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One prominent rural ER physician in Ontario rejected the notion that his province's departments are inferior, saying the focus is more on sending the sickest patients to big trauma centres. Across the country, however, wide variations in emergencydepartment standards definitely do exit, said Alan Drummond, a spokesman for the Canadian Association of Emergency Physicians. "It's a crapshoot, when you go to any hospital in this country, in terms of what you're going to get in the type and quality of care," he said. "We have national variability and for 23 per cent of Canadians (who live outside cities), that's unacceptable." About 6 million Canadians live in rural areas, tend to be older on average, have greater health needs, and are more likely to suffer traumatic injury, partly due to the prominence of dangerous professions like farming and logging.

Fleet became interested in the relative quality of emergency service after cutbacks meant his former hospital in Nelson, B.C., could offer only "bare-bones services to a high-risk population." He lobbied for additional funding, but realized there were no published data comparing different Canadian emergency departments. In the most recent study, just published in the journal PlosOne, he and colleagues looked at rural departments with 24/7 service and an ability to admit patients to acute-care beds in their hospitals - 26 facilities in Quebec and 62 in Ontario. If anything, the Ontario ERs appeared more isolated on average, with a greater percentage of them being at least 300 kilometres from a trauma centre.

Yet 92 per cent of the Quebec emergency departments had a local intensive-care unit, compared to 31 per cent of the Ontario ones. Just over 80 per cent of the Quebec ERs had a general surgeon available on call, versus a third of the Ontario emergency departments. Fleet said he is not sure why Quebec's rural ERs are better equipped, given the provinces' spending on health care is similar per capita. It may relate to the fact its rural hospitals have fewer foreign-trained doctors, who may feel less empowered to demand better facilities. But Drummond said Ontario has a different protocol that ensures rural ER physicians are well-trained to provide basic emergency services - such as treating shock and blocked airways - and emphasizes funnelling critically ill patients to trauma centres in larger cities. The province's CritiCall system helps rural hospitals find facilities that can take their patients.

However, he agreed that having a CT scanner is now crucial to emergency departments anywhere making accurate diagnoses; the one his hospital in Perth, Ont., acquired five years ago "changed the way we practice." Just nine of 62 full-time rural Ontario departments had a CT scanner, according to the new study.

Under this program, paramedics will provide basic health-care services, within their scope of practice, in partnership with local health-care providers. The enhanced role is not intended to replace care provided by health professionals such as nurses, but rather to complement and support the work these important professionals do each day, delivered in non-urgent settings, in patients' homes or in the community. "As a former BC Ambulance paramedic, I understand the potential benefits of community paramedicine," said Jordan Sturdy, MLA for West Vancouver-Sea to Sky. "Expanding the role of paramedics to help care for the health and well-being of British Columbians just makes sense." Community paramedicine broadens the traditional focus of paramedics on pre-hospital emergency care to include disease prevention, health promotion and basic health-care services. This means a paramedic will visit rural patients in their home or community, perform assessments requested by the referring health care professional, and record their findings to be included in the patient's file. They will also be able to teach skills such as CPR at community clinics.

"Community paramedics will focus on helping people stay healthy and the specific primary care needs of the people in these communities," said Linda Lupini, executive vice president, BC Emergency Health Services. "This program also allows us to enhance our ability to respond to medical emergencies by offering permanent employment to paramedics in rural and remote areas of the province." "Community paramedicine brings improved patient care and more career opportunities to rural and remote areas," said Bronwyn Barter, president, Ambulance Paramedics of BC (CUPE 873). "Paramedics are well-suited to take on this important role in health-care provision." Community paramedicine was initially introduced in the province in 2015 in nine prototype communities. The initiative is now expanding provincewide, and will be in place in 31 communities in the Interior, 18 communities in northern B.C., 19 communities on Vancouver Island, and five communities in the Vancouver coastal area this year.

At least 80 new full-time equivalent positions will support the implementation of community paramedicine, as well as augment emergency response capabilities. Positions will be posted across the regional health authorities. The selection, orientation and placement process is expected to take about four months. Community paramedics are expected to be delivering community health services in northern B.C. this fall, in the Interior in early 2017, on Vancouver Island and the Vancouver coastal area in the spring of 2017. BC Emergency Health Services has been co-ordinating the implementation of community paramedicine in B.C. with the Ministry of Health, regional health authorities, the Ambulance Paramedics of BC (CUPE 873), the First Nations Health Authority and others. Copyright 2016 Williams Lake Tribune

Ruddiman, who was recruited to Oliver from South Africa 18 years ago, said the issue comes down to educating young doctors about rural areas while they are still in school, as well as marketing communities to get the right fit. When he was thinking of coming to B.C. in 1991, for instance, Ruddiman said he was warned not to go anywhere with a "prince, a fort, a port or a saint" in its name. "Your towns were generally considered more remote and isolated and less desirable to work in," he said.

Yet many health care specialists are keen to work in communities with a population of 7,000 or more, especially if they are close to a ski hill, he added. Others touted their small communities as being safe and friendly for young families. "Our rural communities have great attributes to offer. You should work with health authorities to spread the word," Ruddiman said. "Port McNeill should be fully stocked with health practitioners, and it's not." Lake acknowledged the problem is rife across B.C., even in mid-sized cities like his riding of Kamloops, which could use another 30 family doctors. He said the province is working on boosting medical residencies to keep B.C. graduates in the province or lure them back from overseas. ksinoski@vancouversun.com Twitter:@ksinoski

P.E.I

Saskatchewan

Now, it’s spreading to other provinces

For Nova Scotia, this began in 2009, when the government sent Dr. John Ross — its advisor on emergency care and a respected emergency room physician — to tour the province’s ERs. His 2010 plan, “Better Care Sooner” found only about 2% of patients going to rural ERs had real emergencies.

Cutting the night shifts in some hospitals, he said, would allow doctors to run more clinic hours.

If you lost the physician, you lost the coverage, so the emergency room just closed.

Now, Mr. Wilson said, patients can get appointments on 48 hours notice, when previously some had to wait five weeks to see a general practitioner.

at the CECs, a doctor, or group of doctors, still cover the busy 12 hours a day. At night, paramedics and nurses are able to treat many of the patients, and are able to quickly transport anyone critical to the nearest full-service ER.

“[If] it’s simply because of a doctor shortage, I really don’t think this is acceptable at all,” Dr. Affleck said. “You need to find the appropriate doctors to staff a true emergency department, if that is what the issue is.”

Mr. Wilson, though, said he is confident in the province-wide paramedic dispatch, which can quickly triage the call and determine whether a CEC or full ER is required.

Both developed and developing countries report geographically skewed distributions of health-care professionals, favouring urban and wealthy areas, despite the fact that people in rural communities experience more health related problems.

Eight collaborative emergency centres have opened in Nova Scotia since 2011.

In Nova Scotia, where we remain married to the old physician-centric delivery model, this has become an obstacle to change. It really should not be about warm bodies, it should be about health outcomes.

The flurry stems from a profile on the lack of assistance given a 70 year old injured man at the doorstep of the Montague hospital Good Friday because of administrative protocols.

Only 8.3 per cent of patients from cities were readmitted, compared to 9.5 of rural residents.

a shortage of home-care services like palliative care and physiotherapy outside major centres could be to blame

nearly one in 10 of those discharged from a hospital end up in an ER within a week.

Clayden said any delay in reinstating surgeries beyond the end of the year would jeopardize the facility's future. A local family physician who performed anesthesia when Clayden operated there said he would need to upgrade his training if his skills are allowed to lapse. He's not prepared to give up his thriving practice for a couple of months to do that. Paulette Goossen, an official with Southern Health, the area's regional health authority, said while the plan was to reopen the Altona OR this month, she couldn't guarantee that will happen. "We are actively recruiting nursing staff to support that service," she said.

Goossen challenged the surgeon's description of the OR as state-of-the-art, saying it is not brand-new, like other sites in the region. The hospital opened in 1994. Only about 150 surgeries a year were performed there, she said. "It is more difficult in rural Manitoba, certainly in smaller communities, to attract nursing staff," she said. Goossen dismissed the idea of hiring private nurses to fill in so surgeries could be performed, saying it would be cost-prohibitive. Such a move would also lead to problems with continuity of care, she added. "It's more difficult to just bring people in who don't know the facility."

Clayden said the Altona OR was already vastly underused. His weekly surgical trips accounted for most of the operations done there, although dental surgery was performed there occasionally. When Progressive Conservative MLA Cliff Graydon raised the matter in the legislature in May, Health Minister Sharon Blady assured him the situation would be rectified "by the fall or sooner."

On Tuesday, Blady said there were challenges in filling nursing vacancies in the community. "I know that they are working on it. I would like it to have been resolved long ago," she said. The province has found it challenging to maintain adequate staffing of doctors and nurses in many rural communities. Blady said one answer may be to build "rural health teams," rather than to focus on shortages of one type of professional or another.

"Maybe the model needs to change," she said. "Maybe we need to see what it is that needs to be done differently so there is a stronger ability to recruit and retain folks." larry.kusch@freepress.mb.ca

Doull said the project will begin rolling out in January, when certain staff members at the Miramichi Regional Hospital will start using the software developed for this initiative and working in collaboration with the scheduling team in Saint John. Ralph McBride, co-ordinator for CUPE Local 1252, said it's a shame the professionals who are currently scheduling staff at various sites across the province aren't able to keep those responsibilities. "We see this as taking away important jobs in rural New Brunswick and moving them to urban centres," he said. He said that based on what he's heard from the Horizon Health Network, between 17-20 health-care professionals working in Miramichi could be affected by this organizational decision.

"To lose 17-20 positions, to lose any positions out of the Miramichi, out of any rural setting and off to a place like Saint John, creates a hardship in that economy, in that area," he said. "I guess what the government failed to consider is that most of the people that are in these central scheduling systems are long-term employees. They've got stakes in their hometowns. That's where many have grown up. That's where they live. Some of them are 20-year employees, 25-year employees, 30-year employees. To ask somebody that's in their mid-50's to uproot and move is, I think, shameful and disrespectful."

Doull said that, to be clear, this decision to centralize staffing was made by the Horizon Health Network - not the Department of Health, as suggested by the union. "A couple of years ago we started on this in a preliminary way and it's now becoming operational for us," he said. Doull also denied that many positions will be in jeopardy.

"There are three staffing support clerks in Miramichi that are affected," he said, explaining that employees impacted by the move to centralized scheduling will have the option to move to Saint John and continue working there. "All employees who work in the staffing support clerk classification have the option to take a position in the staffing centre in Saint John. If they do not take the offered position, they may choose to 'bump' into another CUPE position, if they have the basic qualifications for the position and the person in that position has less seniority. Their right to 'bump' includes any position (as described) at any site in Horizon." McBride said he thinks the provincial government would have to be on board with a plan of this scope. "I believe the government is not wanting to be the forerunners of this so they're using the health authority to deliver a message," he said, explaining that there are already rumours more services - such as accounts payable - could be following suit in the months ahead. "Things don't happen in health care in New Brunswick without the Department of Health knowing. Somebody has to give the blessing on this."

The union representative said the changes will cause turmoil for work units across the province as, per the terms of the existing collective bargaining agreements, senior employees affected by the scheduling changes choose to bump junior colleagues out of other positions. "(The affected employees) will exercise their right to bump under the collective bargaining agreement. But somewhere down the line it's going to take away from the economy," he said.

McBride said that he hopes the new centralized scheduling program works effectively when employees begin using it in January, explaining that it was initially slated to kick off earlier. "There's going to be some stuff they'll have to work out," he said.

"This move was supposed to happen the first of November. But we got word (this week) that it had been delayed because there had been glitches in the system. It's like any software program, it's not been tested to its full extent. So there's going to be issues with it." It's too bad, he said, that the employees who were already working on scheduling staff at various sites across New Brunswick couldn't join the centralized scheduling team, yet remain at their initial site. "With today's technology, they should be able to do scheduling from any office, any facility in the province. They don't need to centralize them all into one location," he said.

Smaller hospitals, like Pembroke where five medical and two pediatric beds were cut recently, have been “harshly and disproportionately affected,” Hurley says.

The $7 million in funding for 56 hospitals amounts to $125,000 per hospital. That’s about 3 and a half one hundredth of one per cent increase in the overall (provincial) hospital spend.