Portrait of rural emergency departments
in Quebec and utilisation of the Quebec
Emergency Department Management
Guide: a study protocol
To cite: Fleet R,
Archambault P, Légaré F,
et al. Portrait of rural
emergency departments in
Quebec and utilisation of the
Guide: a study protocol. BMJ
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Received 27 March 2013
Accepted 3 April 2013
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Professor Richard Fleet;
Introduction: Emergency departments are important
safety nets for people who live in rural areas.
Moreover, a serious problem in access to healthcare
services has emerged in these regions. The challenges
of providing access to quality rural emergency care
include recruitment and retention issues, lack of
advanced imagery technology, lack of specialist
support and the heavy reliance on ambulance transport
over great distances. The Quebec Ministry of Health
and Social Services published a new version of the
Emergency Department Management Guide,a
document designed to improve the emergency
department management and to humanise emergency
department care and services. In particular, the Guide
recommends solutions to problems that plague rural
emergency departments. Unfortunately, no studies
have evaluated the implementation of the proposed
Methods and analysis: To develop a comprehensive
portrait of all rural emergency departments in Quebec,
data will be gathered from databases at the Quebec
Ministry of Health and Social Services, the Quebec
Trauma Registry and from emergency departments and
ambulance services managers. Statistics Canada data
will be used to describe populations and rural regions.
To evaluate the use of the 2006 Emergency
Department Management Guide and the
implementation of its various recommendations, an
online survey and a phone interview will be
administered to emergency department managers. Two
online surveys will evaluate quality of work life among
physicians and nurses working at rural emergency
departments. Quality-of-care indicators will be collected
from databases and patient medical files. Data will be
analysed using statistical (descriptive and inferential)
Ethics and dissemination: This protocol has been
approved by the CSSS Alphonse–Desjardins research
ethics committee (Project MP-HDL-1213-011). The
results will be published in peer-reviewed scientific
journals and presented at one or more scientific
The practice of emergency medicine in rural
areas in Canada represents a signiﬁcant chal-
lenge, and there is a lack of knowledge to
properly understand this issue.
of research on emergency medicine is con-
ducted in tertiary academic centres with
patients from urban areas. It is important to
study the particular difﬁculties encountered by
rural emergency departments (ED), as these
EDs constitute a safety net of sorts for the 20%
of Canadians who live in rural areas.
▪This research protocol aims to develop a com-
prehensive portrait of all rural emergency depart-
ments in the province of Québec, Canada.
▪It will also allow the policy-makers to evaluate
the utilisation and usefulness of the Emergency
Department Management Guide, a unique tool to
help standardise emergency care.
▪As the first study of its kind in Canada, our
results will undoubtedly be useful to policy-
makers and can be used to guide the attribution
of resources as well as distribution of healthcare
services in rural areas.
▪The results will provide policy-makers with a greater
understanding and appreciation of the unique chal-
lenges faced by rural emergency departments.
▪This project will likely contribute to improved
health in rural Quebec.
Strengths and limitations of this study
▪This is the first study examining access to emer-
gency services in rural Canada, in particular the
province of Quebec.
▪Methodological limitation: we expect that current
clinical databases may not capture all
Fleet R, Archambault P, Légaré F, et al.BMJ Open 2013;3:e002961. doi:10.1136/bmjopen-2013-002961 1
Open Access Protocol
Healthcare professionals and patients in rural areas in
Canada face numerous problems—reduced access to
medical imaging (tomodensitometry
(TDM), ultrasound, MRI)
and intensive care units;
geographical distance from specialised centres and deﬁ-
cient means of transportation.
Further challenges for
rural emergency care include problems with personnel
recruitment, level of training in emergency medicine
and infrequent experiences with complex cases.
Further, several provinces have centralised their medical
care to reduce costs,
resulting in limited access to
local services and specialised care, and increased pres-
sure on prehospital emergency care (PEC).
13 14 16
Limited access in rural regions to primary care,
mental healthcare and to long-term care and services
centres (LTC) may increase the number of visits to
Finally, risk of death subsequent to major trauma
is considerably higher in rural regions and a correlation
between geographical isolation and mortality
has been observed. These problems impact a signiﬁcant
proportion of Canada’s population. Given that the geo-
graphic factor is not changeable, it is imperative to iden-
tify factors that could potentially be modiﬁed to help
resolve these problems.
EMERGENCY DEPARTMENT MANAGEMENT GUIDE
In 1997, the Canadian Association of Emergency
Physicians (CAEP) presented its position on rural emer-
gency medicine in Canada.
Owing to the lack of
research data on the issue at the time, the document
was based on expert consensus. The position paper was
created to inform the development of a framework to
evaluate medical practices in rural EDs. The CAEP docu-
ment did not, however, include speciﬁc recommenda-
tions about appropriate patient transportation times or
access to TDM or other specialised services.
However, the publication of the Emergency Department
in 2006 by the Quebec Ministry of
Health and Social Services (MSSS) raised a number of
critical issues related to rural EDs. Developed by a multi-
disciplinary group of key policy-makers, the Management
is, to our knowledge, the most recent and
concise available document. It speciﬁes the services that
should be accessible in the province’s EDs based on the
number of annual visits to the department and other
variables. The guide
also includes several recommen-
dations for solving the problems faced by rural EDs. In
brief, this forward-thinking guide
could provide a start-
ing point for the development of management standards
in Canadian rural EDs. To date, no studies evaluating its
implementation in rural areas have been conducted.
Shortage of healthcare professionals in rural areas
The challenges related to rural emergency medicine are
multiple and signiﬁcant. In particular, problems related
to the vulnerability of recruitment and retention of
healthcare professionals must be addressed. Despite the
critical nature of the problem, there is a signiﬁcant lack
of data about this sector and about healthcare services
for the rural Canadian population.
A systematic search
of Cochrane Reviews yields a complete absence of rigor-
ous studies that adequately evaluate efforts to recruit
and retain healthcare professionals in rural areas. This
problem is not on the verge of resolution; according to
the National Physician Survey,
only 1% of family medi-
cine residents plan to eventually practice in rural
regions, and rural family doctors tend to leave emer-
gency medicine after only a few years. Anecdotal evi-
dence suggests that such departures are prompted by
high stress, difﬁcult schedules and poor quality of life.
Combined, these factors make training and recruiting
emergency physicians in rural areas a considerable
describe several factors
that could improve retention of healthcare professionals
in rural areas. Promising strategies include selection of
rural students for professional training programmes,
establishment of university departments and training
units in rural regions, provision of grants for students
who commit to working in rural areas and development
of personal and professional support programmes for
professionals working in rural zones.
The Management Guide
also proposes interventions to
increase recruitment and retention of healthcare profes-
sionals in rural areas—encouraging multidisciplinary
training for healthcare professionals; ensuring access to
necessary and appropriate material and technical
resources and help from colleagues, specialists and sur-
geons when necessary; increased access to specialised
treatment centres and access to continuing education.
also suggests reasonable work and on-call
schedules, attractive salaries and adequate beneﬁts.
Finally, it proposes the following suggestions for recruit-
ing and retaining healthcare professionals in rural areas:
an environment conducive to raising and educating a
family; a stimulating social and cultural environment
and employment opportunities for the healthcare pro-
fessional’s partner and ﬁnally, the prospect of an overall
high standard of living and excellent quality of life. The
implementation of these recommendations in Quebec
needs to be explored.
Trauma, prehospital emergency care and
Trauma is one of the most common reasons for a con-
sultation in the ED; correspondingly, it is the most fre-
quently studied subject in research on rural medicine.
Trauma is also the leading cause of mortality in indivi-
duals under 40 and the fourth most common cause of
mortality for people of all ages.
For over 30 years,
major investments have been made in developing trau-
These networks have beneﬁtted
urban patients, but the results are less robust for rural
patients who are often geographically isolated from
designated trauma centres, necessitating complicated
2Fleet R, Archambault P, Légaré F, et al.BMJ Open 2013;3:e002961. doi:10.1136/bmjopen-2013-002961
Portrait of rural emergency departments in Quebec
23 34 35
In fact, in some pro-
vinces, up to 80% of patients in rural regions are over
an hour away from tertiary trauma centres.
The distances between rural EDs and tertiary care or
referral centres, and the elevated risk of medical trauma
in rural areas are such that PEC is essential for rural resi-
dents. A recent American meta-analysis indicated that
PEC response times are signiﬁcantly longer in rural
This result can be attributed to greater travel dis-
tances, hazardous road conditions and to the challenge
of locating and retrieving victims in rural areas. Another
study demonstrated that the elevated rate of mortality
subsequent to trauma in rural areas is partially attribut-
able to lengthy transportation time in ambulances.
One critical component of rural emergency medicine is
the transfer of more complex cases to a referral centre.
Each transfer indicates the failure of the local centre to
meet the patient’s critical needs. Every transfer involves
considerable time and personnel, and exposes the patient
to the risk of complications inherent to transportation by
emergency vehicle. One Canadian study reported that
almost 2% of all rural ED patients in Ontario had to be
transferred to another establishment to receive more
advanced emergency care.
For a medium-sized rural ED
in Quebec (20 000 annual visits), this can mean over 400
transfers per year. The rate of interestablishment transfers
in Quebec rural EDs is a key variable to measure; an ele-
vated transfer rate could indicate a local shortage or a
problem in access to basic services.
Quality-of-care indicators in the emergency department
Research evidence suggests that evaluation of quality
indicators and the publication of data about quality indi-
cators improve quality of care.
The recent publica-
tion of the Consensus on Evidence-Based Quality of Care
Indicators for Canadian Emergency Departments
objective measurement of EDs’performances, allowing
objective comparison among departments. Published in
March 2010, this consensus was created by a panel of 24
Canadian experts including managers, clinicians, emer-
gency medicine researchers, health information specia-
lists and government representatives. Of 48 indicators
selected, consensus was reached on eight groups of indi-
cators determined to have the highest levels of priority
and validity. The selected indicators are related to inter-
ventions for eight pathologies often treated in EDs,
including myocardial infarction, stroke, sepsis, asthma
and several paediatric problems related to infection.
The Management Guide
was published after the con-
sensus document and is therefore not mentioned in this
important publication. However, quality of care is one of
the central principles of the Management Guide.
Although the eight established quality indicators are
keys for future studies comparing performance between
EDs, methodological limitations must be acknowledged.
First, data on all of the indicators are not included in
current clinical databases. Second, the scientiﬁc consen-
sus committee did not include representatives from
rural EDs, and certain quality indicators relevant to rural
EDs may not be included (eg, trauma care in rural areas
with limited access to traumatology centres and investiga-
tive technology, interestablishment transfer needs and
the impact of these issues on quality of care).
This project is designed to
1. Develop a comprehensive portrait of all rural EDs in
2. Evaluate the use of the 2006 Emergency Department
A. Perceived usefulness and implementation of its
B. Factors that promote or impede the implemen-
tation in rural areas;
C. Relations between the implementation and per-
D. Relations between the implementation and
healthcare professionals’work-related quality
METHODS AND ANALYSIS
This project is a descriptive and evaluative study of rural
EDs in Quebec, which offer 24/7 medical coverage,
having hospitalisation beds and are located in a rural or
small town, according to the deﬁnition of Statistics
In a previously conducted pilot study, rural EDs were
identiﬁed using the Health Canada Establishment
and conﬁrmed by the MSSS and the Direction
Nationale des Urgences. There are 26 rural EDs in Quebec.
Phase 1: portrait of all rural emergency departments
To develop a comprehensive portrait of all rural EDs in
Quebec, a questionnaire will be sent by email to the
chief nurse to collect data on (1) hospital centre charac-
teristics (eg, referral centres, availability of local intensive
care unit beds, number of acute and long-term beds);
(2) availability of health information technology (eg,
internet and Wiﬁaccess); (3) knowledge transfer activ-
ities (eg, quality assurance, book club); (4) ED variables
(eg, triage level, wait time, average hospital stay, number
of transfers between facilities); (5) available diagnostic
services 24/7 (eg, lab, basic radiography, TDM, MRI,
ultrasound, portable ultrasound); (6) medical and para-
medical staff (eg, number of emergency doctors, years
of experience and level of training, percentage of locum
doctors per period, availability of specialists, number
and level of training of nurses, presence of other health
professionals); (7) pre-emergency and post-emergency
care resources in the region (eg, number of family
doctors, availability of convalescence beds); (8) long-
term housing and care centres and mental health facil-
ities (eg, number of beds, waiting list). Some data will
also be gathered from databases at the MSSS (eg,
number of annual visits), the Quebec Trauma Registry
Fleet R, Archambault P, Légaré F, et al.BMJ Open 2013;3:e002961. doi:10.1136/bmjopen-2013-002961 3
Portrait of rural emergency departments in Quebec
(information on traumatic event, healthcare institution
implied, emergency department, hospitalisation, patient
acuity (triage level), etc), PEC centres (eg, number of
ambulances deserving each rural hospital) and Statistics
Canada (eg, data on population and rural regions).
For the ﬁrst phase of the study, the project needs no
further ethical evaluation since all of the data required
Phase 2: Emergency Department Management Guide
First, an online survey about use of the Emergency
Department Management Guide
will be developed and
administered electronically to the management person-
nel of the EDs included in the study (chiefs of staff, head
nurse). Research staff will contact managers to introduce
the project and to explain the online questionnaire.
Regular follow-ups will be conducted to obtain the most
complete responses possible. The survey will be devel-
oped using all the Management Guide
(n=69) pertaining to rural hospitals. Respondents will
respond on a seven-point Likert-type scale to two ques-
tions: (1) To what extent is the recommendation useful in my
hospital?; (2) To what extent is the recommendation used in my
hospital? Further, a telephonic interview will be con-
ducted with the respondents to evaluate factors that
promote or impede implementation of the recommenda-
tions perceived equally useful and not used.
Second, the following indicators will be used to explore
the association between use of the Management Guide
and performance and quality of care: (1) the perform-
ance indicators assessed in the ﬁrst phase (eg, average
ED stay) and (2) the following eight high-priority quality
of care indicators established by Canadian consensus
the following categories: ED operations (eg, length of
stay), patient security (eg, unplanned/unexpected read-
missions), pain management (eg, delay in administration
of medication), cardiac and respiratory problems (eg,
treatment delay for thrombolysis, corticosteroid adminis-
tration percentage), stroke (eg, delay in administration of
plasminogenic tissue activator), and sepsis/infections
(eg, delay in administration of antibiotics). Information
missing from the databases will be obtained from patient
medical ﬁles. The number of ﬁle reviews necessary to
obtain the relevant information will vary by indicator.
To evaluate their quality of life, two online surveys will
be administered to all consenting nurses and doctors
working at rural EDs. The exact number of professionals
to complete the survey will vary between EDs, but the
expected response rate is 70%. In an effort to boost
response rate, we will telephone hospital spokespersons
(eg, head nurse) to establish contact and explain the
The ﬁrst survey refers to the quality-of-work life systemic
and will be available for completion
via http://qualitedevie.ca. The measure includes 34
themes divided into 8 subgroups: remuneration, profes-
sional development, work schedule, social environment/
relationships with colleagues, relationships with superiors,
physical environment, factors that inﬂuence employees’
perception and enjoyment of the task and employee
support. A supplementary module of six questions will be
designed to capture aspects speciﬁc to ED, which are not
covered by the existing 34 items. The QWLSI provides an
organisational diagnosis and permits comparison with
over 3000 workers who have already completed the
measure. The internal validity (Cronbach’sα) of the sub-
groups ranges from 0.60 to 0.82.
The overall internal val-
idity is 0.88 and the test–retest reliability is 0.85. The
English language and French-language versions are
equivalent (0.84). Lower scores (below the 25th percent-
ile) indicate greater psychological distress and professional
burnout. The second survey contains questions about
sociodemographic variables, and factors related to recruit-
ment and retention and will also be completed online.
The statistical analyses will be achieved in collaboration
with the biostatistics service from the Unité de recherche
en santé des populations du Centre hospitalier afﬁlié
universitaire de Québec. The data collected as part of
the phase 1 will be described as means, medians and
percentages, according to the variables distribution to
meet the objective 1. To meet the objective 2.1, the
mean of six-point Likert scores measuring the use and
usefulness of the guide
will be presented for each of
its recommendations. Likert scores will also be dichoto-
mised with the intention of showing the agreement or
disagreement between the utilisation and usefulness of
which will allow to calculate the mean
number of useful recommendations, the mean number
of applied recommendations and the proportion of ED
where at least 70% of recommendations are applied.
Answers to the questions concerning the perceived use-
fulness and utilisation will be compared to evaluate the
level of application of recommendations considered
useful. The participants’telephonic interview answers
(objective 2.2) will be qualitatively analysed to show the
obstacles and facilitators considered to be the most
important to the implementation of the guide.
the aim of meeting the objective 2.3, the relation
between the use of the Management Guide
performance and quality-of-care indicators will be mea-
sured with Spearman correlation. The utilisation of the
will be measured by the mean number of
applied recommendations in ED. Finally, regarding the
objective 2.4, the results of the two surveys will be pre-
sented with descriptive statistics in a ﬁrst phase. The
association between the QWLSI score and utilisation of
will be assessed with the aid of a generalised
estimation equations model to take into consideration
the correlation between the responders from a same
ED. The utilisation of the guide
will be measured by
the number of recommendations applied (objective 2.1
analyses) and processed as a continuous or dichotomous
variable. The data collected during phase 1 as well as
information on characteristics of responders collected
4Fleet R, Archambault P, Légaré F, et al.BMJ Open 2013;3:e002961. doi:10.1136/bmjopen-2013-002961
Portrait of rural emergency departments in Quebec
during the second survey of the objective 2.4 will serve
as adjustment variables in the model. However, if the
sample size does not allow such analyses in objective 2.4,
the association between the quality-of-life scores and util-
isation of the guide
will be measured with Spearman
correlation coefﬁcients. Furthermore, some correlational
analyses will allow to compare the quality-of-work life
scores and some retention and recruitment factors.
ETHICS AND DISSEMINATION
This rural project required ethics evaluation through a
complex multicenter study mechanism described below.
In the province of Québec, a study that is conducted in
several centres must conform to an established ethics
procedure according to the MSSS. Two preliminary steps
must be undertaken. First, the project must be peer
reviewed by a recognised expert committee (eg,
Scientiﬁc research committee). Second, a main research
centre ethics committee (main REC), which is normally
the REC that belongs to the research centre where the
project is initiated, must be determined. When these
two conditions are fulﬁlled, the principal investigator
sends the project to the main REC, to each local REC (if
applicable, otherwise no review occurs) and to every par-
ticipating study site. Once the local RECs have reviewed
the project, they send their comments to the main REC,
which takes into consideration their speciﬁc requests
and decides to approve/reject the project within 2 weeks
following the examination. When the expectations of
the main REC are satisﬁed, the preliminary decision is
sent to the principal investigator and to every participat-
ing study site. A feasibility study committee, which evalu-
ates the practicability of the project in each institution,
must submit its evaluation to the institutional director
(Hospital CEO or director) before the end of the
ethical procedure. Once the ethics and feasibility exami-
nations are completed, the decision is reviewed by each
local REC (or its designed authority if it does not have
its proper REC). Once the local REC (or its designed
authority) approves this decision, it sends it to the insti-
tution. Furthermore, the feasibility study committee for-
wards its decision to the general management of the
institution, which will relay its decision to the main REC.
Finally, the main REC sends its ﬁnal decision to the prin-
cipal research coordinator and to each institution and
REC implied in the project.
The phase 1 of this study was exempted from ethical
evaluation as no human subject was involved. The phase
2 of this study has been approved by the CSSS Alphonse–
Desjardins main REC (Project MP-HDL-1213-011).
Results from this study will be published in peer-reviewed
scientiﬁc journals and presented at one or more scientiﬁc
To our knowledge, this will be the ﬁrst study to evaluate
EDs in rural Quebec and Canada at such a broad scale. It
will provide a greater understanding of the factors that
promote and impede the implementation of the recom-
mendations in the Management Guide.
The results could
be used to develop one or several interventions designed
to increase implementation of the Management Guide
recommendations. The questionnaire could also be used
to investigate the implementation of the Management
in EDs outside Quebec and Canada by research-
ers wishing to test the implementation of a management
adapted to their own region and context.
Our use of performance indicators recently published
by Schull and colleagues
to measure the impact of a
knowledge transfer tool (a practical guide) on EDs per-
formance is a further innovation that could advance knowl-
edge transfer research. We plan to identify performance
indicators that are speciﬁc to rural EDs and were not
included in the list of indicators published by Schull and
Eventually, we wish to explore the impact of
the use of the Management Guide
on the quality of care
offered in Quebec relative to that offered in other
Canadian provinces. The proposed project would allow us
to establish an essential knowledge base that would serve
to plan a future comparison with EDs in other provinces.
The results of this study will also allow a greater under-
standing of the factors associated with work-related
quality of life in ED healthcare professionals, and those
relevant to recruitment and retention of ED personnel.
The research evidence generated by this study could
also be used to develop interventions that could, in turn,
be evaluated using the same questionnaires.
Finally, our results will undoubtedly be useful to policy-
makers and can be used to guide the distribution of health-
care services in rural areas. The results will provide policy-
makers with a greater understanding and appreciation of
The results will contribute to the bank of available research
data that can be used to develop policies about attribution
of resources in rural areas. Ultimately, this project will con-
tribute to improved health in rural Quebec.
Department of Family Medicine and Emergency Medicine, Université Laval,
Lévis, QC, Canada
Department of Family Medicine and Emergency Medicine, Knowledge Transfer
and Health Technology Assessment of the CHUQ Research Centre (CRCHUQ),
Unité de Recherche Évaluative, Université Laval, Quebec, QC, Canada
Département de médecine familiale et de médecine d’urgence, Centre de
recherche de l’Hôpital du Sacré-Cœur, Montreal, QC, Canada
Direction des systèmes de soins et services, Institut national de santé publique du
Québec, Montreal, QC, Canada
Département de science politique, Pavillon Charles-De Koninck, Quebec, QC,
Département de psychologie, Université du Québec à Montréal, Montreal, QC,
Department of Family Medicine, St. Mary’s Research Centre, McGill University,
Montreal, QC, Canada
Departement of Emergency Medicine, CSSS de La Matapédia, Québec, QC,
Direction de l’analyse et de l’évaluation des systèmes de soins et services, Institut
national de santé publique du Québec, Université du Québec à Rimouski,
Rimouski, Québec, Canada
Fleet R, Archambault P, Légaré F, et al.BMJ Open 2013;3:e002961. doi:10.1136/bmjopen-2013-002961 5
Portrait of rural emergency departments in Quebec
Acknowledgements We would like to thank Julie Villa and Sylvain Bussières
for their work in formatting the manuscript as well as editorial suggestions.
Contributors RF was responsible for the original idea, literature review and
study design. PA, FL, JMC, JFL, MO, GD, JH, JP, AT, GSR and JG have
contributed to various aspects of the study design with input relating to their
specific expertise in the field. All authors read and approved the final manuscript.
Funding This work was supported by the Fonds de recherche du
Québec—Santé (FRQS) 22481.
Competing interests None.
Ethics approval CSSS Alphonse–Desjardins research ethics committee
Provenance and peer review Not commissioned; internally peer reviewed.
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6Fleet R, Archambault P, Légaré F, et al.BMJ Open 2013;3:e002961. doi:10.1136/bmjopen-2013-002961
Portrait of rural emergency departments in Quebec