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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 recommendations. 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) procedures. 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 conferences.
Portrait of rural emergency departments
in Quebec and utilisation of the Quebec
Emergency Department Management
Guide: a study protocol
Richard Fleet,
Patrick Archambault,
France Légaré,
Jean-Marc Chauny,
Jean-Frédéric Lévesque,
Mathieu Ouimet,
Gilles Dupuis,
Jeannie Haggerty,
Julien Poitras,
Alain Tanguay,
Geneviève Simard-Racine,
Josée Gauthier
To cite: Fleet R,
Archambault P, Légaré F,
et al. Portrait of rural
emergency departments in
Quebec and utilisation of the
Quebec Emergency
Department Management
Guide: a study protocol. BMJ
Open 2013;3:e002961.
Prepublication history for
this paper are available
online. To view these files
please visit the journal online
Received 27 March 2013
Accepted 3 April 2013
This final article is available
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the Creative Commons
Attribution Non-Commercial
2.0 Licence; see
For numbered affiliations see
end of article.
Correspondence to
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 AlphonseDesjardins 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 signicant chal-
lenge, and there is a lack of knowledge to
properly understand this issue.
The majority
of research on emergency medicine is con-
ducted in tertiary academic centres with
patients from urban areas. It is important to
study the particular difculties 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.
Article focus
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.
Key messages
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
quality-of-care indicators.
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 problemsreduced access to
specialised care,
medical imaging (tomodensitometry
(TDM), ultrasound, MRI)
and intensive care units;
geographical distance from specialised centres and de-
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 signicant
proportion of Canadas population. Given that the geo-
graphic factor is not changeable, it is imperative to iden-
tify factors that could potentially be modied to help
resolve these problems.
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 specic recommenda-
tions about appropriate patient transportation times or
access to TDM or other specialised services.
However, the publication of the Emergency Department
Management Guide
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 species the services that
should be accessible in the provinces 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 signicant. 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 signicant 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, difcult schedules and poor quality of life.
Combined, these factors make training and recruiting
emergency physicians in rural areas a considerable
Observational studies
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 areasencouraging 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.
The guide
also suggests reasonable work and on-call
schedules, attractive salaries and adequate benets.
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-
fessionals partner and nally, 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
inter-establishment transfers
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-
matology networks.
These networks have benetted
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
inter-establishment transfers.
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 signicantly 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 patients 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 EDsperformances, 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 scientic 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
Management Guide
A. Perceived usefulness and implementation of its
various recommendations;
B. Factors that promote or impede the implemen-
tation in rural areas;
C. Relations between the implementation and per-
formance indicators;
D. Relations between the implementation and
healthcare professionalswork-related quality
of life.
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 denition of Statistics
In a previously conducted pilot study, rural EDs were
identied using the Health Canada Establishment
and conrmed 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 Wiaccess); (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 rst phase of the study, the project needs no
further ethical evaluation since all of the data required
is non-nominal.
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 rst 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 les. The number of le 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 rst survey refers to the quality-of-work life systemic
inventory (QWLSI)
and will be available for completion
via 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 inuence employees
perception and enjoyment of the task and employee
support. A supplementary module of six questions will be
designed to capture aspects specic 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 (Cronbachsα) of the sub-
groups ranges from 0.60 to 0.82.
The overall internal val-
idity is 0.88 and the testretest 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.
Statistical analyses
The statistical analyses will be achieved in collaboration
with the biostatistics service from the Unité de recherche
en santé des populations du Centre hospitalier aflié
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
the guide,
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 participantstelephonic 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
and the
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 rst phase. The
association between the QWLSI score and utilisation of
the guide
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 coefcients. Furthermore, some correlational
analyses will allow to compare the quality-of-work life
scores and some retention and recruitment factors.
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,
Scientic 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 fullled, 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 specic requests
and decides to approve/reject the project within 2 weeks
following the examination. When the expectations of
the main REC are satised, 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 nal 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
scientic journals and presented at one or more scientic
To our knowledge, this will be the rst 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 specic 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.
Author affiliations
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 durgence, Centre de
recherche de lHôpital 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. Marys Research Centre, McGill University,
Montreal, QC, Canada
Departement of Emergency Medicine, CSSS de La Matapédia, Québec, QC,
Direction de lanalyse et de lévaluation 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
QuébecSanté (FRQS) 22481.
Competing interests None.
Ethics approval CSSS AlphonseDesjardins research ethics committee
(Project MP-HDL-1213-011).
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
... Rural EDs have limited local access to advanced imaging techniques such as computed tomography (CT) and formal ultrasound, and inter-facility transfers are often required to pursue diagnostic evaluations [15][16][17][18]. However, inter-facility transfer processes in rural and isolated areas can be costly, time-consuming and risky for patients and paramedics [19,20]. ...
... This descriptive cross-sectional study used an online survey (SurveyMonkey Inc, Palo Alto, California, USA). The study was added a posteriori to the ongoing Quebec Rural Emergency Department Project [15]. The research ethics committee of the "Centre de Santé et des Services Sociaux (CSSS)" Alphonse-Desjardins hospital approved the amendment to the project. ...
... Complete details on the definition of rural EDs and selection methods for the EDs included in the present study are provided elsewhere [15]. In brief, the Canadian Healthcare Facilities Guide was used to identify rural EDs providing 24/7 physician coverage and located in hospitals with acute-care hospitalization beds. ...
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Background: Point-of-care ultrasound (POCUS) can be used to provide rapid answers to specific and potentially life-threatening clinical questions, and to improve the safety of procedures. The rate of POCUS access and use in Canada is unclear. The objective of this study was to examine access to POCUS and potential barriers/facilitators to its use among rural physicians in Quebec. Methods: This descriptive cross-sectional study used an online survey. The 30-item questionnaire is an adapted and translated version of a questionnaire used in a prior survey conducted in rural Ontario, Canada. The questionnaire was pre-tested for clarity and relevance. The survey was sent to non-locum physicians working either full- or part-time in rural emergency departments (EDs) (n = 206). All EDs were located in rural and small towns and provided 24/7 medical coverage with acute care hospitalization beds. Results: In total, 108 surveys were completed (participation rate = 52.4 %). Of the individuals who completed surveys, ninety-three percent were family physicians, and seven percent had Canadian College of Family Physicians - Emergency Medicine (CCFP-EM) certification. The median number of years of practice was seven. A bedside ultrasound device was available in 95 % of rural EDs; 75.9 % of physicians reported using POCUS on a regular basis. The most common indications for POCUS use were to rule out abdominal aortic aneurysm (70.4 %) and to evaluate presence of free fluid in trauma and intrauterine pregnancy (60 %). The most common reason (73 %) for not using POCUS was limited access to POCUS training programs. Over 40 % of POCUS users received training in POCUS during medical school or residency. Sixty-four percent received training from the Canadian Emergency Ultrasound Society, 13 % received training from the Canadian Association of Emergency Physicians, and 23 % were trained in another course. Finally, 95 % of respondents reported that POCUS skills are essential for rural ED practice. Conclusions: POCUS use in rural EDs in the province of Quebec appears to be relatively widespread. Access to training programs is a barrier to greater use.
... Statistics Canada defines a "rural small town" as a town or municipality outside the commuting zone of larger urban centres with populations of 10 000 or more [13]. Our full methodology for rural ED selection and data collection on hospital characteristics is described elsewhere [1,4,14]. We have piloted and published preliminary descriptive data on the same hospitals [1,4,5]. ...
... This is unfortunate as Quebec is Canada's second most populated province (8 million). Quebec rural hospitals also have better access to CT scanners than other Canadian provinces (74% vs. less than 10%) [5,14]. Further comparison of stroke in Quebec rural hospitals with the rural hospitals in the rest of Canada will be of interest considering their differential access to in-hospital services. ...
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Introduction: Stroke is one of the leading causes of death in Canada. While stroke care has improved dramatically over the last decade, outcomes following stroke among patients treated in rural hospitals have not yet been reported in Canada. Objectives: To describe variation in 30-day post-stroke in-hospital mortality rates between rural and urban academic hospitals in Canada. We also examined 24/7 in-hospital access to CT scanners and selected services in rural hospitals. Materials and methods: We included Canadian Institute for Health Information (CIHI) data on adjusted 30-day in-hospital mortality following stroke from 2007 to 2011 for all acute care hospitals in Canada excluding Quebec and the Territories. We categorized rural hospitals as those located in rural small towns providing 24/7 emergency physician coverage with inpatient beds. Urban hospitals were academic centres designated as Level 1 or 2 trauma centres. We computed descriptive data on local access to a CT scanner and other services and compared mean 30-day adjusted post-stroke mortality rates for rural and urban hospitals to the overall Canadian rate. Results: A total of 286 rural hospitals (3.4 million emergency department (ED) visits/year) and 24 urban hospitals (1.5 million ED visits/year) met inclusion criteria. From 2007 to 2011, 30-day in-hospital mortality rates following stroke were significantly higher in rural than in urban hospitals and higher than the Canadian average for every year except 2008 (rural average range = 18.26 to 21.04 and urban average range = 14.11 to 16.78). Only 11% of rural hospitals had a CT-scanner, 1% had MRI, 21% had in-hospital ICU, 94% had laboratory and 92% had basic x-ray facilities. Conclusion: Rural hospitals in Canada had higher 30-day in-hospital mortality rates following stroke than urban academic hospitals and the Canadian average. Rural hospitals also have very limited local access to CT scanners and ICUs. These rural/urban discrepancies are cause for concern in the context of Canada's universal health care system.
... [5][6][7][8][9][10] Recent studies suggest that rural EDs provide limited services, and an average of 300 patients per year/facility require interfacility transfers often on an urgent basis to access diagnostic services and definitive care at urban referral centres often hundreds of kilometres away. [11][12][13][14] Appropriate care for the specific and significant needs of rural populations requires optimization of rural emergency services. 1,4,[15][16][17] Yet, there are no recent established standards on what services they should provide. ...
... The study constituted one component of a larger evaluative and descriptive study of rural EDs in Quebec and the use of the QEDMG. 12,20 Data were collected from directors of professional services (DPS), directors of nursing services (DNS), head nurses (HN), and emergency department directors (EDD). Eligible participants who worked in a rural hospital in the province of Quebec were 18 years of age or older and had worked full-time in their current position for a minimum of 6 months. ...
Objectives The Quebec Emergency Department Management Guide (QEDMG) is a unique document with 78 recommendations designed to improve the organization of emergency departments (EDs) in the province of Quebec. However, no study has examined how this guide is perceived or used by rural health care management. Methods We invited all directors of professional services (DPS), directors of nursing services (DNS), head nurses (HN), and emergency department directors (EDD) working in Quebec’s rural hospitals to complete an online survey (144 questions). Simple frequency analyses (percentage [%] and 95% confidence interval) were conducted to establish general familiarity and use of the QEDMG, as well as perceived usefulness and implementation of its recommendations. Results Seventy-three percent (19/26) of Quebec’s rural EDs participated in the study. A total of 82% (62/76) of the targeted stakeholders participated. Sixty-one percent of respondents reported being “moderately or a lot” familiar with the QEDMG, whereas 77% reported “almost never or sometimes” refer to this guide. Physician management (DPS, EDD) were more likely than nursing management (DNS and especially HN) to report “not at all” or “little” familiarity on use of the guide. Finally, 98% of the QEDMG recommendations were considered useful. Conclusions Although the QEDMG is considered a useful guide for rural EDs, it is not optimally known or used in rural EDs, especially by physician management. Stakeholders should consider these findings before implementing the revised versions of the QEDMG.
... 14 The primary objective of this study was to investigate the feasibility of measuring the quality-of-care indicators defined by Schull and colleagues 12 in rural emergency departments in Quebec and to identify potential barriers to implementing the indicators. The study is a substudy of a larger cross-sectional multicentre research project 4,15 (Figure 1). ...
... Flow chart of centres participating in project on rural emergency departments (EDs) in Quebec and use of provincial emergency department management guide.4,15,16 ...
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Background: Evidence-based indicators of quality of care have been developed to improve care and performance in Canadian emergency departments. The feasibility of measuring these indicators has been assessed mainly in urban and academic emergency departments. We sought to assess the feasibility of measuring quality-of-care indicators in rural emergency departments in Quebec. Methods: We previously identified rural emergency departments in Quebec that offered medical coverage with hospital beds 24 hours a day, 7 days a week and were located in rural areas or small towns as defined by Statistics Canada. A standardized protocol was sent to each emergency department to collect data on 27 validated quality-of-care indicators in 8 categories: duration of stay, patient safety, pain management, pediatrics, cardiology, respiratory care, stroke and sepsis/infection. Data were collected by local professional medical archivists between June and December 2013. Results: Fifteen (58%) of the 26 emergency departments invited to participate completed data collection. The ability to measure the 27 quality-of-care indicators with the use of databases varied across departments. Centres 2, 5, 6 and 13 used databases for at least 21 of the indicators (78%-92%), whereas centres 3, 8, 9, 11, 12 and 15 used databases for 5 (18%) or fewer of the indicators. On average, the centres were able to measure only 41% of the indicators using heterogeneous databases and manual extraction. The 15 centres collected data from 15 different databases or combinations of databases. The average data collection time for each quality-of-care indicator varied from 5 to 88.5 minutes. The median data collection time was 15 minutes or less for most indicators. Interpretation: Quality-of-care indicators were not easily captured with the use of existing databases in rural emergency departments in Quebec. Further work is warranted to improve standardized measurement of these indicators in rural emergency departments in the province and to generalize the information gathered in this study to other health care environments.
... In a previously conducted pilot study, rural EDs were identified using the Health Canada Establishment Guide. 26 They offer 24/7 medical care, have hospital beds, and are situated in rural and small towns as per the Statistics Canada definition ( population >10 000 and population density <400/km 2 or population <10 000 and population density >400/km 2 or population <10 000 and population density <400/km 2 ). Rural communities in Quebec were identified using Statistics Canada criteria. ...
... Phase 1: generate a portrait of trauma care in rural EDs and explore geographical variations in trauma services in Quebec (objectives 1 and 2) Data sources To meet objectives 1 and 2, data from 2009 to 2013 will be collected from the Ministry's Database of the Quebec Trauma Registry Information System (BDM-SIRTQ), and from data collected in our previous project. 26 The BDM-SIRTQ contains all information on victims of a traumatic event causing injury, victims who died on arrival at the ED or during ED stay, and victims who were hospitalised in a designated trauma centre in Quebec. 35 The data collected in our project on Quebec's rural EDs includes information on the hospital, the ED, prehospital emergency services and interestablishment transfers. ...
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Introduction Trauma remains the primary cause of death in individuals under 40 years of age in Canada. In Quebec, the Trauma Care Continuum (TCC) has been demonstrated to be effective in decreasing the mortality rate among trauma victims. Although rural citizens are at greater risk for trauma and trauma death, no empirical data concerning the effectiveness of the TCC for the rural population in Quebec are available. The emergency departments (EDs) are important safety nets for rural citizens. However, our data indicate that access to diagnostic support services, such as intensive care units and CT is limited in rural areas. The objectives are to (1) draw a portrait of trauma services in rural EDs; (2) explore geographical variations in trauma care in Quebec; (3) identify adaptable factors that could reduce variation; and (4) establish consensus solutions for improving the quality of care. Methods and analysis The study will take place from November 2015 to November 2018. A mixed methodology (qualitative and quantitative) will be used. We will include data (2009–2013) from all trauma victims treated in the 26 rural EDs and tertiary/secondary care centres in Quebec. To meet objectives 1 and 2, data will be gathered from the Ministry's Database of the Quebec Trauma Registry Information System. For objectives 3 and 4, the project will use the Delphi method to develop consensus solutions for improving the quality of trauma care in rural areas. Data will be analysed using a Poisson regression to compare mortality rate during hospital stay or death on ED arrival (objectives 1 and 2). Average scores and 95% CI will be calculated for the Delphi questionnaire (objectives 3 and 4). Ethics and dissemination This protocol has been approved by CSSS Alphonse-Desjardins research ethics committee (Project MP-HDL-2016-003). The results will be published in peer-reviewed journals.
... A major research initiative is underway in Québec, with the objective of providing a detailed portrait of rural EDs and a better understanding of the use/impact of the provincial ED management Guide on quality of care [17]. As an initial step, this article presents a detailed description of Québec's rural EDs and the use of the provincial ED management Guide. ...
... Methodology details are presented in the published protocol [17]. The Québec study was conducted in several phases. ...
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Background: Rural emergency departments (EDs) constitute crucial safety nets for the 20 % of Canadians who live in rural areas. Pilot data suggests that the province of Québec appears to provide more comprehensive access to services than do other provinces. A difference that may be attributable to provincial policy/guidelines "the provincial ED management Guide". The aim of this study was to provide a detailed description of rural EDs in Québec and utilization of the provincial ED management Guide. Methods: We selected EDs offering 24/7 medical coverage, with hospitalization beds, located in rural or small towns. We collected data via telephone, paper, and online surveys with rural ED/hospital staff. Data were also collected from Québec's Ministry of Health databases and from Statistics Canada. We computed descriptive statistics, ANOVA and t-tests were used to examine the relationship between ED census, services and inter-facility transfer requirements. Results: A total of 23 of Québec's 26 rural EDs (88 %) consented to participate in the study. The mean annual ED visits was 18 813 (Standard Deviation = 6 151). Thirty one percent of ED physicians were recent graduates with fewer than 5 years of experience. Only 6 % had residency training or certification in emergency medicine. Teams have good local access (24/7) to diagnostic equipment such as CT scanner (74 %), intensive unit care (78 %) and general surgical services (78 %), but limited access to other consultants. Sixty one percent of participants have reported good knowledge of the provincial ED management Guide, but only 23 % of them have used the guidelines. Furthermore, more than 40 % of EDs were more than 300 km from levels 1 to 2 trauma centers, and only 30 % had air transport access. Conclusions: Rural EDs in Québec are staffed by relatively new graduates working as solo physicians in well-resourced and moderately busy (by rural standards) EDs. The provincial ED management Guide may have contributed to this model of service attribution. However, the majority of rural ED staff report limited knowledge or use of the provincial ED management Guide and increased efforts at disseminating this Guide are warranted.
... This pilot project is derived from a previous study [6,24]. The original study protocol was approved by the CSSS Alphonse-Desjardins Research Ethics Committee (Project MP-HDL-1213-011). ...
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Objective: Rural emergency departments (EDs) are an important gateway to care for the 20% of Canadians who reside in rural areas. Less than 15% of Canadian rural EDs have access to a computed tomography (CT) scanner. We hypothesized that a significant proportion of inter-facility transfers from rural hospitals without CT scanners are for CT imaging. Our objective was to assess inter-facility transfers for CT imaging in a rural ED without a CT scanner. Results: We selected a rural ED that offers 24/7 medical care with admission beds but no CT scanner. Descriptive statistics were collected from 2010 to 2015 on total ED visits and inter-facility transfers. Data was accessible through hospital and government databases. Between 2010 and 2014, there were respectively 13,531, 13,524, 13,827, 12,883, and 12,942 ED visits, with an average of 444 inter-facility transfers. An average of 33% (148/444) of inter-facility transfers were to a rural referral centre with a CT scan, with 84% being for CT scan. Inter-facility transfers incur costs and potential delays in patient diagnosis and management, yet current databases could not capture transfer times. Acquiring a CT scan may represent a reasonable opportunity for the selected rural hospital considering the number of required transfers.
... The study described here constitutes a preliminary step in a larger study designed to develop a portrait of all EDs in rural Quebec [10,11]. This pilot study had two objectives. ...
... 1,8 These definitions generally identify 3% to 10% of the patients who have visited an urban hospital ED. 9 No rural definition of high-frequency ED use has been developed. 10,11 The higher per capita visit rate indicates that rural patients have a lower threshold for visiting their EDs. Given these differences in overall use profile and service context, we sought to develop a functional definition of high-frequency ED use in rural EDs. ...
Objective: To suggest a functional definition for identification of "high-frequency" emergency department (ED) users in rural areas. Design: Retrospective analysis of secondary data. Setting: Sioux Lookout Meno Ya Win Health Centre in northwestern Ontario. Participants: All ED visitors (N = 7121) in 2014 (N = 17 911 visits) in one rural hospital. Main outcome measures: The number of patients and visits identified using different definitions of high-frequency use. RESULTS: By using the most common definition of high-frequency use (≥ 4 annual visits) for our hospital data, we identified 16.7% of ED patients. Using 6 or more annual visits as the definition, we identified 7.9% of ED patients; these patients accounted for 31.3% of the ED visit workload. Using the definition of 6 or more identifies less than 10% of the patients, which is a similar result to using the lower visit standard (≥ 4) in urban centres. Conclusion: We suggest that the definition for high-frequency visitors to a rural ED should be 6 or more annual visits. Other useful subsets might include very high-frequency users (12 to 19 annual visits) and super users (≥ 20 annual visits).
Introduction Although emergency departments (EDs) in Canada’s rural areas serve approximately 20% of the population, a serious problem in access to health care services has emerged. Objective The objective of this project was to compare access to support services in rural EDs between British Columbia and Quebec. Methods Rural EDs were identified through the Canadian Healthcare Association’s Guide to Canadian Healthcare Facilities. We selected hospitals with 24/7 ED physician coverage and hospitalization beds that were located in rural communities (using the rural and small town definition from Statistics Canada). Data were collected from ministries of health, local health authorities, and ED statistics. A telephone interview was administered to collect denominative user data statistics and determine the status of services. Results British Columbia has more rural EDs (n 5 34) than Quebec (n 5 26). EDs in Quebec have higher volumes (19,310 versus 7,793 annual visits). With respect to support services, 81% of Quebec rural EDs have a 24/7 on-call general surgeon compared to 12% for British Columbia. Nearly 75% of Quebec rural EDs have 24/7 access to computed tomography versus only 3% for British Columbia. Rural EDs in Quebec are also supported by a greater proportion of intensive care units (88% versus 15%); however, British Columbia appears to have more medevac aircraft/helicopters than Quebec. Conclusions The results suggest that major differences exist in access to support services in rural EDs in British Columbia and Quebec. A nationwide study is justified to address this issue of variability in rural and remote health service delivery and its impact on interfacility transfers and patient outcomes.
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Efforts at cost containment through regionalization have led to reduced services in several rural emergency departments (EDs) in Canada. As a result, questions have been raised about patient safety and equitable access to care, compelling physicians to advocate for their patients. Few published reports on physicians' advocacy experiences pertaining to rural EDs exist. We describe our experience of patient advocacy after major service cuts at Kootenay Lake Hospital in Nelson, BC. Despite mixed results, we suggest increased physician involvement in patient advocacy.
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Purpose: Ever since the concept of Quality of Work Life (QWL) was first used over 30 years ago, a range of definitions and theoretical constructs have succeeded each other with the aim of mitigating the many problems facing the concept. A historical overview of the concept of QWL is presented here. Given the lack of consensus concerning the solutions that have been developed to date, a new definition of QWL is suggested, inspired by the research on a related concept, general Quality of Life (QOL) which, as the literature shows, has faced the same conceptualization and definition problems as QWL. Based on the suggested definition of QOL, a definition of QWL is provided and the measuring instrument that results therefrom (the Quality of Working Life Systemic Inventory – QWLSI) is presented. Finally, the solutions that this model and measuring instrument provide for the above-mentioned problems are discussed.
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Emergency room utilization in Canada is considerably higher than in other industrialized countries. Despite significant investments, recurrent emergency room crises persist. Focusing particularly on the situation in Quebec, this paper examines the evolution of Canada's and Quebec's healthcare systems over the past 40 years and identifies the key developments that resulted in today's problems and the challenges that must be addressed. In this historical overview, we argue that emergency room problems arise from past decisions that gave hospitals a predominant role in the healthcare system and partly modified their original mission, as well as from counterproductive funding modalities. Other decisions have also weakened primary care services, which are strongly focused on acute health problems and are poorly coordinated with the rest of the system. Symptomatic remedies have only eased the pressure on emergency rooms, but the real solution is more complex and must address the historical residues that are paralyzing our healthcare system.
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A 2002 survey of primary healthcare sites found that 51% of rural and 33% of urban primary care patients reported using the hospital emergency room (ER) in the last 12 months. We did a secondary analysis to identify urban-rural differences in accessibility-related organizational features that predicted ER use. We collected information on clinic organization and physicians' practice profiles from 100 primary healthcare sites across Quebec and 2,725 of their regular patients, who reported on ER use. We used hierarchical logistic regression to identify organizational features that predict the probability of ER use by patients. Patient confidence in rapid access at their clinic decreases ER use (OR=0.73). Rural sites offer fewer walk-in services or on-site medical procedures and less proximity to laboratory and diagnostic services, but paradoxically, rural patients are more confident that their own physician will see them for a sudden illness. Patients from clinics offering a larger range of medical procedures on site have lower ER use (OR=0.92 per procedure). Rural physicians tend to divide their time between hospital and primary care; doing in-patient care increases ER use (OR=1.64). Decreased ER use is found in patients of clinics organized to enhance responsiveness to acute needs, especially in rural areas. Although the high rates of ER use in rural areas partly reflect problems with the accessibility of primary care clinics, in a resource-scarce context rural hospital ERs may cover both primary care urgent problems and emergencies.
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In almost all countries around the world, there are fewer health care professionals working in rural and urban underserved areas. In urban areas in Australia, there is one doctor for every 970 people, but in rural areas there is one for every 1328 people. In the United States of America, only 9% of physicians practice in rural areas where 20% of the population live. In low- and middle-income countries the shortage is even greater. This shortage makes it particularly difficult for people in underserved areas to access health services and be healthy. While some health care professionals choose to work in underserved areas, they are a small minority and strategies are needed to persuade more to do so. A variety of strategies have been adopted including educational, financial, regulatory and supportive strategies. For example, some medical schools try to recruit more people from rural areas in the hope that they will return to those areas to practice. Scholarships, grants, loan repayment schemes, and higher salaries are offered to professionals working in underserved areas. A number of countries have made it mandatory for health care professionals to work for a period of time in underserved areas. While some of these strategies have shown promise, this review found no well-designed studies to say whether any of these strategies are effective or not. Rigorous studies are needed to evaluate the true effect of these strategies to increase the number of health care professionals working in underserved areas.
Context Information about the performance of hospitals, health professionals, and health care organizations has been made public in the United States for more than a decade. The expected gains of public disclosure have not been made clear, and both the benefits and potential risks have received minimal empirical investigation.Objective To summarize the empirical evidence concerning public disclosure of performance data, relate the results to the potential gains, and identify areas requiring further research.Data Sources A literature search was conducted on MEDLINE and EMBASE databases for articles published between January 1986 and October 1999 in peer-reviewed journals. Review of citations, public documents, and expert advice was conducted to identify studies not found in the electronic databases.Study Selection Descriptive, observational, or experimental evaluations of US reporting systems were selected for inclusion.Data Extraction Included studies were organized based on use of public data by consumers, purchasers, physicians, and hospitals; impact on quality of care outcomes; and costs.Data Synthesis Seven US reporting systems have been the subject of published empirical evaluations. Descriptive and observational methods predominate. Consumers and purchasers rarely search out the information and do not understand or trust it; it has a small, although increasing, impact on their decision making. Physicians are skeptical about such data and only a small proportion makes use of it. Hospitals appear to be most responsive to the data. In a limited number of studies, the publication of performance data has been associated with an improvement in health outcomes.Conclusions There are several potential gains from the public disclosure of performance data, but use of the information by provider organizations for quality improvement may be the most productive area for further research.
Whether severely injured patients should be transported directly to tertiary trauma centers, bypassing closer nontertiary facilities, or be transported first to nearby, less-specialized facilities for immediate care and stabilization has been studied with mixed findings. Differences in study locale, case mix, and variation in the structure and level of maturation of the trauma system may explain some of the discrepancy in findings. In addition, risk adjustment strategies used in these studies did not take into account prehospital baseline characteristics as well as time since injury. This was a retrospective cohort study of 1,998 patients treated at a Level I trauma center between January 1, 2006, and December 31, 2007. Propensity-adjusted survival analyses were used to compare short-term mortality outcomes in transferred versus directly transported major trauma patients. A total of 1,398 patients were transported directly to the Level I trauma center and 600 patients were transferred from lower level facilities. After adjusting for the propensity to be transported directly, age, injury severity score, severe head injury, emergency medical service or emergency department intubation, comorbid conditions, and time to definitive Level I trauma care, the 2-week mortality risk in transferred patients was almost three-fold that of patients transported directly to a Level I trauma center (hazard ratio, 2.7; 95% confidence interval, 1.31-5.6). Transferred patients in a predominantly rural region are at an increased risk of short-term mortality. This suggests that severely injured patients should be transported directly to tertiary trauma centers. For patients requiring immediate stabilization at nontertiary facilities, this should be performed promptly without unnecessary delays.
Trauma centers improve outcomes compared with nontrauma centers, although the relative benefit of different levels of major trauma centers (Level I vs. Level II hospitals) remains unclear. We sought to determine whether there was a difference in the patient outcome in trauma victims taken to Level I versus Level II trauma centers. A multicenter, retrospective cohort analysis of all patients with trauma (>15 years), meeting State of Ohio trauma criteria, transported directly from the scene to a Level I or a Level II hospital (27 centers) between January 2003 and December 2006. Propensity score adjustment was used to adjust for nonrandom selection of hospital destination (I vs. II) and included age, emergency medical services (EMS) Glasgow Coma Score, comorbidities, EMS systolic blood pressure, injury type, injury severity, EMS procedures, emergency department procedures, gender, insurance status, and race. A propensity-adjusted multivariable logistic regression model was used to test the association between trauma center level and patient outcomes. Outcomes included in-hospital mortality and discharge destination (skilled nursing facility, rehabilitation center, home). A total of 18,103 patients were included in the analysis; 10,070 (56%) were transported to a Level I center. Patients taken to Level I centers had more severe injuries, more penetrating injuries, more complications, yet similar unadjusted mortality compared with Level II centers. In adjusted analyses, patients taken to Level I hospitals had improved survival compared with Level II centers (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.56-0.98). Similar results were seen when restricting the analyses to patients with serious injuries (Injury Severity Score > 15; EMS Glasgow Coma Score < 9). Patients treated at Level I hospitals were more likely to be discharged home (OR 1.14, 95% CI 1.05-1.25), or a rehabilitation center or skilled nursing facility (OR 1.39, 95% CI 1.27-1.52). Patients taken to Level I centers had improved survival and better functional outcomes compared with injured persons taken to Level II hospitals.
Despite prior research demonstrating higher injury-mortality rates among rural populations, few studies have examined the differences in nonfatal injury risk between rural and urban populations. The objective of this study was to compare injury-hospitalization rates between rural and urban populations using population-based national estimates derived from patient-encounter data. A cross-sectional analysis of the 2004 Nationwide Inpatient Sample was conducted in 2007. Rural-urban classifications were determined based on residence. SUDAAN software and U.S. Census population estimates were used to calculate nationally representative injury-hospitalization rates. Injury rates between rural and urban categories were compared with rate ratios and 95% CIs. An estimated 1.9 million (95% CI=1,800,250-1,997,801) injury-related hospitalizations were identified. Overall, injury-hospitalization rates generally increased with increasing rurality; rates were 27% higher in large rural counties (95% CI=10%, 44%) and 35% higher in small rural counties (95% CI=16%, 55%). While hospitalization rates for assaults were highest in large urban counties, the rates for unintentional injuries from motor vehicle traffic, falls, and poisonings were higher in rural populations. Rates for self-inflicted injuries from poisonings, cuttings, and firearms were higher in rural counties. The total estimated hospital charges for injuries were more than $50 billion. On a per-capita basis, hospital charges were highest for rural populations. These findings highlight the substantial burden imposed by injury on the U.S. population and the significantly increased risk for those residing in rural locations. Prevention and intervention efforts in rural areas should be expanded and should focus on risk factors unique to these populations.