Needs Assessment that is coordinated across the LHIN. Recommendation#15(HighPriority):Whileendorsingcontinued community-basedphysicianrecruitment,thatthenorthwestlhin EmergencyServicesMedicalCouncildevelopsaStrategicPlanfor improvingregionalphysicianrecruitmenttothenorthwestlhin. Elementsofthisplancouldinclude: DevelopmentofaformalrelationshipbetweenEmergency ServicesMedicalCouncilandTrainingProgramDirectorsat thenorthernontariomedicalschooltopromotegreater exposureofundergraduatesandresidentstonorthwest LHINcommunities; Developmentofspecificrecruitmenteffortsdevotedto studentsandresidentsrotatingtonorthwestlhinhospitals; Surveyingstudents,residentsandlocumphysiciansregarding theirviews/concernsrelatedtomedicalpracticeinthenorth WestLHINandacttodevelopacompendiumofissuesand planstoaddressthemwhilealsoacknowledgingworkload variation; Developmentofregion-wideadvertisingandpromotional material; RepresentationofNorthwesternOntarioatjobfairs; Standardizationofincentivepackages; Creationofprofessionaldevelopmentandmentorship opportunitieswithinthelhin; NorthWestLHINRegionalEmergencyDepartmentStudy 39

Facilitationofregion-widecredentialingandprivileging processesthatwouldencouragephysicianstoworkat multiplesites. Outcome Measures: 1. Coordinated approach to physician recruitment throughout the North West; 2. Enhanced relationship between North West LHIN Emergency Services Medical Council and NOSM; 3. Focused recruitment efforts toward rotating residents and students; 4. Increased understanding of concerns of recent graduates relative to medical practice in the north; 5. Enhanced physician professional development; 6. Greater mobility of physicians to meet needs throughout LHIN 7. Improved physician recruitment and retention. Recommendation#16(HighPriority):TBRHSCshouldensurethatthe specialistphysicianrecruitmentprocessattbrhscisnotprimarily drivenbyspecialistphysiciansinthesamediscipline,thuseliminating anypotentialconflictofinterest.whileinputshouldbesoughtfrom practicingspecialists,theirinputshouldnotbeabarriertothe recruitmentofnewspecialists.specialistrecruitmentshouldbebased onpopulationneedratherthanphysicianpreference/interests. Outcome Measures: 1. Development of a corporate specialist physician recruitment initiative at TBRHSC; 2. Avoidance of physician conflict-of-interest; 3. Enhanced specialist physician recruitment. Recommendation#17(HighPriority):Whilerespectinglong-standing relationshipsandcommunitypractices,chargethenorthwestlhin EmergencyServicesMedicalCouncilwiththetaskofdeveloping acceptableregion-wideapproachestoenhanceproactiverecruitmentof andimprovedeploymentoflocumphysicians,includingthe developmentofalhin-basedpooloflocumresources. Thisshouldincludethedevelopmentofaninformationsystemtotrack whothelocumsare,howoftentheyprovideservice,theirrelativeskill sets,theirpreferenceofcommunitiesandhospitals,theamount requiredfortravelandtheircompensationrequirements.this informationwouldprovidearobustdatasetforthecoordinationand administrationofcentrallyorganizedlocumprograms. NorthWestLHINRegionalEmergencyDepartmentStudy 40

Outcome Measures: 1. Evolution to a more standardized approach to recruitment of and utilization of locum physicians within the North West LHIN. 2. Minimization of expensive, short duration locum engagements; 3. Ensuring compensation arrangements are aligned with locum work responsibilities; 4. Ensuring a unified approach from the North West LHIN to agencies such as HealthForceOntario. Recommendation#18(MediumPriority):TheNorthWestLHIN EmergencyServicesGovernanceCommitteeshouldworkwiththe MedicalCounciltodevelopalistofgovernmentinitiatives/Programsin thenorthwestlhinthathavetheunintendedeffectofreducing physiciancommitmenttoemergencydepartmentwork.thislist shouldthenformthebasisofdiscussionwiththemohltcrelatedto modificationofsuchinitiatives/programs;thiswillhelpensurethateach communitywillbeabletocontinuetoprovidemedicalcoveragetotheir EmergencyDepartment. Outcome Measures: 1. Development of a list of initiatives/programs that lessen attractiveness of emergency work for physicians; 2. Discussion with the MOHLTC to modify such initiatives/programs; 3. Increased willingness of physicians to work in Emergency Departments. Community Supports Summary of Findings: ThemandateofCCACsresultsinalimited rangeofservicesbeingprovidedincommunities.furthermore,thereis widevariabilityinthelhinintheavailabilityofcommunitysupports (e.g.familyhealthteams,longtermcare,communitycareaccess Centres,SocialandCommunitySupportAgencies,assistedliving environments)thatwouldlessendemandsupontheemergency Departments. Recommendation#19(MediumPriority):TheNorthWestLHINshould workwiththeccac/fht/chcandotherpartnerstodevelop communityambulatoryclinicswhereappropriatetoclustercareand increaselevelsofcarethatcanbeprovidedinthecommunity(e.g.for patientsrequiringchronicwoundcare). NorthWestLHINRegionalEmergencyDepartmentStudy 41

Outcome Measures: 1. Expanded community services for patients requiring chronic wound care and others; 2. Decreased Emergency Department volumes, particularly in communities such as Kenora and Dryden Recommendation#20(MediumPriority):TheNorthWestLHINshould conductaneedsassessmentforsupportivehousing(assistedliving)in itscommunities. Outcome Measures: 1. Fewer visits to the Emergency Department by the elderly population; 2. Fewer hospitalizations of elderly patients, which often result in prolonged hospitalization, deconditioning and requirements for ALC. Recommendation#21(MediumPriority):TheNorthWestLHINshould continuetosupportthedevelopmentofintegratedchronicdisease ManagementprogramsacrosstheLHINtosupporttheneedsof individualsinthelhinwithchronicmedicalconditions.thenorth WestLHINEmergencyServicesAdministrativeCommitteeshould identifyotheropportunitiesforchroniccaremanagementinlinewith thelhinandprovincialstrategyonchronicdiseasemanagement(e.g. diabeteswithcomplications). Outcome Measures: 1. Enhanced care of patients with chronic disease; 2. Enhanced patient accountability; 3. Lessened demands upon Emergency Departments and hospitals. Patient Safety and Clinical Quality Summary of Findings: ThereisnoPatientSafetyandClinicalQuality FrameworkforemergencyservicesthroughouttheNorthWestLHIN. TherearefewsharedMedicalDirectivesorotherexamplesof standardizedpatientcareinemergencydepartmentsthroughoutthe NorthWestLHIN. Recommendation#22(HighPriority):TheNorthWestLHIN EmergencyServicesAdministrativeCommitteeandMedicalCouncil shouldworktogethertoconductanenvironmentalscanofcurrent NorthWestLHINRegionalEmergencyDepartmentStudy 42

patientsafetyandclinicalqualityinitiativesinthenorthwestlhin s EmergencyDepartmentsand,buildingonthis,developandimplement aplanforalhin-wideemergencyservicespatientsafetyandclinical QualityInitiative.Anincrementalcontinuousimprovementapproach shouldbetaken,buildingoncurrentstrengths. Acontinuousimprovementapproachshouldemployleadingpractice methodologiessuchasplan-do-study-actforincrementalchange.this includesdecidingwheretofocus,implementingthechange,studying theimpact,andmakingchangesasrequiredtofine-tuneperformance. Thisrequiresthemechanismstocollectdataandsupporting infrastructuretoactontheresultsofthedata. Outcome Measures: 1. Completion of a survey of current Patient Safety and Clinical Quality initiatives within the LHIN; 2. Development and implementation of an incremental Patient Safety and Clinical Quality Program, building on existing strengths. Recommendation#23(HighPriority):Asapriority,theEmergency ServicesAdministrativeCommitteeincoordinationwiththeEmergency ServiceMedicalCouncilshoulddevelopamenuofmedicaldirectivesin currentuseinthelhin semergencydepartmentsanddetermine whichofthesecanbestandardizedforusethroughoutthelhin. Medicaldirectivesinplaceinothersitesacrosstheprovincemayalso besuitableforadjustmentandimplementationinthelhin shospitals (e.g.trilliumhealthcentreisoneexample)theuseofmedical directivescanhelptostandardizecareacrossthelhin shospitalsto helpfacilitatethemovementofphysiciansandlocumsacrossthe hospitals.theuseofmedicaldirectivescanalsohelptoleveragethe useofnursesintheemergencydepartment,makingmoreeffective useofphysicianresources. Outcome Measures: 1. Increased use of medical directives in Emergency Departments; 2. Increased standardization of care, resulting in enhanced quality. Recommendation#24(HighPriority):OftheEmergencyDepartments inthelhin,onlytbrhscandkenorahavesecurityfordesignated Form1patients.TheNorthWestLHINEmergencyServices NorthWestLHINRegionalEmergencyDepartmentStudy 43

AdministrativeCommitteeshouldexplorestrategiestoaddresssafety issuesfordesignatedform1patients. Outcome Measures: 1. Increased patient and staff safety; 2. Reduced reliance for provision of security by OPP. Information Management Summary of Findings:Thereisnostandardizationofinformation technologysystemsordatadevelopmentandutilizationregarding emergencyservicesthroughoutthenorthwestlhin. Recommendation#25(MediumPriority):Coordinatedmanagementof emergencyservicesthroughoutthenorthwestlhinrequires consistentdata.thenorthwestlhinemergencyservices AdministrativeCommittee,workingwiththeMedicalCouncil,should determinetheinitialdata/informationneedsofan EmergencySystem inthenorthwestlhin.thiscommitteeshouldexploreadditional informationneedsandensuresystemsareinplacetocollectand collateinformationefficientlyfortheongoingadministrationofan EmergencyDepartmentsystemintheLHIN. Thedatacollectionandinformationtechnologysupportrequiredshould alsobedetermined.basedupontheaboveinformation,the AdministrativeCommitteeshoulddevelopanInformationManagement Plan,includingrequiredresources,forpresentationtotheEmergency servicesgovernancecommittee. Informationrequirementswillincludethefollowing: Patientvolumes,acuityanddemographiccharacteristics; Diagnosesandreasonsforsystemuse; Flowthroughthesystem; o o o o o Waittimesforentry; Waittimesfortransfer; Waittimesonairporttarmac; Waittimesforspecialistconsult; Otherwaittimesandperformancedata; Acceptanceratesbyspecialists; NorthWestLHINRegionalEmergencyDepartmentStudy 44

Outcomes; PatientExperience. Outcome Measures: 1. Data/information needs in emergency services determined; 2. IT and human resource needs documented; 3. Emergency Services Information Management Plan developed and submitted to Governance Committee for consideration and action. In Summary TheRecommendations,ifacceptedandimplemented,willresultina trueemergencyservicessysteminnorthwesternontario.theywill alsocreatetheorganizationalstructuretogovernandleadsystem changeandtoensureaccountabilityfortheongoingimprovementand sustainabilityofthesystem. NorthWestLHINRegionalEmergencyDepartmentStudy 45

Implementation EnsuringsustainabilityoftheEmergencyDepartmentsysteminthe NorthWestLHINwillrequireanewapproachtoregionalcare,one characterizedbythepresenceofavision,bygovernanceand managementstructures,bymeasurementandbyaccountability. Tobegintheprocessofsystemchange,theLHINshouldfacilitatea discussionamongstsystemshareholdersoftherecommendationsin thisreportandbegintheworkofdevelopingasharedvisionofatrue emergencynetwork innorthwesternontario.thelhinwillbe requiredtoprovideinitialleadershipuntilthesharedstructuresarein placeasshownintheganttchartbelow. InadditiontoasharedVisionofcoordinatedemergencyservices deliveryfornorthwesternontario,thereisaneedforstructuresto supporttheimplementationofthisvision.thesestructuresinclude regionalgovernanceandadministrativeconstructstosupportthe governancemodel.tocreateasystemthatisaccountablefor emergencypatientcareacrosstheregion,anappropriateaccountability frameworkmustbedeveloped. AsidentifiedintheRecommendationssectionsomeofthe recommendationsareconsideredhighprioritybecauseoftheirabilityto impactthesustainabilityofemergencycareinthelhin,ortheir necessitytoprovidestructuretosupportfurtherrecommendationsfor ongoingsystemchange.thefollowingdiagramhighlightsthe recommendationsbypriorityincolourwithhighpriorityingreenand mediumpriorityinyellow.theyhavealsobeenanalysedinamatrix againsttheireaseofimplementationcomparedwiththeirimpacton improvingthesustainabilityofthesystem.thismatrixwillhelp decision-makersdecideonthecourseofactionforprioritizingthe implementationofrecommendations.thoseinitiativesthatareeasyto implementwithhighimpactshouldbeconsideredfirst,followingwith thosethatarehighimpactanddifficulttoimplement. NorthWestLHINRegionalEmergencyDepartmentStudy 46

High Impact on Sustainability 17 1 2 3 4 13 15 11 5/6 16 14 18 22 23 19 26 10 21 12 20 8 9 7 25 24 Low Priority: Difficult Ease of Implementation Easy # High # Medium # Low Recommendationsforreference: 1. DevelopVisionregardingthemannerinwhichtheLHIN semergency Departmentsandhospitalsshouldworkasanetwork; 2. CreatetheNorthWestLHINEmergencyServiceGovernance Committee; 3. CreatetheNorthWestLHINEmergencyServiceAdministrative Committee; 4. CreatetheNorthWestLHINEmergencyServiceMedicalCouncil; 5. DefinespecificrolesforhealthcarefacilitiesintheLHIN; 6. ClarifytheroleofTBRHSCastheregionalhospitalintheLHIN; 7. IdentifyopportunitiesforexpansionofTelemedicine; 8. Developtransferprotocols; 9. Developanescalationpolicy; 10. Developarepatriationpolicy; 11. Createaninter-jurisdictionaltaskforceontransportation; 12. Exploreoptionstoaddressnurseescortchallenges; 13. Developa10-yearnon-physicianhealthhumanresourceplan; NorthWestLHINRegionalEmergencyDepartmentStudy 47

14. Developa10-yearregionalintegratedphysicianhumanresource needsassessment; 15. Developastrategicplanforphysicianrecruitment; 16. Assessthespecialistrecruitmentprocess; 17. Enhancerecruitmentandimprovelocumdeployment; 18. Assessruralphysiciancommitments; 19. WorkwiththeCCACtodevelopcommunityclinics; 20. Conductaneedsassessmentforsupportivehousingfacilities; 21. Expandintegratedchronicdiseasemanagementprograms; 22. Exploreregionalpatientsafetyandclinicalqualityinitiatives; 23. Developstandardizedmedicaldirectives; 24. ExplorestrategiestoimprovesafetyofdesignatedForm1patients; 25. Determinethedata/informationneedsoftheEmergencySystemin thelhinanddevelopaninformationmanagementplan. Thediagrambelowhasbeendevelopedasapotentialstagingplanto demonstratewhatimplementationcouldlooklike.ittakesthe informationprovidedintheprioritizationmatrixandappliestheroles andresponsibilitiesofeachorganizationorinstitutionintheapplication ofsolutionstoimprovethesustainabilityoftheemergencydepartment SystemintheLHIN. Asshownacrossthecolourphasinginthediagrambelow, responsibilityfortheimplementationofsystemchangeisspreadout amongallprovidersandadministratorsinthesystem.thissystem changewillrequireacommitmentbyallpartiestomakethisareality. Itwillbeimportantinthebeginningstagestobuildtheinfrastructure thatcanhelptosupporttheimplementationoftherecommendations toimprovethesustainabilityofthesystem. Thetimingofthetasksasdescribedinthegraphicbelow,aremeantto describeprimarilytheorderinwhichtherecommendationsshouldbe initiated.thedurationofthetasksmayextendbeyondthetimelines setoutabove,howeverthestartingpointsshouldbeapproximatelyas noted.tasksthattakeprecedenceshouldhaveprogressedenoughto provideastartingpointforthetasksthatfollow.itwillbeimportantto keepmomentummovinginthetimeline.extendingthetimelinemore than3-5yearsrisksalossofmomentum.. NorthWestLHINRegionalEmergencyDepartmentStudy 48

Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 5 Qtr 6 Qtr 7 Qtr 8 Year 3 Year 4 Year 5 Leaddevelopment ofsharedvision CreateGovernance Body CreateRegional HRCommittee MOHLTC Hospitals LHIN DevelopEmergency ServicesAdminCmte DevelopEmergency ServicesMedicalCouncil Develop10-yearNon-Physicians HealthHumanResourcePlan Implementation Timeline DefineRoleforSpecificHealthcare Facilities&ClarifyRegionalRoleforTBRHSC DevelopTransferProtocols DevelopEscalationPolicy DevelopRepatriation Protocol CreateInter-jurisdictionalTaskForceon Transportation DevelopInformationManagementPlan ExploreEmergencyServicePatient Safety&ClinicalQualityProgram/Initiatives SupportexpandedIntegratedChronic DiseaseMgmtPrograms ConductaNeedsAssessment OfSupportiveHousing AssessSpecialist RecruitmentProcess Develop10-YearIntegrated RegionalPhysicianHRPlan DevelopStrategic RecruitmentPlan ImproveDeployment oflocums Emergency Service Governance Committee Emergency Service Administrative Committee WorkwithMOHLTCtoassess RuralPhysicianCommitments ExpandTelemedicine Exploresafetyinitiative ForForm1patients Exploreoptionstoresolve NurseEscortissues DevelopMedical Directives ExpandCCACservices inthecommunity TBRHSC Emergency Service Medical Council Thefollowingtablelaysouttheresponsibilitiesofeachpartyincarrying outtherecommendations.thistablehelpstoprovideaquick referenceguide: AccountableBody LHIN Recommendation/Task Leaddevelopmentofsharedvision Helpcreategovernancebody Participateininter-jurisdictionaltaskforceon transportation Conductsupportivehousingneedsassessment SupportexpansionofChronicDiseaseManagement programs Supportemergencyservicesadministrativecommitteein theresolutionofnurseescortissues RedefinetheroleforTBRHSCasaregionalcentreand makeexplicitinnexthsaa NorthWestLHINRegionalEmergencyDepartmentStudy 49

NorthWestLHINRegionalEmergencyDepartmentStudy 50 AccountableBody Recommendation/Task WorkwithCCACtoexpandserviceinthecommunity Leaddevelopmentofsharedvision HelpcreategovernanceCommittee AllHospitals Participateininter-jurisdictionaltaskforceon transportation Assessspecialistrecruitmentprocess TBRHSC Redefine/ClarifyregionalroleforTBRHSC Developemergencyservicesadministrativecommittee Supportregionalnon-physicianhumanresource coordination Developemergencyservicesmedicalcouncil Helpdefineroleforspecifichealthcarefacilities HelpclarifyregionalroleforTBRHSC Createinter-jurisdictionaltaskforceontransportation WorkwithMOHLTCtoassessruralphysician commitments EmergencyServices GovernanceBody HelptoexpandCCACservicesinthecommunity Developtransferprotocols DevelopEscalationpolicy Developrepatriationprotocols CreatesafetyinitiativefordesignatedForm1patients ExpandTelemedicine Helpconductaneedsassessmentofsupportivehousing Expandintegratedchronicdiseasemanagementprograms Develop10-yearnon-physicianhealthhumanresource plan Createemergencyservicespatientsafetyandclinical qualityprogram ExploreoptionstoresolveNurseEscortissues EmergencyServices AdministrativeCommittee DevelopMedicalDirectives Createemergencyservicespatientsafetyandclinical qualityprogram Develop10-yearintegratedregionalphysicianHRplan Developstrategicrecruitmentplan Improveregionaldeploymentoflocums EmergencyServices MedicalCouncil Developmedicaldirectives Itisimportanttoconsidertheneedforcontinuousqualityimprovement andevaluation.thisresponsibilityshouldfallonboththelhinandthe proposedemergencyserviceadministrativeandmedicalcommittees withoversightforthisfunctionfallingontheemergencyservice GovernanceCommittee.

AppendixA InterimReport NorthWestLHINRegionalEmergencyDepartmentStudy 51

AppendixB Bibliography Alberti,G.,(2004)Transforming Emergency Care in England,October2004. Alberti,K.(2003),Skill mix: an advance or an excuse?, EmergencyMedicine Journal,20. Alonzo,A.andSimon,A,(2008) Have stethoscope, will travel: contingent employment among physician health care providers in the United States,Work, EmploymentandSociety,22(4). Ashton,C.,AAikenandDDuffie(2007)Physician Assistants A solution to wait times in Canada? HealthcareManagementForum,Summer2007: http://www.caopa.net/hfhg-publication-pas- CCHSE%20Forum%20Summer%202007.pdf Chiarella,M.,(2008)AustralianGovernmentNationalHealthandHospitals ReformCommission:DiscussionPaperNewandEmergingnurse-ledmodelsof primaryhealthcare. CanadianInstituteforHealthInformation(2005)Understanding Emergency Department Wait Times: Who is Using Emergency Departments and How Long Are They Waiting? CanadianInstituteforHealthInformation(2007)Understanding Emergency Department Wait Times: Access to Beds and Patient Flow? Closson,T.,(2005), Integrated Service Plan for Northwestern Ontario,Report forthespecialadvisor,june2005. Doty,B.,MAndres,RZuckermanandDBorgstrom(2009) UseofLocum TenensSurgeonstoProvideSurgicalCareinSmallRuralHospitals.World JournalofSurgery,33(2). Elliot,P.(2005)EngagingAboriginalPeopleandTorresStraitIslanderstoCreate SaferCommunities. EMSChiefsofCanada,(2006)The Future of EMS in Canada: Defining the New Road Ahead May2006. Freeman,V.,RSlifkin,DPatterson(2008)Rural-Urban Differences in Characteristics of Local EMS Agencies,RuralHealthResearchandPolicy AnalysisCentre,May2008 GeneralPracticeVictoria,(2008)Sustaining rural emergency services Proposal for nurses to supply medicines,dvsdiscussionpaper,april2008: http://www.gpv.org.au/files/downloadable_files/policy/submissions/sustainingr uralemergencyservice.pdf Goodyear-Smith.FandR.Janes, New Zealand rural primary health care workforce in 2005: More than just a doctor shortage,theaustralianjournalof RuralHealth,16(1),pp40-46:http://www3.interscience.wiley.com/cgibin/fulltext/119412685/HTMLSTART. NorthWestLHINRegionalEmergencyDepartmentStudy 52

GovernmentofAustralia.(2009).A Healthier Future for All Australians: Final Report of the National Health and Hospitals Reform Commission. HealthForceOntario,(2008),PhysicianAssistants Frequentlyaskedquestions: (http://www.healthforceontario.ca/whatishfo/faqs/physicianassistants.aspx Howard,M.,JGoertzen,JKaczorowski,BHutchison,KMorris,LThabane,M LevineandAPapaioannou,(2008)Emergency Department and Walk-in Clinic Use in Models of Primary Care Practice with Different After-Hours Accessibility, HealthcarePolicy,4(1):73-88. HospitalEmergencyDepartmentandAmbulanceEffectivenessWorkingGroup (2005)Improving Access to Emergency Services: A SystemCommitment, Summer2005. InstituteforClinicalEvaluativeStudies(2001)Emergency Department Services in Ontario,ResearchAtlas. Kelly,M.L.,KBrownlee,KKuluski,SSnow(2005),PhysicianSatisfactionand FuturePracticeIntentionsinNorthwesternOntario,LakeheadUniversity. Kelley,M.L,B.Parke,N.Jokinen,andR.Wilford,(2008). Thunder Bay Regional Health Science Centre, Senior Friendly Acute Care Strategy (S-FACS), Emergency Department Environmental Scan.CentreforEducationand ResearchonAgingandHealth,LakeheadUniversity,ThunderBay,ON. KriegsmanWE,MaceS(1998)The Impact of Paramedics on Out-of-Hospital Cardiac Arrests in a Rural Community,October1998 Lowes,R.,(2007)Locumtenens:whenyouneedone,howtogetone,Medical Economics,May2007. MacLeod,H.,B.Bell,K.DeaneandC.Baker,(2008)Creating sustained improvements in patient access and flow: Experiences from Three Ontario Healthcare Institutions,HealthcareQuarterlyVol.11No.3. Meleskie,J.,andDEby(2009)AdaptationandImplementationofStandardized OrderSetsinaNetworkofMulti-hospitalCorporationsinRuralOntario, HealthcareQuarterly,12(1):78-83. Mason,S.,JWardrope,andJPerrin(2009)Developing a community paramedic practitioner intermediate care support scheme for older people with minor conditions,emergencymedicinejournal,20(2). MinistryofHealthandLong-termCare(2008),LHIN Patient Flow Report, HealthSystemIntelligenceProject. MinistryofHealthandLong-termCare(2006) Population Health Profile: North West LHIN,HealthSystemIntelligenceProject. Moore,L.,ADeehan,PSeed,RJones(2009),Characteristics of frequent attenders in an emergency department: analysis of 1-year attendance data, EmergencyMedicineJournal,26. NorthWestLHINRegionalEmergencyDepartmentStudy 53

Mutrie,D.,KSBailey,SMalik,(2009) Individualemergencyphysicianadmission rates:predictablyunpredictable,canadianjournalofemergencymedicine, March01. NorthWestLHIN(2006)IntegratedHealthServicePlan. NSWRuralCriticalCareCommittee,(2004).Triage in NSW rural and remote Emergency Departments with no on-site doctors.nswdepartmentofhealth O Meara,P.(2003)Would a prehospital practitioner model improve patient care in rural Australia,EmergencyMedicineJournal,20. O Meara,P.,(2005)Expanded-Scope Paramedic (ESP) role for rural ambulance services,charlessturtuniversity. O'MearaPF,KendallD,KendallL(2004)Working together for a sustainable urgent care system: a case study from south eastern Australia,Ruraland RemoteHealth4(online),2004:312June2004 OntarioHospitalAssociation(2004)Non-Emergency Ambulance Transfer Issues for Ontario s HospitalsSeptember. Page,D.(2003),Mississippi aims to bring emergency care to underserved rural areas with telemedicine,dial-upcareapril2003. PhysicianHospitalCareCommittee(2006), Improving access to emergency care: addressing system issues,reportofthephysicianhospitalcare Committee,aTripartiteCommitteeoftheOntarioHospitalAssociation,Ontario MedicalAssociation,andtheOntarioMinistryofHealthandLongTermCare, August. Robinson,V.,VGoel,RDMacDonaldandDManuel(2009),Inter-Facility Patient Transfers in Ontario: Do you know what your local ambulance is used for?, HealthcarePolicy,4(3):53-66. Sakr,M.,RKendall,JAngus,ASaunders,JNicholl,JWardrope(2003) Emergency nurse practitioners: a three part study in clinical and cost effectiveness,emergencymedicinejournal20. Sherer,J.(1994).Bringing providers to the people. Hospitals and Health Networks,68(3). Stiell,I.,LNesbitt,WPickett,DMunkley,DSpaite,JBanek,BField,L Luinstra-Toohey,JMaloney,JDreyer,MLyver,TCampeau,GWells(2008) The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity,cmaj,178(9). Sullivan,E.,FKaren,DHegney(2007) Review of small rural health services in Victoria: how does the nursing medical division of labour affect access to emergency care? JournalofClinicalNursing,17(12). Sylvain,M.(2008).Maori MD Offers Advice to Canada on Native Health Issues, TheMedicalPost,August. NorthWestLHINRegionalEmergencyDepartmentStudy 54

VictoriaHealthcareAssociation,(2007)Rural Emergency Services Funding in Victoria: http://www.vha.org.au/uploads/rural%20emergency%20services%20position %20Statement%20Summary.pdf West,G.,(2007),Urgent Care without the wait: emergency room alternatives arrived in Alaska in the 1980s and continue strong,alaskabusinessmonthly, December2007: http://www.entrepreneur.com/tradejournals/article/172437203.html Wilhelmsson,S.,Foldevi,M.(2003) Exploring views on Swedish district nurses' prescribing - a focus group study in primary health care,journalofclinical Nursing12,643-650. Peterson,L.,MDodoo,KBennett,ABazemore,RPhillips(2008).Nonemergency Medicine-Trained Physician Coverage in Rural Emergency Departments,JournalofRuralHealth,24(2). Henry,L.,RHooker,(2007),RetentionofPhysicianAssistantsinRuralHealth Clinics,JournalofRuralHealth,23(3). Galli,R.,JKeith,KMcKenzie,GHall,KHenderson,(2008),TelEmergency:A NovelSystemforDeliveringEmergencyCaretoRuralHospitals,Annalsof EmergencyMedicine,51(3). NorthWestLHINRegionalEmergencyDepartmentStudy 55

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