Progress Report

Home , Vernon Jubilee Hospital

PROVINCIAL EMERGENCY SERVICES PROJECT

PROGRESS REPORT

presented by

PHSA in collaboration With FHA, IHA, NHA, VCHA & VIHA to BC’s CEO Leadership Council

April 2003

Â improving emergency services in British Columbia

Province-wide solutions. Better health.

TABLE OF CONTENTS

EXECUTIVE SUMMARY 3 CHAPTER 1 INTRODUCTION 9 CHAPTER 2 BACKGROUND 11 2.1 The role of the PHSA...... 11 2.2 Our objectives and goals ...... 12 2.3 Accountability...... 12 CHAPTER 3 LITERATURE REVIEW 14 3.1 Improving BC’s emergency services – a brief summary of published research ...... 14 3.2 Leverage Point One: Managing unscheduled demand ...... 16 3.3 Leverage Point Two: Accessing specialist care in hospitals ...... 18 3.4 Leverage Point Three: Dealing with congestion in the ED ...... 18 3.5 Leverage Point Four: Improving community linkages ...... 19 CHAPTER 4 ISSUES FACING BC’S EMERGENCY SERVICES – WHAT WE LEARNED 21 4.1.1 ED data analysis lacks face validity ...... 26 4.2.1 ED data collection systems are not standardized ...... 27 4.2.2 Survey reveals many concerns, but staffing is “Problem Number One” ...... 28 4.2.3 Geography and demographics ...... 29 4.2.4 Pre-hospital transport and ambulance service organization...... 30 4.2.5 Pre-hospital crews and inter-hospital transport ...... 30 4.2.6 Nurse staffing and initial patient-nurse contact ...... 31 4.2.7 Emergency physician and specialist availability ...... 32 4.2.8 Diagnostic facilities ...... 32 4.2.9 Emergency demand...... 33 4.2.10 Options for referral ...... 33 4.2.11 Procedures required of family physicians ...... 33 4.2.13 Continuing education ...... 34 4.2.14 Capacity of the system...... 34 4.2.15 Physical work environment ...... 34 CHAPTER 5 BETTER PRACTICES IN EMERGENCY SERVICES 36 5.1.1 Managing unscheduled demand...... 37 5.1.2 Accessing specialist care ...... 38 5.1.3 Dealing with congestion in the ED ...... 38 5.1.4 Improving community linkages...... 39 CHAPTER 6 SHORT-TERM RECOMMENDATIONS AND NEXT STEPS 47 6.1 HAs should gather better information that can contribute to better performance...... 48 6.1.1 Getting started with indicators ...... 49 6.1.2 Assessing inputs to the ED ...... 50 6.1.3 Assessing practice within the ED ...... 50 6.1.4 Assessing outputs from the ED ...... 51

Ë Immediate action on Recommendation One ...... 52

Â Recommendation 2 ...... 53 6.2 A senior executive should lead system-wide planning for emergency services within each health authority...... 53 6.2.1 One HA has already proposed a regional coordinating structure...... 53 6.2.2 Some initiatives will require Executive Team support for implementation in the HA .. 54 6.2.3 Clinical leadership is important...... 54 short term task group progress report – april 2003 1 6.2.4 Good data will be required to support policy development in HAs...... 55

Ë Immediate action on Recommendation Two ...... 56

Â Recommendation 3 ...... 56 6.3 HAs should develop systemic approaches to coordinate and manage access to inpatient and diagnostic resources ...... 56

Ë Immediate action on Recommendation Three...... 57

Â Recommendation 4 ...... 58 6.4 HAs should improve outcomes and access through better co-ordination in planning community services...... 58 Ë Immediate action on Recommendation Four ...... 59 6.5.1 Create a province-wide information management program for emergency departments ...... 59 6.5.2 Apply Better Practice consistently...... 60 6.5.3 Use whole-system planning to manage complex issues...... 60 6.5.4 Develop solutions related to the patients’ journey...... 61 CONCLUSION 66 APPENDICES 67 APPENDIX 1 CEO LEADERSHIP COUNCIL BRIEFING NOTE (APPROVED: NOVEMBER 18, 2002) 68 APPENDIX 2 PROVINCIAL EMERGENCY SERVICES STEERING COMMITTEE TERMS OF REFERENCE 70 APPENDIX 3 SHORT-TERM TASK GROUP MEMBERSHIP LIST 73 APPENDIX 4 INFORMATION MANAGEMENT SUB-COMMITTEE MEMBERSHIP LIST 75 APPENDIX 5 STAKEHOLDERS, CONTACTS AND OTHER CONTRIBUTORS 76 APPENDIX 6 DATA SOURCES 78 Emergency Departments...... 78 Emergency Room Visits for BC Hospitals by Health Authority and Health Service Delivery Area 2000/01, 2001/02 and 2002/03 ...... 83 Non Scheduled Emergency Room Visits for 2000-01 and 2001-02 ...... 87 APPENDIX 7 SURVEY QUESTIONNAIRE TEMPLATE & LIST OF SURVEY PARTICIPANTS 89 APPENDIX 8 JOINT PLANNING WORKSHOP 93 APPENDIX 9 TOP FIVE LIST 99 Provincial Emergency Services Project – Short Term Task Group “Top 5 list” of issues & solutions: February 6, 2003 ...... 99 SHORT → LONG TERM SOLUTIONS ...... 104 SHORT → LONG TERM SOLUTIONS ...... 105 APPENDIX 10 WINTER ACTION PLANS 106 APPENDIX 11 BIBLIOGRAPHY 111

short term task group progress report – april 2003 2 EXECUTIVE SUMMARY

In Chapter 1, we set out the purpose of this Progress Report, which is to improve emergency health services in British Columbia (BC). Pressures in Emergency Departments (ED) are due in part to demands upon the service, the supply of resources to meet the demands and the way in which supply and demand are managed. At times, these pressures create serious problems and may even result in unsafe patient care situations. Staff working in the ED experience frustration as they struggle to provide a safety net for more systemic problems. We acknowledge the significance of these problems and the urgent need for remedies. The work presented here will only partially address these very grave concerns. This Progress Report focuses on immediate actions that can be implemented without delay for modest costs. Therefore we have concentrated on those actions most likely to create the greatest impact. Recognizing both the pressures and the urgency, we have tried to identify “leverage points” where strategic actions can have big effects.

Chapter 2 sets out the Background for the Provincial Emergency Services Project (PESP), including the project structure with a Steering Committee, Short Term Task Group (STTG) and Long Term Task Group (LTTG). We describe briefly the activities that led to this Progress Report, including a survey, a workshop and review meetings. Time did not allow us the opportunity to interview patients or their representatives about their experience of emergency health services in BC; we plan to remedy this in the next phase of work.

Chapter 3 is a brief summary of published research that illustrates some of the “Better Practices” used around the world to address ED pressures. The most useful published references from the international literature are described briefly. We also note relevant reports from other Canadian jurisdictions and summarize recommendations from the 1998 report of the Lower Mainland/North Shore/Fraser Valley Emergency Services Coordinating Committee. Two principles emerged from this literature review: 1 The co-ordination of emergency care services is as important to the outcome of emergencies as the individual components. 2 The notion of inappropriate or unnecessary attendance at any point in the health care system is being superseded by the idea that services may be inappropriate, rather than the individuals seeking care.

In Chapter 4 we present information used by the STTG to assess the situation. The first section provides some quantitative information about BC’s EDs. This shows the great variation in utilization and some of the differences between rural and urban settings. The greater concern though, is that data are gathered inconsistently or not at all, so it is impossible to analyze problems such as waiting times. The STTG identified data integrity and information development as a major area for improvement.

Also in this chapter, the second section presents results of a survey about pressing issues affecting EDs in each Health Authority. Many concerns were identified, but nurse staffing was by far the most serious. Issues related to ambulance services also ranked highly, as did through-put in the ED, and availability of specialists and diagnostics. The STTG then validated the top issues from the survey as shown below (Exhibit E1). short term task group progress report – april 2003 3

Exhibit E1 Priority Issues Identified by Short Term Task Group

Chapter 5 identifies opportunities for improvement in BC emergency services. It is based on three sources: a survey of Better Practices already used in each HA, a workshop with an outside expert that generated many suggestions, and a prioritizing process with the STTG. “Short-term” opportunities were defined as • reasonably expected to be substantially implemented by March 31, 2004, • within a health authority’s mandate, • reasonably manageable in the context of the many competing priorities, • less dependent on recruitment of skilled staff.

Our survey revealed that many excellent innovations are already underway around BC. Again, we referred the survey findings about the HAs’ Better Practices to the STTG for validation. They identified several priorities for applying these good ideas more consistently:

Exhibit E2 STTG Priority Improvement Opportunities

Canadian Triage Acuity Scale Educating staff and patients re. community services Community care staff support specific populations Standard protocols Specialized clinics especially in ambulatory areas Advanced practice nurses Daily bed meeting with all managers Utilization management and bed allocation policies Overflow beds (“flex”) Discharge planner based in ED Home-care support to transition patients

short term task group progress report – april 2003 4 Later in Chapter 5, we present the main themes for improvement that came out of the workshop and subsequent STTG discussions:

1. Improve information management. The one issue that dominated discussions with STTG members was information management. Consistent data collection, meaningful performance indicators and information management systems are important for quality monitoring and planning, as much as for improving individual patient care.

2. Use the Canadian Triage and Acuity Scale consistently and appropriately in all EDs. CTAS is a tool for providing and monitoring patient care as well as for planning. Presently CTAS is used inconsistently in BC EDs.

3. Identify within each HA a senior executive to lead system-wide planning for emergency services. Such a role will ensure that emergency services issues are addressed holistically at a strategic level in the organization. This executive would lead the organization in linking key concerns and issues with appropriate management action. To be successful, the STTG recommends that this role would require organizational supports.

4. Develop systems to coordinate and manage access to in-patient and diagnostic resources. At the policy level, this might include, for instance, the ability to admit or discharge patients at all appropriate times. From a structure perspective, this might involve hiring bed utilization managers or hospitalists.

5. Develop processes for community co-ordination and planning. Success in the Lower Mainland suggests wider use of regional plans for ambulance diversions. Community co-ordination may also lead to expanded home care support or home nursing services delivered from EDs.

In Chapter 6, the Progress Report first provides general recommendations with some ideas that could be used at the HA level. These ideas will require local adaptation so we have provided only high-level guidance rather than concrete details.

Second, each theme results in some “immediate actions”, those steps that can be implemented at once. All of these are measurable and specific, with action statements and timeframes.

Third, recognizing that many of the problems require system-wide changes, some issues will be referred to the Long Term Task Group. We have provided some supporting information for these to assist the LTTG to build its work-plan. Even these have some immediate action steps identified so as to ensure continuity in taking this work forward.

short term task group progress report – april 2003 5 Recommendation 1 HAs should develop better information that can contribute to better performance

1.1 Create a plan for a province-wide information management program for EDs.

1.2 Ensure that appropriate patient care protocols are available in all EDs for high-risk or high-volume care. Adherence to protocols should be part of the monitoring system.

1.3 Create indicators of performance for emergency services.

1.4 Use CTAS consistently and appropriately in all EDs.

1.5 Assess feasibility, success factors and other requirements for the information system.

1.6 HAs should analyze their EDs using the CAEP framework, as a helpful basis for tailoring policies and redesign activities to local needs.

1.7 Undertake periodic patient satisfaction surveys within EDs.

Recommendation 2 A senior executive should lead system-wide planning for emergency services within each Health Authority

2.1 HAs should appoint an executive lead for emergency services by June 1, 2003.

2.2 HAs should identify or confirm by June 30, 2003 the resources required in each HSDA for clinical leadership in emergency services.

2.3 HAs should work with PHSA to develop appropriate educational sessions for all the executive and clinical leaders in emergency services.

Recommendation 3 HAs should develop systemic approaches to coordinate and manage access to in-patient and diagnostic resources

3.1 HAs should create the coordinating capability for facility-wide access to inpatient beds. This would include the ability to admit or discharge patients at all appropriate times, 24/7. This could include use of hospitalists, linkages to other services, and methods to give patients and care-givers instructions and information. 3.2 HAs should create mechanisms to identify and release in-patient beds for use of emergency admissions on a proactive basis. 3.3 HAs should undertake a planning process in each hospital to identify the daily and seasonal average number of beds required each day for emergency admissions, and create a proactive process to make these beds available. 3.4 HAs should ensure that every regional hospital (or any hospital with ED visits greater than 20,000 per annum) has an assigned bed utilization manager or access director and a bed utilization management process. Where this is short term task group progress report – april 2003 6 not already in place, this individual should be hired by June 30, 2003 with a mandate to address the recommendations above.

3.5 Discussions should proceed immediately through the LTTG to create a plan of work related to guidelines and protocols to meet clinical needs in emergency services.

3.6 PHSA and the other HAs should develop a plan to build a network of peer- based process improvement resources (“better practice experts”) to share information about improving emergency services.

Recommendation 4 HAs should improve outcomes and access through better co-ordination in planning community services.

4.1 HAS should explore the following approaches to improve coordination with community services: a. Develop an unscheduled services team within each community to manage “after-hours” utilization, to include representatives from appropriate community organizations, BCAS and primary care. b. Create regional plans for ambulance diversions to alternate facilities, to avoid inpatient bed congestion as well as ED congestion. c. Where workload merits, expand 24/7 home care support and home nursing services delivered from EDs. d. Create mechanisms to supply services into the community for common non-emergent conditions or care requirements that may result in an ED visit or in-patient hospitalization. e. Build a “whole systems” approach to partnerships. This requires a multi-agency planning group that meets regularly to discuss issues around capacity, demand levels and access. f. Create communication plans that support both strategic goals (e.g. public education) and operational goals (e.g. to link front-line managers). 4.2 Each HA should appoint a team led by a designated staff person to organize a joined-up planning approach. The first meeting of this team should occur before June 30, 2003, with preliminary plans completed by September 15, 2003.

4.3 PHSA and the HAs should develop a planning framework and educational resources to support this joined-up planning work.

4.4 PHSA will convene a meeting of HAs by September 15, 2003 to identify any common resource requirements for this work

5.0 Recommendations for the longer term

short term task group progress report – april 2003 7 5.1 PHSA will continue work with MoH/S staff to develop data sources that will build the picture of emergency services in BC.

5.2 Regarding training requirements for ED clinicians, PHSA will develop a briefing note and proposal to take to the LTTG.

5.3 HAs should examine whether and how non-nursing duties in EDs are affecting access, throughput and performance in their emergency service system.

5.4 Identify structure and resources required to implement a redirect and critical care bypass system throughout the province.

5.5 HAs should use a system planning approach to analyze how access to specialists and specialized facilities could be enhanced.

5.6 Regarding public education programs, PHSA will develop a briefing note and proposal to take to the LTTG.

5.7 Regarding mechanisms to support unscheduled care of individuals living in residential care facilities, PHSA will develop a briefing note and proposal to take to LTTG.

5.8 PHSA will develop a briefing note and proposal to take to LTTG about support mechanisms for those suffering from concurrent serious mental illness and substance misuse.

Appendices to the Progress Report provide important background material. These include the STTG and committee membership, names of those consulted and those who participated in the survey, data sources, the survey tool, workshop notes, the STTG “Top Five Issues and Solutions” list, briefing note on Winter Action Plans and the Bibliography.

This progress report has gathered the helpful suggestions of many committed individuals dedicated to the improvement of emergency services across BC. We are confident that the recommendations could make a difference in service delivery, as well as improving patient and staff satisfaction and system effectiveness. Ultimately it will be up to clinicians and mangers within HAs to determine whether and how to implement any of these suggestions as part of their redesign plans for emergency services. PHSA is willing to support these teams within the HAs as appropriate.

Our aim is to put patients and their families at the very centre of improved emergency health services. They need to have confidence that their problem will be quickly identified by appropriately qualified staff and, if treatment or hospitalization is needed, that this will be delivered quickly and to a high standard.

The LTTG will continue with this important work. As we strive to improve performance in our emergency services, there is much to be done and much to learn. All agree that we want staff working in BC’s emergency services to be able to practice their professional skills in an environment they can be proud of. And we want patients to receive the best emergency services we can provide.

short term task group progress report – april 2003 8 CHAPTER 1 INTRODUCTION

The Provincial Emergency Services Project (PESP) was launched in November 2002 as the first collaborative, province-wide approach to improve access to and the effectiveness of BC’s emergency health services system

Based on the Performance Agreements between the Ministry of Health Services (MoH/S) and all health authorities (HAs), the Provincial Health Services Authority (PHSA) coordinates the PESP on behalf of all the Health Authorities.

This project focuses on the inputs, internal processes, and outputs of hospital EDs. The primary problem facing all of BC’s HAs is that current approaches to the management of emergency and elective care are not effective in addressing and preventing capacity problems and their outcomes such as disrupted scheduled cases and excessive waiting. This is a whole system problem that requires collaborative planning across all sectors. The solutions must include the EDs, but also involve the acute, primary and community care sectors.

Our approach addresses this “system functioning” problem collaboratively across all HAs since they are the service providers. Redesign initiatives are already underway within each HA. This project is not intended to duplicate these, address restructuring, or review operations. Rather, this project builds on the excellent work of each HA as it strives to improve emergency care in its communities. The focus is on province-wide systemic solutions and improvements through the sharing of ideas and innovative strategies.

This report summarizes progress from November 2002 to March 2003. It is built upon the work of experts and stakeholders−not just those directly involved in the project, but also many others who contributed information and ideas. Time did not permit us to interview patients or their families about their experience of emergency health services in BC; we hope to remedy this in the next phase of this work.

This progress report is intended to satisfy the MoH/S/PHSA performance deliverable for 2002/2003:

Direct and support the process, with all other HAs and MoH/S, to develop guidelines to better manage demands on the emergency health services in the acute hospital system. The process will include a

short term task group progress report – april 2003 9 review of literature research, as well as practices and performance in other jurisdictions. The product during 2002/2003 will be a set of guidelines and best practices in the management of emergency health care, including reporting requirements, measures and assessments of service co-ordination. These guidelines will be adopted by the HAs.

A more immediate purpose of this report and the work it represents is to assist all HAs as they improve emergency services. It also provides the foundation for longer-term improvements and better practices for improving emergency services throughout BC.

Chapter What you will find Key messages 1 Introduction • Whole-system problems Purpose • Collaboration not duplication Performance • Addresses PHSA and HA Agreement details Performance Agreement deliverables. 2 Background • Short Term and Long Term Task What we are trying to Groups at work achieve • Experts and stakeholders helped Our approach identify “Better Practices” 3 Literature Review • Co-ordination is critical Summary of • Inadequate or inappropriate international research services, not inappropriate patients • “Leverage points” to manage demand for services • Common problems, many solutions 4 Issues facing BC’s • Inconsistent data collection Emergency Services • Nurse staffing is the #1 problem; HSDA Survey results Throughput is problem #2 STTG view • Other problems include ambulance services and access to specialists and diagnostics 5 Opportunities for • Better Practices for short-term Improvement action HSDA Survey results • Key themes are information Workshop results management, CTAS, executive Key themes from STTG lead for ED, internal coordination, external collaboration. 6 Recommendations • The recommendations could make General a difference in service delivery, as recommendations well as improving patient and staff Immediate actions satisfaction and system Longer-term answers effectiveness.

short term task group progress report – april 2003 10 CHAPTER 2 BACKGROUND

2.1 The role of the PHSA

The Provincial Health Services Authority (PHSA) is one of six health authorities in BC. Its mission is to promote and deliver accessible quality health services for all British Columbians through an integrated health system.

The PHSA fulfills its mission in five ways. It: • ensures the delivery of quality specialty and province- wide services; • sets directions and develops province wide standards; • allocates resources to support optimal health outcomes; • measures, monitors, and reports on performance, and • fosters the creating of knowledge and innovation through research and teaching.

Emergency Services is a priority system performance improvement deliverable assigned to the PHSA by the MOH/S as a part of its 2002/2003 Performance Agreement. This deliverable is also found in the Health Authority (HA) Performance Agreements with the MOH/S.

A Briefing Note entitled PHSA Priority System Performance Improvement: Emergency Services was approved by the CEO Leadership Council on November 18, 2002 (Appendix 1). The Briefing Note reflects the culmination of discussions to clarify the performance deliverables between MoH/S and the PHSA. This document was the starting point for the project.

Therefore, as part of its coordination responsibility, PHSA is leading this collaborative province-wide project to improve access to and utilization and effectiveness of emergency services throughout B.C. Any recommendations from this project that are approved by the CEO Leadership Council will be subject to a comprehensive implementation plan agreed to by all HAs and the MoH/S. Implementing these recommendations may require the participation of others who are involved in introducing innovation into other areas of the health care system such as community and acute care sectors.

short term task group progress report – april 2003 11 2.2 Our objectives and goals

This project aims to improve care for patients who require unscheduled care in BC EDs. We have not taken the popular view that people seeking care do so inappropriately; instead we have considered ways to provide appropriate services to meet public needs. In this project we also endeavour to find ways to support the clinicians working in emergency services, including BCAS. We recognize that staff and managers throughout the HAs are all working to improve the system of care, of which emergency services can only be one part.

PHSA and the regional HAs have approached this as an opportunity to develop a collaborative provincial effort to improve ED utilization and care. Many of the enabling strategies will take time to develop and implement. Meanwhile, there are ongoing and emergent problems that place hospitals in a state of continual stress. Therefore we need some immediate solutions while we develop systems for lasting improvements.

With the short and long term opportunities in mind, the PHSA is coordinating and supporting a two-stage approach, using two task groups plus a province wide steering committee.

2.3 Accountability

The Provincial Emergency Services Steering Committee (PESSC) was established to provide strategic direction and overall management of the Project. The Steering Committee is accountable to the CEO Leadership Council, through the CEO of the PHSA (Appendix 2). The Ministry of Health Services and all HAs are represented by executives with an interest or responsibility for emergency services, so their system perspectives have provided an essential context for this work. The PESSC has met regularly and has reviewed and revised this progress report. Committee members also provide the informal linkage to members of the CEO Leadership Council. In addition, and of great importance, the PESSC members will provide project oversight and continuity as we make the transition from the work of the task groups to implementation in the field.

The first planning team is a time-limited “Short Term Task Group” (STTG) to address emergent issues and recommend immediate solutions that can be implemented within a year. The STTG comprises service providers from various EDs

short term task group progress report – april 2003 12 within HAs, plus staff from MoH/S, and other service sectors (Appendix 3). The STTG’s key roles were as follows: 1. Identify & prioritize emergent problems and recommend innovative solutions. 2. Develop a common understanding and determine the “better practices” in ER management. 3. Identify gaps (including rural versus urban) and recommend opportunities for improvement.

To date, the STTG has held four meetings, including an all-day workshop to examine issues and short-term solutions. It also completed a survey of health authorities to determine priority issues. This initiative is not meant to duplicate the current good work of health authorities and hospitals, but rather to build on it; the purpose is province-wide system improvements. Accordingly, the STTG received a research assessment (Chapter 3) which summarized the major findings of relevant studies, including the 1998 Lower Mainland Emergency Report. Project staff also reviewed similar studies from other provinces, the BCMA Section of Emergency Medicine presentation “ED Overcrowding”, and a draft 2003 report from the Vancouver Coastal Health Authority (VCHA).

The STTG has used its collective expertise, and the resources of outside expert advice (Appendix 5). It identified and examined the emergent problems and recommended the solutions described in this Progress Report. At the last meeting of the STTG, March 11, 2003, this report was reviewed and revised.

The second team, with a mandate for the longer-term reform of the Emergency Services System, we have called the “Long Term Task Group” (LTTG). This planning group is responsible for identifying redesign options that will effect major longterm changes in the provincial emergency services system; the group will likely report on its findings by fall 2003.

short term task group progress report – april 2003 13 CHAPTER 3 LITERATURE REVIEW

3.1 Improving BC’s emergency services – a brief summary of published research

This summary has been prepared to illustrate some of the better practice solutions that were considered by the Short- Term Task Group. A literature review of emergency services was one of the pre-planning activities that helped to create a conceptual framework for the project. This background information was intended to stimulate discussion with the STTG and Steering Committee about which solutions would be feasible and worth pursuing in the BC context. The review comprised three areas: • The most useful published references from the international literature are described briefly. • Relevant reports and reviews from other Canadian jurisdictions are noted with some commentary. • Relevant recommendations from the 1998 report of the Lower Mainland/North Shore/Fraser Valley Emergency Services Coordinating Committee are summarized.

Two principles emerged from this literature review: 1 The co-ordination of emergency care services is as important to the outcome of emergencies as the individual components.

2 In recent years, the view that health services may be inappropriately or unnecessarily used by individuals seeking care is being superseded by the idea that health services themselves may be inappropriate or inadequate.

The main problem facing all health authorities (HAs) is that current approaches to the management of emergency care have not been adequate to prevent capacity problems of overcrowding and bumping of elective cases and the outcomes related to this. Hospital EDs are often blocked with admitted patients waiting for in patient beds. Maintaining capacity for emergency care is especially difficult in smaller hospitals and communities where “rogue waves” or workload surges may overwhelm staff and resources. This is a “whole system” problem that requires collaborative planning across all care sectors and especially throughout the acute care sector, plus shared responsibility for implementing and managing solutions.

During the 1990s, the literature focused on "inappropriate" ED visits and strategies to triage these visits away from the short term task group progress report – april 2003 14 ED. By the late 1990s, the demonstrated risks of denying emergency care and analyses of system costs led to renewed focus on the critical role of the ED as a safety net provider. The notion of inappropriate or unnecessary attendance by individuals seeking care at any point in the health care system is being superseded by the idea that services may be inappropriate or inadequate. This, together with an increasing awareness that consumers make active choices to use services based on their preferences and knowledge has highlighted the importance of providing better information about services.

Exhibit 3.1 a systems model for managing demand for emergency health services

Source: SRG Consulting 2003

Four leverage points to manage demand for emergency health services

Managing Accessing Dealing with Improving unscheduled specialist care in congestion in community demand hospitals the ED linkages

Review OR Improve the linkages practices to Ensure that clients between acute and Develop specialty make best use of throughout the primary care, networks to resources year- system receive especially for support local round. timely, appropriate secondary prevention providers. care through and early diagnosis Address impact collaborative programs. of high hospital planning by primary Refine referral and occupancy. care, acute care and transfer home and Work with BCAS, arrangements. Coordinate community care Nurseline, bcbedline, planning to programs. Community Health prepare for rapid Develop modern Centres and other assessment and approaches to Develop “pathways community providers treatment of hospital-based home” for patients to develop medical patients specialty care. referred for alternatives to presenting as emergency hospital-based care. emergencies. treatment to

specialty centres. Introduce streaming methods for assessment and treatment in EDs.

short term task group progress report – april 2003 15

Many jurisdictions have demonstrated “better practices” that could be the starting point for BC’s efforts. Therefore, it is necessary to think about all the possible “leverage points” or strategic junctures in the system where such guidelines could be effective.

The model shown in Exhibit 3.1 organizes and synthesizes the better practices described in the literature into a systems approach to better manage demands for emergency health services. Each of the leverage points provides a focus for strategic action. Two caveats apply to any tactics aimed at service change: Nicholl et al, in their review of evidence for the provision of emergency services argue that the co-ordination of emergency care services is as important to the outcome of emergencies as the individual components. Roberts and May warn that “simply transferring interventions which succeed in one setting without understanding the underlying process of change is likely to result in unexpected consequences locally.” The following sections describe in more detail the origins and features of these leverage points and the better practices that have been implemented there.

3.2 Leverage Point One: Managing unscheduled demand

Australia’s Monash Institute developed and evaluated a triage screening system in 2000-01(Monash Institute of Health Services Research). As with the Canadian Triage and Acuity Scale (CTAS), the Australasian Triage Scale (ATS) was developed to prioritize patient care and provide a consistent approach to triage practice at a national level. Triage decisions are made in response to the patient’s presenting signs or symptoms and no attempt to formulate a medical diagnosis is made. The allocation of a triage category, for example using the ATS, is made on the basis of necessity for time-critical intervention to improve patient outcome, potential threat to life or need to relieve suffering. The decisions made by a triage nurse are a pivotal factor in the initiation of emergency care. Therefore the accuracy of triage decisions is a major influence on the health outcomes of patients.

Certain ambulance systems in North America are known as "High Performance Emergency Medical Systems" (HPEMS). EHS Nova Scotia has adopted many of the principles of HPEMS, including response time reliability, use of System

short term task group progress report – april 2003 16 Status Management, and performance measurement including benchmarking tools for system quality improvement.

In a Los Angeles hospital study reported in 2002, Washington et al. investigated the effects on health status and access to care of systematically referring patients with non-acute conditions to next-day primary care. They concluded that clinically-detailed standardized screening criteria can safely identify patients at public hospital EDs for referral to next-day care.

Fortune (2001) examines the issue of telephone help lines for an Irish ED after a first attempt at formal telephone triage failed. In hindsight, this was attributed to inadequate research into the topic and lack of staff motivation. An overview of the international literature addresses both the positive and negative sides of a telephone helpline. This suggests that telephone support can be successful but advises the use of formal protocols, training of staff and accurate documentation.

Cooke et al. assess whether a separate stream of minor injuries care in a UK ED decreased the waiting time, without delaying the care of those with more serious injuries. The introduction of a separate stream for minor injuries can produce a 30% improvement in the number of trauma patients waiting over an hour. If this is associated with an increase in consultant presence, it may be possible to achieve a 50% improvement in decreasing the number of patients enduring long waits.

GP-registered, “inappropriate” attendees at EDs tend also to utilize primary care services more. Martin et al. demonstrate that this pattern of service utilization appears unrelated to chronic physical illness. Thus, simply providing new, directly accessible primary health care services may not significantly reduce ED use. Coleman et al demonstrated that monthly group visits can reduce ED utilization for chronically ill older adults. ED utilization by chronically ill older adults may be an important sentinel event signifying a breakdown in care coordination. A primary care group visit (i.e., several patients meeting together with the provider at the same time) may reduce fragmentation of care and subsequent ED utilization. These reports are consistent with the Chronic Disease Management approach now underway in BC HAs as part of primary health care renewal.

In Melbourne, Australia, an Emergency Demand Coordination Group aims to better understand emergency demand focused preventive initiatives. It provides a broad description and overview of the literature about models of care and interventions that are relevant to preventive initiatives. short term task group progress report – april 2003 17

3.3 Leverage Point Two: Accessing specialist care in hospitals

Ardagh et al. examine the effect of a rapid assessment clinic for patients presenting to an urban ED in New Zealand. Jaklevic describes a similar program in Chicago. The rapid management of patients with problems which do not require prolonged assessment or decision making is beneficial not only to those patients, but also to other patients sharing the same limited resources.

Expanding the scope of nursing practice in the ED, including increasing the numbers of emergency nurse practitioners (ENPs) is recommended by the UK Audit Commission (1996). ENPs are normally able to diagnose, treat, and refer or discharge patients without reference to a doctor, providing they follow agreed protocols. Recent evidence appears to confirm that ENPs can make a difference to the care received by patients. In a randomized controlled trial by Sakr et al (1999) to assess the care and outcome for patients with minor injuries managed by a nurse practitioner or junior doctor, nurse practitioners working with agreed guidelines provided care that was equal to and in some respects better than care provided by junior doctors.

Nicholl et al (1998) reported some evidence that patients attended by senior doctors following major trauma have better outcomes, but also noted that patient outcomes may be related to the experience of those senior doctors in managing major trauma. However, simply increasing the number of senior doctors may reduce the exposure each has to the patient and ultimately reduce the benefits to patients. Other evidence of the importance of senior medical personnel was identified in a confidential enquiry into short term emergency admissions (Denman-Johnson et al, 1997). An expert panel considered that a senior specialist opinion in the ED would have prevented admission in most of the potentially avoidable admissions observed (9.5% of all admissions).

3.4 Leverage Point Three: Dealing with congestion in the ED

Although much work has been done evaluating causes for increased demand for ED services, few ways are available to help determine that an individual ED is overcrowded. Reeder and Garrison have developed calculations using real-time data for accurately diagnosing an ED with potential for failing both as a safety net and as a source for quality health care. Based on these, predetermined processes can be instituted to short term task group progress report – april 2003 18 help remedy the overcrowded situation. Trended over time, the ratios can also provide the data needed for better resource assessment, planning, and allocation.

Athey and Stern analyze the productivity of information technology in emergency response systems. The impact of E911 on health outcomes is assessed using Pennsylvania ambulance and hospital records. As a result of E911 adoption, patient health measured at the time of ambulance arrival improves, suggesting that E911 enhances the timeliness of emergency response. Further analysis using hospital discharge data shows that E911 also reduces mortality and hospital costs.

Emergency ambulances traditionally inform receiving hospitals of impending arrival of patients only in instances of load and go situations, which on average constitute less than 5% of ambulance runs. Anantharaman and Swee describe a comprehensive electronic ambulance case record created as a pilot project in Singapore between three emergency ambulances and the busiest ED there. All information captured by the ambulance crew, including vital signs information and ECGs, was transmitted to the ED via the public mobile data network. It is only a matter of time before enhanced features such as electronic data collection at patient site, voice activated data entry, transmission of data from site, automated ambulance audits and an enhanced level of professional care in the ambulances become common-place reality.

Increasing the availability of inpatient beds is particularly important in responding to workload surges through the ED. Not surprisingly, the UK Department of Health, in its National Beds Inquiry, focuses on Alternate Level of Care as the most important factor. A major outcome of this large scale inquiry was the recommendation to reduce hospital occupancy rates.

3.5 Leverage Point Four: Improving community linkages

A model of ED case management consisting of a social worker and a nurse case manager can prevent inappropriate admissions, improve discharge planning, decrease cost, and enhance patient satisfaction. Bristow and Herrick describe how a case management dyad team can decrease utilization of the ED for non-emergent visits, promote the use of community resources, and improve discharge planning to avoid excessive costs.

The notion of the Extra-Mural Hospital was introduced in New Brunswick as a means of providing acute care to people

short term task group progress report – april 2003 19 in their own homes. The first unit was established in Woodstock in 1981, and it was extended throughout the province over the next 10 years. The Extra-Mural Hospital is considered to be an integral part of the health care system, providing a range of services.

In Denmark, adults having four or more out-of-hours contacts in a year (10% of all contacts) were defined as ”frequent attenders” and strongly associated with frequent contact out- of-hours (Vedsted, 2001). The authors suggest that intervening to optimize their care during the day is likely to have an impact on their need for care out-of-hours.

A major restructuring is underway in Ontario in the delivery of a wide range of public services, including healthcare, public transit, and ambulance services. The resulting trends in these three industries have converged in a number of models for the delivery of non-emergency patient transfers. Hospitals now find themselves involved in the business of transportation, using new partnerships, making new choices, and managing the movement of stable patients between sites, to medical procedures, and home.

Winter is a season of extreme pressures for a variety of reasons: children and people with chronic illness suffer from the weather as well as flu and other communicable diseases; staff experience higher rates of absence due to illness; and weather-related trauma also increases. Media reports of emergency room waits, cancelled operations and ambulance diversions create public anxiety and political pressure to “do something”. These factors warrant a special focus on coping with winter pressures. All of these issues have been addressed in the UK where NHS reports provide numerous helpful recommendations.

The notion of inappropriate or unnecessary attendance at any point in the health care system is being superseded by the idea that services, rather than individuals’ use of health services, may be inappropriate (Nicholl). This, together with an increasing awareness that consumers make active choices to use services based on their preferences and knowledge has highlighted the importance of providing better information about services. For instance, in PEI the Queen Elizabeth Hospital has provided guidelines for determining if one should go to the ED or seek out an After Hours Clinic if one is unwell.

short term task group progress report – april 2003 20 CHAPTER 4 ISSUES FACING BC’S EMERGENCY SERVICES – WHAT WE LEARNED

In order to support the work of the two Task Groups, we attempted to provide some factual data that would paint a picture of the current scene and the key issues. This chapter describes the methodology used to gather data, the results of our research, and the synthesis of this research into a picture of issues affecting BC’s EDs. First we present some descriptive quantitative data gathered with assistance of MoH/S staff in Victoria; then we present the results of a telephone survey of key informants in each Health Service Delivery Area (HSDA).

4.1 The differences among BC’s many EDs

At the outset, we attempted to construct a picture of BCs emergency services from centrally-collected data. In all there are 99 EDs operating in BC’s 106 hospitals. Recent organizational changes are reflected in Exhibit 4.1 below, which summarizes the distribution of EDs by HA. (Full details for all data tables are in Appendix 6.)

Exhibit 4.1 Emergency Services by HA – 2003

Emergency Services based on bcbedline Records Total Open Total Health Authority EDs 24h <24h No ED sites Fraser 12 12 1 13 Interior 33 23 10 3 36 Northern 25 19 6 25 PHSA 1 1 0 3 4 Van. Coastal 14 9 5 0 14 Van. Island 14 12 2 2 14 99 76 23 9 106

Source: bcbedline 2003

This high-level table naturally masks much detail. When we look at the number of visits at each ED, as shown in Exhibit 4.2, much greater variation is apparent. A large number of hospitals with relatively fewer emergency visits can be seen in the Interior, Northern and Vancouver Coastal Health Authorities. The Canadian Association of Emergency Physicians has proposed a classification system for rural hospitals. Although time did not permit its application for this exercise, we refer to this classification system later in the recommendations.

short term task group progress report – april 2003 21

Exhibit 4.2 ED visits by hospital and HA, 2001/02

Source: MoH/S 2003

10 8 6 4 Interior Fraser Northern

Number of of Number 2 Vancouver Island Vancouver Hospitals (n) Hospitals Vancouver Coastal Vancouver

0 PHSA

? 9 9 9 9 9 9 9 9 9 9 9 9 9 9 921 499 99 1-4999 -9999 6499 6999 84 00 0- 0- 00-499900-549900-5999 50 000-1 000-1 000-249000-299 0 0 0 00 00 5 0 5 10 1 2 2 30000-34935000-3999940000-4499945 50 55 60 65

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6 Strategic Resource Group SandR AssociatesG

short term task group progress report – april 2003 22

The actual ED utilization in each region also shows a considerable range. There are many reasons for this, including historical practice, availability of walk-in clinics, access to full- service GPs or other community-based services, underlying morbidity, and social determinants of health. Exhibit 4.3 shows the rate of utilization by HSDA based on population in 2000/01 and 2001/02. ED utilization rates range from 2200 to 6300 visits per 10,000 population−almost a three-fold difference. Although no conclusions can be drawn from these data, there are certainly many interesting questions that could be explored at the HSDA level.

Looking at change in utilization between 2000-01 and 2001- 02, we can also see significant variation. Notably, most HSDAs experienced a decline in rates for utilization of the ED, some as high as 15% fewer visits based on population. One large increase appears to be due to anomalous data, and two other HSDAs had single digit increases. We can offer no explanation for the overall decline or for the variation among HSDAs. However, all these raise important questions about root causes of emergency demand.

short term task group progress report – april 2003 23 Exhibit 4.3 Utilization rate for emergency visits by health region 2001/02

Source: MoH/S 2003

short term task group progress report – april 2003 24 Exhibit 4.4 Change in utilization rate for ED Visits 2000-2002

Source: MoH/S 2003

short term task group progress report – april 2003 25 4.1.1 ED data analysis lacks face validity

Unfortunately, when we tried to develop information about either the root causes or indicators of performance, we immediately ran into serious data problems. Exhibit 4.5 shows the results of our basic query about how many patients admitted to any hospital come through its ED. Both large and small hospitals have been unable to submit this data, so that meaningful analysis is impossible.

The STTG pointed out the lack of consistency, face validity, or even completeness of data routinely collected in EDs. Our efforts to analyze hospital occupancy, waiting time in EDs, waiting time for transfer to specialist care, and admitted patients in EDs were frustrated by these shortcomings. This issue of data integrity was tackled by the STTG and is addressed below.

Exhibit 4.5 An example of poor data (data sources deliberately obscured)

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short term task group progress report – april 2003 26 4.2 Surveying BC’s health authorities about emergency services

All health authorities were surveyed by telephone during December 2002 and January 2003. The key objectives for conducting the survey were:

1. Collecting baseline facility data for all EDs within BC;

2. Obtaining a “snapshot of the state of affairs" within EDs;

3. Obtaining a broad health authority-wide overview of what improvement initiatives are contemplated or have been implemented.

The survey results were not expected to be robust research- quality data; rather, they would be used by the STTG to assess the scope and scale of issues in the field, as a basis for problem-solving and building the short-term action plan. The review of current improvement initiatives would illustrate some possible actions that could be used elsewhere.

The picture in this “snapshot”- the focus and level of detail - depended on the level of responsibility, experience, and perspective of the participant. In some instances, participants were individuals who worked for and spoke about the issues affecting a single facility. In other instances, the participants were Chief Operating Officers for large Health Service Delivery Areas (HSDA). The number of individuals involved in each interview varied from a single person to a teleconference of ten people. In all, forty-seven (47) people participated (see Appendix 7). A single surveyor conducted all interviews to improve consistency.

4.2.1 ED data collection systems are not standardized

Each survey interview began by collecting very basic information about the ED facilities and emergency services within each area. This section of the interview included the following two questions: • Is ED data routinely collected (above and beyond ED visits/inpatient admissions)? and • What is the typical wait time for an individual requiring urgent care (CAEP level 3)?

In many instances, the ED data question evoked strong responses from participants who were unable to collect such information and yet felt it was critical to collect and analyze data from their ED(s). The lack of ED data collection also meant many of them were unable to respond to the question regarding typical wait times for urgent care. short term task group progress report – april 2003 27

Most facilities reported that urgent patients were seen within appropriate time periods. More to the point here, though, the participants also responded to this question about typical wait times by noting their lack of capacity to provide triage and/or the need for a standardized triage screening tool. ‘Standards’ were a recurring theme throughout the interviews. Again, this is a problem that affects analysis of root causes, as well as follow-up actions such as benchmarking, performance monitoring and evaluation of remedies.

4.2.2 Survey reveals many concerns, but staffing is “Problem Number One”

One of the objectives of the Emergency Services interviews was to obtain a “snapshot” of ED concerns across the province. This picture would assist the STTG to identify priority concerns, to develop hypotheses about root causes, and to consider province-wide opportunities for improvement.

In Section 2 of the survey, participants were asked to respond to the list of issues provided in the questionnaire, and then were given an opportunity to raise additional issues they felt impacted emergency services in their areas/facilities. The survey tool was based on work by the Canadian Association of Emergency Physicians (CAEP).1

Participants were also asked to prioritize their five most important issues from the questionnaire. To identify priority concerns, we weighted the issues: The total score for each concern was based on the actual number of citations, plus 1 additional point if the participants ranked the item fifth, or least concern to them; 2 additional points for 4th rank; 3 for 3rd rank; 4 for 2nd rank; 5 for 1st rank or most important issue. Based on the number of times an issue was cited and its priority then, it was weighted and rank ordered as listed in Exhibit 4.6.

In the section following, we provide a brief synopsis of participant comments for each issue (with the number of participants commenting shown in brackets after each comment). The synopsis follows the sequence of the survey questions, again based on the original CAEP source. Where appropriate for clarity, issues have been combined in the discussion.

1 www.caep.ca “Comparison of the urban and rural contexts of emergency medicine”

short term task group progress report – april 2003 28 Exhibit 4.6 HSDA Survey Participants’ Top 20 Issues

HOW ST ND RD TH TH ISSUES 1 2 3 4 5 Weighted RANK OFTEN CITED TOTAL Nurse Staffing 21 6 5 1 2 78 1 Prehospital crews 15 2 3 2 1 1 46 2 Geography 20 3 1 2 41 3 Specialist availability 16 1 2 2 2 1 40 4 Prehospital Transport 15 2 3 2 3 39 5 Interhospital Transport 19 2 1 1 3 38 6 Demographics 21 2 2 35 7 Extra ED support staff 19 1 2 4 30 8 Other – Bed availability/ 11 2 1 2 29 9 utilization management Diagnostic facilities 14 1 1 3 28 10 Continuing education 15 2 1 2 2 28 10 Options for referral 10 1 1 2 1 26 12 Other – Physical Plant/space 8 4 1 1 22 13 Initial patient nursing 9 2 1 20 14 contact Emergency physician 7 1 1 1 17 15 availability Ambulance service regions 11 1 1 16 16 Rate of encountering major 9 1 1 1 15 17 emergencies Procedures required of 11 1 13 18 family physicians Other - ED overcrowding 18 (moving ALC patients; 4 1 1 13 preventing inappropriate admissions) Other - throughput 2 2 12 20

4.2.3 Geography and demographics

Geography and demographics ranked 3rd and 7th respectively among issues affecting emergency services. Weather, distances and road conditions, complicated by the need for ferry, boat and/or air evacuation, affect most of the rural and remote areas of the province. Participants also cited geography (size of service area) and demographics (overall population) as issues in service provision for regional/tertiary referral centres.

A number of participants identified as an issue the increasing population of the service area or health authority. Nine (9) participants identified the number of elderly in the area as having a major impact. Participants also identified as a concern the number of “oldest old” and elderly people in remote areas. In addition to the size of the elderly population, short term task group progress report – april 2003 29 participants cited their complexity of care requirements and length of hospitalization, as well as a lack of home care and some specialized care (e.g., cardiac) as factors affecting ED services.

Participants recognized that social and cultural issues affected their ability to provide ED services, including: low income populations (and transportation); people needing mental health and alcohol and drug services; and various challenges associated with providing ED services to specific ethnic or cultural groups (e.g., First Nations, East Indian and Asian).

4.2.4 Pre-hospital transport and ambulance service organization

Pre-hospital transport and ambulance service regions ranked 5th and 16th respectively among issues affecting Emergency Services. The most prevalent issue in pre-hospital transport and ambulance service regions was air evacuation (n=12), specifically lack of capacity and the time required to transport.

Ground transport issues also focused on capacity and included: a need for more service (n=5); gaps in service (n=3); change of ambulances at halfway points; inability to meet optimum response time targets; and no ability to divert ground crews when necessary.

Participants cited BCAS policies and dispatch decisions as issues, particularly the policy that requires ambulance crews to deliver patients to the nearest hospital, rather than to the most appropriate one. Ambulance crews need to be able to bypass smaller EDs when the level of care requires it; they need to be able to ‘bypass’ tertiary facilities when that level of care is not required. This issue is tied to the pre-hospital crew’s ability to triage, their communication capability and support, and their possession of higher-level skills to stabilize and transport for longer distances.

One other issue in ambulance service organization is that the service regions do not match the health service areas.

4.2.5 Pre-hospital crews and inter-hospital transport

Pre-hospital crews and inter-hospital transport ranked 2nd and 6th respectively among issues affecting emergency services. There are three major issues with pre-hospital crews and inter-hospital transport: availability of crews and associated delays getting patients to higher level care (n=20); the need for higher skill level crews (n=14); and the need to send ED

short term task group progress report – april 2003 30 staff with patients because ALS crews are not available (n=16).

Participant responses indicate a need for more (and more timely) inter-hospital transport that does not require the attendance of ED staff -- for instance, if paramedics could manage IV medications. In remote areas, the availability of higher skill level crews is thought to be important due to the long distances traveled.

Participant issues related to the availability/timing of crews included: turnover and recruitment, stranded crews, inconsistent staffing, and on-call and volunteer crews. Participant issues related to crew skill levels included: variation in crew skills and inadequate training.

Participants also raised the following issues related to communication: a transport crew arrives when an ACLS crew is needed; a crew arrives but cannot transport due to lack of required skill; unnecessary use of high skill crews to transport patients for diagnostics; and facilities that do not know they must request the BCAS infant team.

4.2.6 Nurse staffing and initial patient-nurse contact

Nurse staffing and initial patient-nurse contact ranked 1st and 14th respectively among issues affecting emergency services. The shortage of nurses ranks as the major issue (n=16) in staffing, with the corresponding problems of recruitment and retention (n=10). Participants cited an increasingly difficult work environment, ED congestion, acuity and type of clientele as additional factors affecting recruitment and retention of ED nurses. In addition, some participants identified the need for additional casual nurses (n=5).

Funding was cited as an important issue in relation to: the number of RNs available; replacing RNs with LPNs; nurses covering multiple areas within small hospitals; the nurse- patient ratio; and an inability to provide training.

Issues related to education and training included: a lack of available ED trained nurses; not enough highly-qualified nursing staff in rural areas; a lack of consistency in training; and difficulty training other nurses to the ER.

In the area of initial patient-nursing contact, participants spoke of an inability to provide triage and the need for clinical protocols.

short term task group progress report – april 2003 31 The factors cited in nurse staffing and initial nursing-patient contact are interrelated and, taken together, pose a much larger concern than they do as individual issues. The lack of staff and increasingly difficult work environment (patient acuity) is occurring at a time when BC has the oldest average age of nurses (44.8 years) in Canada. There is an expectation that large numbers of these nurses will soon be retiring, or at least moving out of the more demanding area of ED nursing.

4.2.7 Emergency physician and specialist availability

Specialist availability and emergency physician availability ranked 4th and 15th respectively among issues affecting emergency services. Lack of manpower (recruitment and retention) is the most common issue participants raised related to specialists (n=5) and Emergency Room Physicians (n=5). In addition, in some HSDAs participants cited a lack of certain specialists (n=8), especially internal medicine.

Participants raised issues related to accessing physicians and specialists when they are on call, contacting them, and their response time. Participants also cited issues of perceived inequity in the ability to access specialists and deploy of specialists based on historical utilization.

Lack of physician manpower was cited as preventing a service area’s ability to switch from GPs to EPs, as well as the ability of specialists to find physicians to consult with or to accept patients. Some participants felt that fee-for-service payment is a poor funding method for EPs.

4.2.8 Diagnostic facilities

Diagnostic facilities ranked 10th among issues affecting emergency services. Participants raised the issue of service availability (n=10) and the fact that while certain clinical services were advertised as being provided, corresponding essential diagnostic services were not available.

Participants cited as major problems: the availability of technicians (n=8); availability of diagnostic services after hours (n=4); treatment delays due to lack of availability (n=3); the need to transport patients in rural areas to acquire needed services; and a lack of ‘point of care’ testing by mobile services. As a result of problems with access to diagnostic facilities patients may wait undue lengths of time in the ED. Alternatively, some may be admitted to hospital because waits for inpatient diagnostics are shorter than for outpatients.

short term task group progress report – april 2003 32 This was seen as a poor use of resources and a contributor to ED congestion.

4.2.9 Emergency demand

The rate of emergencies ranked 17th among issues affecting emergency services. While some participants noted seasonal increases, other participants noted a shift from seasonal peaks to an increasing or continued problem through the year. Issues raised as sources of the problem included: an inability to plan for continued high volumes, lack of capacity in the ER, and lack of capacity in the higher level referral centres.

4.2.10 Options for referral

Options for referral ranked 12th among issues affecting emergency services. Participants cited the following issues: a lack of options (n=3); limited capacity of higher referral centres (n=3); limited bed availability and access (n=3) and limited availability of specialists.

4.2.11 Procedures required of family physicians

Procedures required of family physicians ranked 18th among issues affecting emergency services. Participants noted a problem with physicians using the ED for non- urgent procedures (n=8). Participants also felt there were issues related to the skill level of family physicians in the ER, including: cardiac response (n=3), intubation/chest insertion (n=3), assessment and triage and ACLS.

4.2.12 Extra ED support staff

Extra ED support staff ranked 8th among issues affecting emergency services. Participants noted the following issues: no support staff at all (n=3); no specific support staff, i.e., porters, ward clerks (n=9), no community access staff (n=4), no multi-disciplinary teams (n=2), lack of RN support staff (LPNs and RTs) (n=3).

short term task group progress report – april 2003 33

4.2.13 Continuing education

Continuing education ranked 10th among issues affecting Emergency Services. Participants noted one issue above all others – lack of funding (n=12). In addition, the issue of staff availability to backfill was raised (n=4). It was also noted that BCAS staff required ongoing education.

The need for standards was another common theme raised by participants. They raised the issue of standards or standard practice in relation to: triage, ED staff and ambulance crew skill levels, and nurse/physician training, certification and competency review. Participants cited issues such as the need for increased nurse training in areas lacking physicians and the need to maintain ED skills and re-certify. Participants also raised issues related to lack of: mentoring, access to training, standardized training, hands-on training for technology, and experiential training for new grads.

4.2.14 Capacity of the system

One issue that was not included in the interview questionnaire but that was repeatedly raised by participants was the overall capacity of the system and its affect on the ER. The issue was raised in the following forms: bed availability and utilization management (ranked 9th); ED overcrowding– moving patients out of inpatient beds and preventing inappropriate admissions (ranked 18th); and as throughput (ranked 20th).

Participants were concerned that changes to the structure and the components of the system–closure of beds/facilities and changing the status of beds/facilities, i.e., acute to sub acute– all have an effect of the rest of the system.

Participants also noted that the availability of walk-in clinics and family physicians was a component of the overall system that directly affected the utilization of ERs.

4.2.15 Physical work environment

Physical plant/space ranked 13th among issues affecting emergency services. While this issue was not included in the interview questionnaire, it was raised by a number of participants (n=8)

short term task group progress report – april 2003 34 4.3 The Short Term Task Group validated the survey findings

The STTG members reviewed the survey data at several stages. The Chair asked them to confirm the HSDA issues and concerns, as well as possible solutions. This was done through a separate poll in which each STTG member prepared his/her own “Top Five Priorities” list. These were then collated and tabulated (Appendix 8). As shown in Exhibit 4.7, the results closely mirrored the survey participants’ priority issues.

Exhibit 4.7 Priority Issues Identified by Short Term Task Group (not ranked)

Issues from survey Nurse staffing Prehospital transport Specialist availability Interhospital transport Diagnostic facilities Emergency physician availability Ambulance service regions Throughput through EDs Lack of available beds Overcrowding Other STTG issues Level of competence in other EDs Overall capacity of system Data tools/ data base Configuration/ balance of acute care system Community capacity for discharge of patients Community support Management of psychiatry patients Lack of bed management systems

short term task group progress report – april 2003 35 CHAPTER 5 BETTER PRACTICES IN EMERGENCY SERVICES

Three separate phases of work helped to identify “better practices” or opportunities for improving emergency services in BC.

First, we asked about better practices in the telephone survey of all HSDAs during December 2002 and January 2003. As with the priority issues noted above, this was supplemented by an additional survey of our STTG members to capture their expertise and knowledge. We asked them to identify their “Top 5 Solutions”.

Second, PESSC and STTG members attended a workshop with an external expert. This session generated numerous suggestions for long and short-term improvements. The complete workshop notes were circulated to all participants for feedback and discussion.

In the third phase, we refined the long list of suggestions to focus on key action steps for moving forward in the short term. The STTG validated these action steps in an exercise conducted at their February 25 meeting. While it is obviously a relative term, “short-term” has been defined as those initiatives that would be: • reasonably expected to be substantially implemented by March 31, 2004, • within a health authority’s mandate, • reasonably manageable in the context of the many competing priorities, • less dependent on recruitment of skilled staff.

5.1 Our survey shows that BC’s EDs have already introduced many Better Practices

In the first phase, our survey of BC EDs included questions about innovations that they had already introduced or were contemplating. The objective was to determine how practitioners have been able to address existing problems. Through this part of the survey we were able to identify some better practices appropriate to urban, semi-urban and rural settings. The previous chapter identified a great variety of issues affecting EDs; this chapter will link issues with opportunities for action.

short term task group progress report – april 2003 36

As noted above, our preliminary work included a review of previous studies in BC and other Canadian provinces; we also conducted a brief assessment of published research (Chapter 3). While not intended to be exhaustive, this was a helpful source for prompting survey participants to identify their better practices.

5.1.1 Managing unscheduled demand

Tactics to manage unscheduled demand are important because we know that many people, especially the elderly, fare better if they are assisted in community settings. Once hospitalized, they are exposed to adverse effects of treatment, disorientation and difficulty readjusting to activities of daily living. All of these may result in unnecessary length of stay, adding to the ALC problem that, in turn, results in back-up in the ED.

All of BC’s HAs are already using a number of these Better Practices (n=HSDA using tactic):

• Referral to 1-800 Nurse Help Line (n=13)

• Canadian Triage Acuity Scale (n=11)

• Fast Tracks and minor treatment areas (n=10)

• Educating staff and patients about community services (e.g., IV clinics, Well Women Clinic, mental health) (n=5)

• Community Health providing support to specific populations (n=5)

• Standardized protocols (n=4)

• Discharge planning occurs in ED (n=2)

• Specialized clinics available from ED (n=2)

• Promotion of injury prevention (n=2).

short term task group progress report – april 2003 37 5.1.2 Accessing specialist care

Many patients can be managed without hospitalization if seen promptly by a specialist. In other cases, consultation is necessary before any decision to discharge or admit a patient. Delays in accessing specialists may, therefore, contribute to slower flow of patients through the ED or even unnecessary hospitalization. Better practices used by BC’s EDs to improve access to specialists include: • Advanced practice nurses (e.g., oncology, hepatitis C, diabetes educators) (n=4) • Fast Tracks to specialist consultation (n=2) • Outpatient clinics in ambulatory areas (n=2) • Digital storage and transmission system for radiology (n=2)

5.1.3 Dealing with congestion in the ED

One of the most vexing problems for providers and patients is managing the unpredictability of demand for emergency services. Surges of workload can occur at any time, although they tend to occur most often during holiday periods due to trauma and in wintertime when influenza outbreaks are prevalent. Staff shortages compound the problem, which may result in cancellation of elective care or unsafe conditions. BC’s EDs have introduced better practices to manage these problems: • Nurse First Call (n=5) • Including ambulance leaders on ED management team (n=5) • Ambulance staff available on-site (n=2) • Daily bed meetings with all managers (n=5) • Utilization management policies, e.g. bed allocation (n=4) • Protocols that deal with peaks e.g. over-flow beds (n=4) • Contingency funding for seasonal pressures (n=2) • Nurses on-call during holidays and peak seasons (n=2) • Nurses allowed to call-in more staff (n=2) • Protocols/clinical pathways for heart attack/ unstable angina/stroke (n=2)

short term task group progress report – april 2003 38 5.1.4 Improving community linkages

This tactic is essential both to prevent hospitalization in the first place and to ensure patients can return home when medically appropriate. As hospital occupancies have increased over the last decade, many HAs have developed better practices to assist patients in returning to their homes and lives:

• Quick Response Teams, discharge planner in ED (n=12)

• Profiling of patients, at-risk registries, care plans (n=9)

• Links with home-care support service to ensure transitioning of patients back to the community, client care coordinators, case conferences (n=6)

• Pamphlets and self-care brochures for patients (n=3)

5.2 The Task Group validated the opportunities for improvement

The survey shows that many better practices are already underway in the HAs. In preparation for the Workshop, the STTG reviewed and validated the survey findings, as noted above The STTG members also reviewed the survey list and each identified their own priorities for improvement (Exhibit 5.1).Their “Top Five Priority Solutions” are shown in Appendix 8 below. These supported the notion that this list of better practices could serve as a guide to HAs to assist in more consistent application.

Exhibit 5.1 STTG Priority Improvement Opportunities

short term task group progress report – april 2003 39 Some consideration could also be given to developing “beacon sites” where emergency demands have been addressed effectively. There was also a suggestion that clinicians and managers from high-performing sites could assist other EDs to implement policies and other changes aimed at emergency services improvement. This group of “better practice” experts could be developed as a network resources to support all EDs.

Notwithstanding the many excellent innovations already in place, this survey showed that there are also opportunities for improvement. Better practices are not applied consistently and many are used sparsely. Some of the ideas that have been successful in other settings could be adapted to BC applications.

5.3 The PESP Workshop was a foundation for action and planning

The second phase of action planning was on February 7, 2003, when the STTG and PES Steering Committee met jointly for a workshop session. The object was to provide a basis for moving on to short-term action planning by building agreement around accessible issues. The Workshop also helped to build a bridge to the work of the Long-Term Task Group by identifying some of the more complex suggestions for future reference (see full workshop notes in Appendix 8).

The workshop keynote speaker was an external resource person, Dr. Fred Dennis, a practicing Emergency Physician and also Lead Administrative Consultant and Clinical Coordinator for ED Redesign at Kaiser Los Angeles Medical Center, California.

An early focus of the workshop was the problem of limited information on performance, and the related problems of data collection and data consistency. It was acknowledged that “one size does not fit all”. Selected system competency measurements need to be customized to reflect realistic expectations for rural & remote, rural & community, rural/urban, and urban settings. All the workshop participants agreed that a composite of indicators would be required covering functional outcome, patient satisfaction, staff satisfaction, and system effectiveness. This topic was considered so important that the Chair of the STTG quickly convened a meeting of an Information Management Sub-Committee. A progress report from that work is included in Chapter 6.

short term task group progress report – april 2003 40 In summarizing his impressions of the workshop at the closing plenary, Dr. Dennis made several points: • “Although there are many excellent innovations, there is a tendency to look outward rather than at what can be done with what you have. This means applying your own critical thinking about whether you have achieved maximum improvements in your own EDs.” • “ This is basically still about communication. Your real strength is your collective energy to address the issues creatively. How will you maintain this communication and liaison after the workshop?” • “Training is a constant theme. How will you identify the priorities and resources for staff development?” • “ Collectively the HAs are joining together to address these issues. Where will the linkage occur? What are your collective goals, especially for consistency and standardization?”

5.4 The PESP Workshop led to many suggestions for improvement

5.4.1. System issues The workshop participants developed concrete suggestions around several topic areas. First and foremost, they identified systemic issues that require system-wide planning. Emergency services do not exist in isolation; indeed, they are often the safety net to support other parts of the health care system. Suggestions included: • The “Winter Action Planning” or “Capacity Planning” concept is helpful for “joining up” many agencies. • Joined-up planning can also serve as a transitioning strategy, to ensure that system-wide planning processes and impacts are considered while the HAs are reconfiguring services. • Agreed upon directives and policies must be applied consistently within and between HAs. For instance, a “No Refusal/ Transfer Back” policy for referral centres could be helpful, but it will require the HA to commit and support. This will certainly require a collaborative agreement with the specialists.

5.4.2 “Upstream” impacts require attention • Most agreed when one commented: “The biggest problem in the system is communication.” This referred

short term task group progress report – april 2003 41 to communication within hospitals, with other agencies and across HAs. • They noted improvement in care of mental health clients in some areas, due to central intake away from the hospital. However, problems continue with care for clients with complex needs, especially with substance misuse. • Engaging differently with primary care is a key strategic initiative expected to have a major effect on demand. • All agreed that there could be many ways to improve linkages with community-based services, for instance home nursing. Providing more advanced nursing skills and GP support to enhance home support, assisted living, and respite would also be useful.

5.4.3 Solutions within the ED • Setting priorities within the ED to address local problems, for instance using different personnel such as Clinical Nurse Specialists to supplement EPs. Another example of priorities would be phasing in the implementation of patient care protocols. • “Unbundling” ED functions (such as scheduled ambulatory care and after-hours services) to find opportunities for process improvement. • Addressing non-nursing duties to improve productivity, for instance with admitting clerks, porters, or social workers.

5.4.4 Solutions related to post-ED impacts • Developing systems so that hospitals can discharge or transfer patients at any time. This would require improved communication, hospitalists, “fast-track” linkages, and methods to provide information to caregivers (including GPs). • Establishing quick-response or Geriatric Assessment and Treatment Units for the elderly. • Provincial guidelines to enable admissions to residential care beds 24/7.

5.4.5 Ways to take the work forward in the short term

• Prepare a communication plan to get information out to people working in the system so they understand the process and plans.

short term task group progress report – april 2003 42 • Develop a process to identify and share information about better practices and “beacon” sites.

• One suggestion was to use the CAEP classification of rural and urban hospitals to assess ED capacity, capabilities and risks. This framework can help determine competencies and hence education needs, as well as equipment and infrastructure appropriate to each level of facility. Applying this framework, discussed further in Chapter 6, would help prevent a “one size fits all” approach and ensure that appropriate expectations are used to guide planning.

• Move ahead with developing “the essential few” indicators and a data collection system using a small group of experts led by a consultant.

• Develop guidance for HAs to use to implement system- wide winter action or capacity plans.

5.5 Task Group recommends short term action steps

The third phase of action planning occurred at the February 25 meeting of the STTG, which focused on short-term initiatives likely to be of benefit to HAs. This led to a lively discussion to determine clear priorities for early action.

Underlying Task Group members’ discussion was a common concern about the human resource situation that had featured so prominently in the survey of HSDAs. This complex topic involves many matters beyond the scope of the Task Force’s mandate. However, there was consensus that remuneration, recruitment, development and retention of clinical staff will be key success factors for any of the initiatives. These should be aligned with clinical priorities and strategic directions for service improvement in each HA.

In several discussions, the Task Group grouped opportunities for early action into five themes discussed below. In addition to identifying these themes, the Task Group also suggested factors that could help or hinder progress with each recommendation. A general discussion follows, with supporting detail in Exhibit 5.2.

5.5.1 Improve information management. The one issue that dominated discussions with STTG members was information management. All the subsequent recommendations require better information for planning and quality improvement. Consistent data collection, performance indicators and information management systems are as important for quality improvement and planning as they are for

short term task group progress report – april 2003 43 improving patient care. Good quality data could ultimately be used for benchmarking and resource planning.

5.5.2 Use the Canadian Triage and Acuity Scale consistently and appropriately in all EDs. CTAS is a tool for providing and monitoring patient care as well as for planning, so it requires separate consideration. Presently CTAS is used inconsistently in BC EDs. The STTG members pointed out that differences between rural and urban settings will be important considerations in implementation; hence the term “appropriately” is used in the recommendation. Also, resources will be required for implementing this system, notably for staff education.

5.5.3 Identify within each HA a senior executive to lead system-wide planning for emergency services. Such a role will ensure that emergency services issues are addressed holistically at a strategic level in the organization. Unless all aspects of health services are considered, unintended consequences may simply transfer emergency pressures elsewhere in the system. This executive would lead the organization in linking key concerns and issues with appropriate management action. The personal qualities and characteristics of all the individuals involved in redesigning emergency services will obviously be critical to its success. For this role, in particular, exceptional leadership will be required. Policy change would sometimes require executive support, for instance to change organizational culture related to discharge times. Incentives may be appropriate to encourage people to tackle some of the long-standing difficult issues. To be successful, the STTG recommended that this role would require organizational supports, including planning support, policy authority, and contingent resources to manage “rogue waves”.

5.5.4 Develop systems to coordinate and manage access to in-patient and diagnostic resources. At the policy level, this might include, for instance, the ability to admit or discharge patients at all appropriate times. Processes to support this might involve enhanced linkages to other services, and methods to give patients and caregivers instructions. From a structure perspective, this might involve hiring bed utilization managers or hospitalists. It would also be helpful to create the coordinating capability for facility-wide access to in-patient beds.

5.5.5 Develop processes for community co-ordination and planning. This might mean developing an unscheduled services team with representatives from appropriate community organizations, BCAS, bcbedline and primary care to manage “after-hours” utilization. Success in the Lower Mainland suggests the wider use of regional plans for ambulance diversions. Community co- ordination may also lead to expanded home care support or home nursing services delivered from EDs. The STTG also suggested short term task group progress report – april 2003 44 that the process to move forward with any of these recommendations at the HA level should be based on respect and trust, accountability, and consistency, the behaviours exhibited at the STTG. This was described as a change in attitude: “a sense of ownership, so that people offer to help the ED, rather than being pushed unwillingly”.

Exhibit 5.2 provides additional detail on all these themes from the discussion with STTG during several meetings.

Exhibit 5.2 STTG Short-term Action Steps and Enabling Factors

Use the Canadian Triage and Acuity Scale consistently and appropriately in all EDs General Comments • acknowledge urban versus rural variance • CTAS should be seen as suggested guidelines, not “legislated standards” • CTAS was developed to be used a clinical tool • it could also provide credible data to assess resources • a CTAS version is being adopted in USA to address ER congestion.

Enablers • education & training process, e.g., 1/2 day didactic sessions • requires individual facilities to develop protocols • scenario planning would be helpful • dedicated space for a triage location re: confidentiality, vital signs • designated staff to triage • 24/7 application • need critical mass, modify according to volume limits • all patients should be assigned a triage level • develop/implement CQI process to ensure quality control

Identify within each HA a senior executive to lead system-wide planning for emergency services.

General Comments • avoid creating more “silos” • this role could facilitate coordinated planning & decision making that considers the impact on EDs

Enablers • requires an appropriate organizational structure & supports • appointed executive must have the power, ability & time to do the job plus other characteristics such as capability, credibility, and respect.

short term task group progress report – april 2003 45 Exhibit 5.2 continued…STTG Short-term Action Steps and Enabling Factors

Develop systems to coordinate and manage access to in-patient and diagnostic resources.

General Comments • bed utilization management helps but does not resolve ED congestion • proprietary systems can be used to measure appropriateness of admission, e.g., ISD, MCAP, etc.

Enablers • ensure “round the clock” accountability within the hospital; expand “in-house” support resources beyond M-F, 9 am- 5pm hours • develop over-census policy • “shift in culture” to shared accountability, responsibility and goals • standardize discharge process and policies, e.g., “standard” discharge times • regular communication about performance • ownership for CQI processes • “incentives” to move patients out of ED

Develop processes for community co-ordination and planning.

Enablers • requires a “major shift in culture” • creative scheduling of staff resources, e.g., 1-10 pm social worker • flexibility to tap into additional resources • access to community resources • access to primary care • improved communication to & from doctors’ offices • mechanisms to return patients to LTC facilities on week ends

short term task group progress report – april 2003 46 CHAPTER 6 SHORT-TERM RECOMMENDATIONS AND NEXT STEPS

As noted in the previous chapter, the STTG identified opportunities for early action according to five themes:

1 Improve information management.

2 Use the Canadian Triage and Acuity Scale consistently and appropriately in all EDs.

3 Identify within each HA a senior executive to lead system- wide planning for emergency services.

4 Develop systems to coordinate and manage access to inpatient and diagnostic resources.

5 Develop processes for community co-ordination and planning.

This chapter discusses how these initiatives related to these general themes can be progressed provincially and within each HA. These are certainly not all the good ideas that would be feasible; they may not all be high priorities in every HA. However, we have tried to identify some short-term provincial solutions to improve the situation. Again, we defined as “short- term” those initiatives that would be: • reasonably expected to be substantially implemented by March 31, 2004 • within a health authority’s mandate, • reasonably manageable in the context of the many competing priorities, • less dependent on recruitment of skilled staff.

Each recommendation below addresses these themes in three ways. First we develop the general recommendation with some ideas that could be used at the HA level. These ideas will only be examples and will require local adaptation as the intention is to provide high-level guidance. We have referenced sources for these ideas in Exhibit 6.3.

Second, each theme results in some “immediate actions”, those steps that can be implemented at once. All of these are measurable and specific, with action statements and timeframes.

Third, some issues will be referred to the Longer-Term Task Group. We have provided supporting information for these to assist the LTTG to build its work-plan. Even among these larger issues, some immediate action steps are identified so as to ensure continuity in taking this work forward.

short term task group progress report – april 2003 47 Â Recommendation 1

6.1 HAs should gather better information that can contribute to better performance

Good data to provide information on performance is important, not just a way for EDs to “score well”. Task Group members all noted that high-performing systems have a respect for information and invest in data infrastructure. Information is required for strategic planning, for feedback to clinicians, and to shape and monitor specific quality improvement initiatives.

As noted above, better production and use of information to manage emergency services was the over-riding concern of the STTG. Accordingly, an Information Management Sub- committee has been created. This group has already held one meeting and approved the following work plan:

1.1 Create a plan for a province-wide information management program for EDs.

1.2 Ensure that appropriate patient care protocols are available in all EDs for high-risk or high-volume care. Adherence to protocols should be part of the monitoring system.

1.3 Create indicators of performance for emergency services.

1.4 Use CTAS consistently and appropriately in all EDs.

1.5 Assess feasibility, success factors and other requirements for the information system.

This work plan captures many of the issues already identified. Some of the recommendations below belong with HAs; others will be referred to this group.

STTG members noted the concern about customizing data collection and referred to differences based on the “rurality” of facilities. As an example, the Canadian Association of Emergency Physicians has addressed this issue (see Exhibit 6.1).

1.6 The STTG recommends that HAs should analyze their EDs using the CAEP framework, as a helpful basis for tailoring policies and redesign activities to local needs.

short term task group progress report – april 2003 48 Exhibit 6.1 The Canadian Association of Emergency Physicians framework for levels of rural health care facilities

Source: CAEP, 1997.

Level of Rural Emergency Health Care Facility

Rural 1 Rural 2 Rural 3 Rural 4 Rural 5

Typical Rural industrial Remote or Very small Medium Larger rural location site. isolated rural sized rural communities. community. community, communities. often near a larger one.

Service Not open 24 Not open 24 Not open 24 Open 24 Open 24 availability. hours. hours. hours. hours. hours. Provider might Provider might Physician be on call. be on call. usually on call.

Physician Usually not on Usually not on Local Local Local Staffing site. site. physicians physicians on physicians on Might visit on call. call. call. periodically. Should have Should have in-house ED in-house ED staffing when staffing when volumes are volumes are high high

Registered Optional, Broadly trained May include Registered Registered Nurse depending on nurses with a mix of nurse 24 nurse 24 Staffing local additional skills basic and hours/day. hours/day. regulations. and training. advanced Nurse Nurse nurse skills manager manager and training. skilled in skilled in emergency. emergency.

Management Protocols for Protocols for May be Nurse and Nurse and stabilization, stabilization, provided by physician physician triage, triage, nurse, dual manager dual manager communication, communication, administrator team, team, local treatment local treatment or physician preferably preferably and transport. and transport. manager. both with both with additional additional emergency emergency training. training.

6.1.1 Getting started with indicators

As the PESP Workshop participants agreed, data should support action planning and performance management. They recommended that surrogate measures for each indicator should be easily and readily collected in a timely manner. Also, indicator development should align with and enhance the accreditation requirements.

short term task group progress report – april 2003 49 While acknowledging the need to customize somewhat, they recommended that well-functioning emergency services systems should be operated under a broad set of performance measures including: • functional outcome for patients, including evidence-based clinical indicators • patient satisfaction • staff satisfaction • system effectiveness, including stewardship of resources.

Immediate action: The Information Management Sub- committee has included indicators of performance for emergency services in its work plan.

6.1.2 Assessing inputs to the ED

The Canadian Triage and Acuity Scale (CTAS) should be applied consistently in all EDs for effective triage to predict level of acuity, admissions, resources, and so on. There must also be resources to educate staff on how to use CTAS properly plus the right systems in place to use it effectively and to sustain application. CTAS may need some modification to meet the needs of rural facilities appropriately.

Immediate action: The Information Management Sub- committee is analyzing implications of applying the Canadian Triage and Acuity Scale (CTAS) consistently in all EDs.

6.1.3 Assessing practice within the ED

Patient care protocols should be made available to all EDs for a prioritized set of high-volume or high risk cases such as pneumonia and antibiotics; thrombolytics and management of chest pain; trauma; asthma; head injury; meningitis. Appropriate measures could then be defined for all of these. As shown above, the survey of BC EDs revealed many instances of better practices–but also inconsistency in how these are applied across BC. Better practice should be supported with better tools and a plan to assess and disseminate the improvements.

short term task group progress report – april 2003 50 Immediate action: The Information Management Sub- committee is analyzing implications of providing patient care protocols to all EDs for a prioritized set of high volume or high risk cases.

Undertake periodic patient satisfaction surveys within EDs. A joint HA/MoH/S steering committee has already initiated this work, with EDs being one of the settings for early application. Staff satisfaction surveys could also be used to assess opportunities for improvement through better practice.

1.7 ED patient satisfaction will be sampled in the 2003/04 fiscal year in all HAs in the province.

6.1.4 Assessing outputs from the ED

The Task Group identified a number of indicators related to flow out of the ED to other areas that might be considered for monitoring: • Percentage admitted patients and length of time to admission • Patient left without being assessed • Time to see specialists and diagnostics • Time to discharge/home care with appropriate support at home • Re-admission to ER (defined as return in 48 hours with the same diagnosis) • Linkage to GPs – appropriate follow-up – getting information to them • Use of Critical Care Bypass or Redirect

In smaller hospitals, other measures are also important: • Transportation (time to transport, inability to return patient) • How long patients are held awaiting move to nearest ‘appropriate’ centre

Similarly, the BCMA section of Emergency Medicine has identified data capability as a top priority. It recommends standardized data collection, benchmarks for time to care (e.g. Canadian Triage and Acuity Scale), and evidence- based planning.

short term task group progress report – april 2003 51 These recommendations echo similar points made in the 1998 Emergency Services Coordinating Committee report.

Immediate action: The Information Management Sub-Committee will be asked to take these ideas about performance indicators forward into its planning.

Ë Immediate action on Recommendation One

Because of the consistent emphasis on this topic, work has already begun to identify requirements to improve data collection in the province’s EDs. The Information Management Sub-committee has held one meeting. This IM/IT work is already underway with these initial steps:

• Initial observations developed on what EDs are collecting in terms of data.

• Survey drafted to collect data from hospitals throughout the province.

• Review of potential information management software solutions.

• Research collected on performance indicators and measurements in other jurisdictions.

short term task group progress report – april 2003 52 Â Recommendation 2

6.2 A senior executive should lead system-wide planning for emergency services within each health authority

Because ED pressures are often driven by broader system issues, it is important to ensure that these are addressed holistically at a strategic level in the organization. A regional structure can drive collaborative planning, using the influence of an identified executive to link key concerns and issues with appropriate management action.

The STTG recommends an integrated approach to developing leadership for emergency health services in each HA, based on the discussion and three linked recommendations below.

6.2.1 One HA has already proposed a regional coordinating structure

VCHA is considering a “Regional ED Leadership Coordinating Structure”. Such a model appears suitable for implementation in most of BC’s health authorities. The stated purpose is “to facilitate the development and implementation of strategies, policies and practices directed at improving the access and care of ED patients.” Guiding principles for this structure include collaboration and peer support, a systemic and analytical approach, and shared accountability for improving emergency access.

The proposed structure includes: • a regional ED council with Administrative and Medical Co- Chairs, • an Executive Lead, • sub-committees (Redirect, Rural, Access, Workforce, Best Practices) and • dedicated staff support.

short term task group progress report – april 2003 53

6.2.2 Some initiatives will require Executive Team support for implementation in the HA

Many planning and policy issues would require the support of the senior executive team in each HA. They have much larger implications than within the ED alone; others would require resources for monitoring and performance management; some might even require incentives or sanctions for adherence. In some cases, executive leaders will need to address changes in attitude and culture with consistent applications of policies that improve access. For instance: • “no refusal” guidelines for access to specialist care, including provincial programs; • ambulance redirect strategies for ED and inpatient bed congestion; • regional planning for service redesign and reconfiguration; • policies to enable key programs to admit or discharge patients at all hours, including “Transfer Back” arrangements with referring agencies; • protocols for after-hours access to community and primary care services; • internal contingency planning.

In some cases contingency planning will identify a need for additional resources to manage unanticipated pressures. The executive lead for emergency services should be able to allocate contingency funds as appropriate to expedite service improvements.

6.2.3 Clinical leadership is important

As seen in the VCHA structure, clinical leadership is a vital part of making these changes. The analysis, planning, and policy development proposed above will be enriched and validated with the input, participation, and implementation skills of clinical leaders. Accountable champions of emergency services redesign should be identified and developed as part of the strategy. Multi-disciplinary teams will be needed for leading the process of changing practice.

short term task group progress report – april 2003 54

6.2.4 Good data will be required to support policy development in HAs

In addition to the data required for improving emergency services performance, it will be important to understand how the entire health services system performs. Data will be required for planning, managing change and monitoring improvements. Exhibit 6.2 shows how some readily available measures can be used for planning purposes. This type of benchmarking can assist to analyze current functions as a first step towards process improvement. This type of data collection could be developed locally to address HA or HSDA requirements. Alternatively, it could be developed at the provincial level for consistency in comparison of programs, resources and performance.

Exhibit 6.2 Data points for analyzing options and impacts for emergency services

Managing Accessing Dealing with Improving unscheduled specialist care congestion in the community demand in hospitals ED linkages

1 Unscheduled 1 Wait for urgent 1 Wait after arrival 1 Wait after care visits /1000 care for triage, referral to LHA pop’n. treatment, another centre 2 ED capacity admission 2 Services (e.g. stretchers) 2 Acute beds/ available per 1000 pop’n 2 Occupancy of 1000 pop’n hospital for 3 Distance to 3 Availability of specified services next facility and emergency MDs map of (e.g. whether on- 3 Distance to next adjacencies. call or staffed, facility specialists, GPs 4 Out of region or EPs) 4 Utilization by admits via ED emergency admits per 1000 pop’n

short term task group progress report – april 2003 55 Ë Immediate action on Recommendation Two

2.1 All HAs should appoint an executive lead for emergency services by June 1, 2003.

2.2 HAs should identify or confirm by June 30, 2003 the resources required in each HSDA for clinical leadership in emergency services.

2.3 HAs should work with PHSA to develop appropriate educational sessions for all the executive and clinical leaders in emergency service.

Â Recommendation 3

6.3 HAs should develop systemic approaches to coordinate and manage access to in-patient and diagnostic resources

In recommendations 3 and 4, the STTG has identified broad areas for priority development in the short-term. With a focus on actions that would have an impact within a year, these suggestions focus on leverage points where the greatest influence and impact can be felt.

Many better practices were identified in Chapter 5, and hence are only referenced in this chapter. Also, Appendix 9 provides the STTG analysis of these, with complete literature sources in the Bibliography. HAs are in the best position to determine which solutions would work best for them. The STTG hopes that executives within each HA will explore every opportunity to apply these Better Practices. However, some collaboration across HAs would certainly help in implementation. PHSA has already offered to assist in this collaborative work.

Recommendation 3 looks inward at actions that could be taken within hospitals. Task Group members selected this area as a priority for directly addressing the problems they deal with on a daily basis. Most outside observers would agree. The relationship between emergency care, critical care, and the peri- operative areas must also be a priority.

At the micro level, patient-centred clinical pathways for common conditions were also identified by the Task Group. (This was also a key recommendation of Ontario’s Hospital Report 2001: ED Care.) Standardized protocols and guidelines should be agreed by clinicians and widely disseminated and implemented. Consistent adherence to these pathways can then be measured as part of the quality management program in the acute care program. short term task group progress report – april 2003 56

Again, the Emergency Medicine Section of BCMA identifies two key aspects of this approach: for HA executives and MoH/S to make access a top priority, and to use a multidisciplinary team to develop strategies. They go on to recommend use of access directors or bed utilization managers and hospitalists. These recommendations are very similar to those made in the 1998 Emergency Services Coordinating Committee report.

The STTG recommends the following actions: 3.1 Create the coordinating capability for facility-wide access to inpatient beds. This would include the ability to admit or discharge patients at all appropriate times, 24/7. This could include using hospitalists, linkages to other services, and methods to give patients and care-givers instructions and information. 3.2 Create mechanisms to identify and release in-patient beds for use of emergency admissions on a proactive basis. 3.3 Undertake a planning process in each hospital to identify the daily and seasonal average number of beds required each day for emergency admissions, and create a proactive process to make these beds available.

Ë Immediate action on Recommendation Three

3.4 HAs should ensure that every regional hospital (or any hospital with ED visits greater than 20,000 per annum) has an assigned bed utilization manager or access director and a bed utilization management process. Where this is not already in place, this individual should be hired by June 30, 2003 with a mandate to address the three STTG recommendations noted above.

3.5 Discussions should proceed immediately through the LTTG to create a plan of work related to developing guidelines and protocols to meet clinical needs in emergency services.

3.6 PHSA and the other HAs should develop a plan to build a network of peer-based process improvement resources (“better practice experts”) to share information about improving emergency services.

short term task group progress report – april 2003 57 Â Recommendation 4

6.4 HAs should improve outcomes and access through better co-ordination in planning community services

This recommendation, is distinct from the previous one in that it looks outwardto the community or larger health services system at actions that could be taken to improve emergency service delivery. BCMA’s Emergency Medicine Section considers this an important area for improvement, recommending nursing home protocols, proactive elderly intervention and changes in the way primary care is delivered.

Numerous suggestions throughout this report point to better practices in this area. The key concept is the “joined-up planning” approach that has been so successful in the UK National Health Service. The purpose of this work is to identify the linkage points, gaps, and bottle-necks that affect access; this can then be analyzed for seasonal pressures, staffing shortages and other risks. Local needs will vary in each HA and HSDA so the planning process should allow for this variation. The guidance attached as Appendix 10 provides an overview of the Winter Planning approach in the BC context.

4.1 The STTG recommended the following steps for better coordination with community services: a. Develop an unscheduled services team within each community to manage “after-hours” utilization, to include representatives from appropriate community organizations, BCAS and primary care. b. Create regional plans for ambulance diversions to alternate facilities, to avoid inpatient bed congestion as well as ED congestion. c. Where workload merits, expand 24/7 home care support and home nursing services delivered from EDs. d. Create mechanisms to supply services into the community for common non-emergent conditions or care requirements that may result in an ED visit or inpatient hospitalization. e. Build a “whole systems” approach to partnerships. This requires a multi-agency planning group that meets regularly to discuss issues around capacity, demand levels and access. f. Create communication plans that support both strategic goals (e.g. public education) and operational goals (e.g. to link front-line managers).

short term task group progress report – april 2003 58 Ë Immediate action on Recommendation Four

4.2 Each HA should appoint a team with an executive sponsor and led by a designated staff person to organize a joined-up planning approach as outlined in Appendix 10. The first meeting of this team should occur before June 30, 2003, with preliminary plans, implementation strategies and resource requirements completed by September 15, 2003. Some dispersed HAs may need planning teams in each HSDA.

4.3 PHSA and the HAs should develop a planning framework, infrastructure support and educational resources to support this joined-up planning work.

4.4 PHSA will convene a meeting of HAs by April 30, 2003 to identify any common resource requirements for this work, such as 24-hour home care and focused support for medical needs in residential facilities.

6.5 Some issues will be referred to the Longer-Term Task Group

There are so many opportunities for improvement that some issues could not be explored in detail during this phase of the work. All of the following suggestions were validated by the STTG as meriting further study; these will be referred to the LTTG for follow-up. They are listed here for reference with some supporting information.

6.5.1 Create a province-wide information management program for EDs

This could be used to develop predictive models for anticipatory planning. Our early analysis of the data shows that bed occupancy, ALC, acute and emergency utilization, and critical care resources vary across HAs. As these have an impact on access, it would be helpful to identify any as root causes of ED pressures. Combined with provincial indicators of performance, this information can also provide a common approach for HAs to benchmark services for service balancing and redesign.

5.1 Immediate action: PHSA to continue work with MoH/S staff to develop data sources that build the picture of emergency services in BC for benchmarking and planning.

short term task group progress report – april 2003 59 6.5.2 Apply Better Practice consistently

Peer-based improvement “collaboratives” could share process improvements in EDs. For instance, IHA has developed a registry system for high users that includes care plans and contact details for caregivers. Introducing this type of change can be facilitated with advice from the pioneers. This could also include a process to share information about better practice sites, which would be recommended by the LTTG.

Recommendation 3.2 above identifies high-risk, high-volume care as the priority for protocols and guidelines. Chronic care protocols are more complex. The LTTG will be asked to consider a process to create clinical pathways for more complex care needs that will be available for all EDs, updated by clinical leaders, and posted on a web site available to all practitioners. This work will be linked to the provincial initiatives related to Chronic Disease Management.

6.5.3 Use whole-system planning to manage complex issues

Human resources, particularly availability of nurses, was identified as the most significant issue affecting all EDs. Resolving this urgent problem requires an approach far beyond the mandate of the STTG or even the LTTG. This topic will be a priority issue referred to the LTTG .

A provincial process will be required to identify common training requirements for ED staff and to facilitate mechanisms to deliver this education in both rural and urban areas. This could include advanced practice roles and/or delegation of function within EDs and also BCAS.

Some issues fall within the mandate of HA emergency services. The CAEP framework (Exhibit 6.1) could be used as a basis for developing standards for categorization of emergency services in order to assess priorities for staff development.

5.2 Immediate action: Develop briefing note and proposal about training and professional development needs of emergency services staff and take to LTTG.

5.3 Immediate action: HAs need to examine whether and how non-nursing duties in EDs are affecting staff retention, and patient access, throughput and performance in their emergency service system.

short term task group progress report – april 2003 60 Create a system-wide approach to access and transfer to manage cross-boundary referral and transportation issues. FHA and VCHA have collaborated with bcbedline and BCAS to implement a Redirect and Critical Care Bypass system to manage ED workload. The new system is still being tested and improved. Once it is stable, it would be helpful to consider how this approach could be introduced in other HAs. Such an approach can be particularly helpful in regional areas where a single hospital is the only specialty site. In these cases, contingency planning to transfer less critical patients can be instrumental in depressurizing situations before they become unsafe for patients or staff.

5.4 Immediate action: Identify structure and resources required to implement a redirect and critical care bypass system throughout the province.

5.5 Immediate action: HAs should use the system planning approach noted in Recommendation 4 above to analyze how access to specialists and specialized facilities could be enhanced.

Develop high-profile public educational programs (as in Ontario) to advise the public of the most appropriate sources of health and illness information in order to avoid unnecessary utilization of hospital and walk-in clinic resources.

5.6 Immediate action: Develop briefing note and proposal for LTTG about public education.

6.5.4 Develop solutions related to the patients’ journey

Study the feasibility of using resources such as the BC Nurseline to support residential care facilities and BCAS in reducing unnecessary transportation to EDs. (This should involve discussions to resolve professional, medical-legal and regulatory issues that currently prevent management of patients in the community.)

Create mechanisms for staff in residential facilities to access medical information and support on a 24/7 basis so that care for residents can be provided in their own facilities. Improve the adoption, utilization and communication of advanced directives for patients in long-term care and residential facilities.

short term task group progress report – april 2003 61 Achieve better movement of patients between facilities by analyzing ways to expedite transfer of patients based on acuity, distance traveled and so on. Create accountability and incentive mechanisms for care in residential facilities to enable more medical care to be provided, obviating the need for ambulance transport and ED visits. This could include the development of a rapid geriatric triage system.

5.7 Immediate action: Develop briefing note and proposal to take to LTTG about support mechanisms for residential care to reduce unnecessary use of emergency services.

Develop dedicated, comprehensive services for mental health clients to avoid traumatic ED situations. This refers especially to the need for services to those suffering serious mental illness and substance misuse. This was a key recommendation of the 1998 ESCC report.

5.8 Immediate action: Develop briefing note and proposal to take to LTTG about support mechanisms for those suffering from concurrent serious mental illness and substance misuse.

The very nature of emergency health services is unpredictable. These recommendations of the Short-Term Task Group suggest that there are many ways to manage performance better and more consistently. This report outlines an approach to improving access to emergency services. It proposes significant, but manageable change to deliver faster, consistent, high quality care tailored to patients’ needs.

short term task group progress report – april 2003 62 Exhibit 6.3 Sources for the recommendations directed to Health Authorities

Please also see Appendix 9

Recommendations that are directed to HAs for Text reference Bibliography follow-up, consideration or action. (Some (page) Reference recommendations are directed to Long Term Task (citation #) Group or Information Management Sub-committee.) 1 HAs should develop better information that can contribute to better performance. 1.2 Ensure that appropriate patient care protocols 3.2, 3.3, 5.1.1, 2, 3, 30, 37, 51, are available in all EDs for high-risk or high-volume 5.1.3, 5.2, 5.4.3, 82 care. Adherence to protocols should be part of the 6.1.3, 6.5.2 monitoring system. Appendix 10

1.4 Use CTAS consistently and appropriately in all 3.2, 5.5.2, Exhibit 22, 35, 60 EDs. 5.2, 6.1.2, 1.7 Undertake periodic patient satisfaction surveys 6.1.3 14 within EDs.

2 A senior executive should lead system-wide 5.5.3, 6.2.1, 6.2.3 planning for emergency services within each Health Authority.

3 HAs should develop systemic approaches to coordinate and manage access to inpatient and diagnostic resources 3.1 HAs should create the coordinating capability Exhibit 3.2, 4.2.7, 14, 51, 54, for facility-wide access to inpatient beds. This 4.2.8, 5.1.2, 5.1.3, would include the ability to admit or discharge 5.5.4, Exhbit 5.2, patients at all appropriate times, 24/7. This could 6.2.1, 6.2.2, include use of hospitalists, linkages to other services, and methods to give patients and care-givers instructions and information.

3.2 HAs should create mechanisms to identify and 5.1.3, 5.5.4, 31, 32, 33, 38, 68, release in-patient beds for use of emergency Exhibit 5.2 admissions on a proactive basis. 3.3 HAs should undertake a planning process in each hospital to identify the daily and seasonal average number of beds required each day for emergency admissions, and create a proactive process to make these beds available. 3.4 HAs should ensure that every regional hospital (or any hospital with ED visits greater than 20,000 per annum) has an assigned bed utilization manager or access director. Where this is not already in place, this individual should be hired by June 30, 2003 with a mandate to address the recommendations above.

short term task group progress report – april 2003 63

Recommendations that are directed to HAs for Text reference Bibliography follow-up, consideration or action. (Some (page) Reference recommendations are directed to Longer Term Task (citation #) Group or Information Management Sub-committee.)

4 HAs should improve outcomes and access through better co-ordination in planning community services. 4.1.a. Develop an unscheduled services team within 5.1.1, 5.1.4, 5.4.2, 33, 86, 88 each community to manage “after-hours” 5.5.5, Appendix utilization, to include representatives from 10 appropriate community organizations, BCAS and primary care. b. Create regional plans for ambulance diversions 5.1.3, 5.5.5 33, 83 to alternate facilities, to avoid inpatient bed congestion as well as ED congestion. c. Where workload merits, expand 24/7 home care 5.1.4, 5.4.2, 5.4.4 14 support and home nursing services delivered from EDs. d. Create mechanisms to supply services into the 5.4.2, 5.4.4 28, 39, 70, 81 community for common non-emergent conditions or care requirements that may result in an ED visit or in-patient hospitalization. e. Build a “whole systems” approach to 5.4.1, Appendix 31, 47 partnerships. This requires a multi-agency planning 10 group that meets regularly to discuss issues around capacity, demand levels and access. f. Create communication plans that support both 5.4.2 strategic goals (e.g. public education) and operational goals (e.g. to link front-line managers).

4.2 Each HA should appoint a team led by a Appendix 10 28, 31, 33, 54, 61, designated staff person to organize a joined-up 5.5.5 63, 64, 65, 82 planning approach. The first meeting of this team should occur before June 30, 2003, with preliminary plans completed by September 15, 2003. 4.3 PHSA and the HAs should develop a planning framework and educational resources to support this joined-up planning work.

short term task group progress report – april 2003 64

5 Longer Term Recommendations 5.3 HAs should examine whether and how non- 5.4.3 nursing duties in EDs are affecting access, throughput and performance in their emergency service system.

5.5 HAs should use a system planning approach to 4.2.7, 5.1.2, 5.4.1, 33, analyze how access to specialists and specialized Appendix 10, facilities could be enhanced.

short term task group progress report – april 2003 65 CONCLUSION

This progress report has gathered the helpful suggestions of many committed individuals dedicated to the improvement of emergency services across BC. We are confident that implementing the recommendations could make a difference in service delivery, as well as improving patient and staff satisfaction, and system effectiveness. The next task is to ensure that at least some of these ideas are introduced so that their benefit can be assessed.

Throughout, we have been concerned with two objectives. The first is feasible action– ensuring that the ideas have practical relevance to our dedicated front-line providers. Change will be most effective where it is brought about locally through the close involvement of professional staff responding to the patients’ needs in their community. Ultimately it will be up to clinicians and mangers within HAs to determine whether and how to implement any of these suggestions as part of their redesign plans for emergency services. PHSA is willing to support these teams as appropriate.

The second objective is to achieve results that are meaningful for patients − ensuring that the actions have a positive impact on patient care. We all need to know that emergency care will be there when we need it without delay. For the vast majority of people, visiting the ED is fortunately a rare occurrence. They need to have confidence that their problem will be quickly identified by appropriately qualified staff and, if treatment or hospitalization is needed, that this will be delivered quickly and to a high standard. Our aim is to put patients and their families at the very centre of improved emergency health services.

The LTTG will continue with this important work. As we strive to improve performance in our emergency services, there is much to be done and much to learn. However, all agree that we want staff working in BC’s emergency services to be able to practice their professional skills in an environment of which they can be proud. And we want patients to receive the best emergency services we can provide.

short term task group progress report – april 2003 66

APPENDICES

short term task group progress report – april 2003 67 APPENDIX 1 CEO LEADERSHIP COUNCIL BRIEFING NOTE (APPROVED: NOVEMBER 18, 2002)

Subject: PHSA Priority System Performance Improvement (Schedule A) Emergency Services

Background Emergency Services is a priority system performance improvement deliverable assigned to the PHSA by the MOH/S as a part of its 2002/2003 Performance Agreement. This deliverable is also found in the respective Regional Health Authority Performance Agreements with the MOH/S.

Development Strategy There is a strong desire across the province to improve the utilization and effectiveness of the Emergency Services system in BC. There is an opportunity to develop a provincial collaborative approach to the understanding of the key enablers to effective ER utilization and care – many of the enabling strategies will take time to develop and implement, both in and outside the acute care system. There are however ongoing emergent problems that place hospital EDs in a state of continual stress, with few short-term solutions apparent for more appropriate access and egress from the ER.

With the short and long term states in mind, the PHSA will coordinate and support a two-pronged approach, with two groups that will be created simultaneously, in addition to a province wide PES Steering Committee.

Creation of a time limited task group to address emergent problem solving and planning needs. This time limited group will use their collective expertise, and the resources of outside expert advice to identify and examine the emergent problems, and recommend solutions to a Provincial PES Steering Committee. After a period of time, not exceeding approximately twelve months, this group will merge their interests with the team below.

Creation of a planning team with a mandate for the longer-term reform of the Emergency Services System.

A provincial collaborative approach will be created to the understanding of the key barriers to effective utilization of Emergency Services resources. The intra- authority provincial team will participate in the creation of a high level description of the Emergency Services process, its components and inter- relationships. This will include the description of the roles and relationships of community emergency resources, including walk in clinics, use of BC Health Guide resources, family practitioners offices, public health resources, early intervention programs, ambulance service and bcbedline services. At the hospital level, the team will support a similar descriptive process of acute care resources that impact the flow of patients out of the ER, such as OR’s for emergency surgery, ICU’s, surgical and medical beds, home care and residential care. A concurrent review of best practices in ER management and necessary data collection will take place, along with development of guidelines for appropriate utilization of ER services. With consulting support, process gaps will be identified short term task group progress report – april 2003 68 and redesign options identified to effect major change in Emergency Services. Modeling techniques will be utilized to test options for improvement in the process. Desired outcomes will be identified, and measured through indicators of performance of critical elements of the whole process, in the community, the ER and other acute facility resources.

The two teams will work under the auspices of a Provincial Emergency Services Steering Committee (PESSC) of senior management officials of the regional health authorities to guide the development of the project. Representatives from other organizations, such as the BC Ambulance Service and the Canadian Association of Emergency Medicine, will join this core group as determined.

The first priority of this group will be to clarify and develop consensus around the intended outcomes of the project and to set out a work plan, including timelines for completion of various components of the work plan for each of the core task groups. The PESSC will determine any other advisory teams, work groups, and advisors and consultants that will be required to conduct the project. Target Date for the first meeting of the PESSC will be by December 1, 2002. The PESSC will be comprised of representatives from the Regional health authorities and the Ministry of Health.

During the course of the project, the PESSC will:

1. Undertake an assessment of the current state of emergency services within the province and elsewhere, and the information that is available or required to assess the opportunities for improvement in the service in BC. An important component of this work will be development of a comprehensive standardized provincial overview of the status of emergency services province wide.

Based on this review, establish the imperatives for the improvements in the service and related timelines for the conduct of the work required.

2. Conduct a review of well-functioning models of emergency services in BC and other jurisdictions, including best practice and other literature reviews, and develop proposals for the redesign of the provincial system of emergency services, including the development of standards, goals and targets for significant improvements in the performance of the system.

Improvement opportunities for organizational and service levels may be identified to: • Impact the demand on emergency services. • Improve the delivery of emergency services, and • Improve mechanisms to move emergency patients to appropriate levels of care and service. • Measure the effectiveness of any improvements to the system and create information resources for continuous improvement of emergency services.

3. Support the development and operationalization of a comprehensive implementation plan.

short term task group progress report – april 2003 69 APPENDIX 2 PROVINCIAL EMERGENCY SERVICES STEERING COMMITTEE TERMS OF REFERENCE

1.0 MANDATE

The Provincial Emergency Services Steering Committee (PESSC) is responsible for providing strategic direction and overall management of the Emergency Services Performance Improvement Project. The Committee will oversee all aspects of the project and will support the achievement of the Performance Agreement objectives for the Health Authorities which were established by the Ministry of Health Services. The overall goal is to improve the access, utilization and effectiveness of the Emergency Services system within BC.

For the purposes of this project, Emergency Services is defined as those services which are focused on the inputs, internal processes, and outputs of hospital EDs. The PESSC will be responsible considering both urban and rural emergency services issues and plans.

The PESSC is accountable to the CEO Leadership Council through the CEO of the Provincial Health Services Authority. The Committee’s mandate and scope of work were approved by the Leadership Council on November 18, 2002. (Refer to Briefing Note: PHSA Priority System Performance Improvement Emergency Services)

2.0 FUNCTIONS

2.1 Clarify and develop consensus regarding the intended outcomes of the PESP.

2.2 Identify and confirm the key deliverables to achieve the intended project outcomes. Develop a work plan and confirm the required resources to carry out the work plan.

2.3 Anticipate and resolve project issues in a timely and efficient manner.

2.4 Establish and direct a Task Group to identify and prioritize emergent problems and recommend solutions before March 31, 2003. This group will disband and integrate into the task group identified in 2.6 at a time to be determined by the PESSC.

2.5 Establish and direct a Task Group to create a strategic plan for the longer- term reform, improvement and ongoing performance evaluation of Emergency Services. At minimum, the Strategic Plan must include recommendations for the sustainability of Physician Specialists and other staffing resources to support Emergency Services.

short term task group progress report – april 2003 70 2.6 Support the development and operationalization of a comprehensive implementation plan. At minimum, this plan must identify the priority areas of focus for guiding resource allocation decisions.

2.7 Ensure timely and effective communication of project information and outcomes to key stakeholders based on a considered implementation plan.

2.8 Link with other key stakeholders and relevant provincial/regional initiatives, e.g., BCAS, bcbedline, etc.

3.0 MEMBERSHIP

Provincial Health Services Authority (PHSA): Brian Schmidt (Chair), VP, Strategic Health Development & Performance Management

Vancouver Coastal Health Authority (VCHA): Carl Roy, President & CEO, Providence Health Care

Northern Health Authority: (NHA): Malcolm Maxwell, CEO

Vancouver Island Health Authority (VIHA): Glen Lowther, Executive VP/ Chief Medical Officer

Fraser Health Authority (FHA): Kathy Kinloch, COO, Fraser North

Interior Health Authority: (IHA): Martin McMahon, COO, Thompson/Cariboo/ Shuswap (Dec. 6, 2002 – Feb. 20, 2003)

Rick Riley, COO, Kootenay Boundary (Feb. 21, 2003 – present)

Ministry of Health Services (MoH/S): Bert Boyd, ADM, Performance Management and Improvement Division

PHSA Secretariat: Susie Wai, Transition Director, Strategic Planning

short term task group progress report – april 2003 71 4.0 OPERATIONAL PROTOCOL

4.1 Frequency of Meetings: Monthly (more frequently as required initially)

4.2 Time and Duration: 1 to 2 hours

4.3 Meeting format: Teleconference and Videoconference. Face to face meetings for visioning and significant deliberations

4.4 Agenda: Agenda items must be submitted to the Chair, ten days prior to the meeting. Agenda packages will be distributed seven days prior to the meeting.

4.4 Task Group(s): The Steering Committee may establish Task Group(s), as required.

4.6 Delegates: In general delegates to the Steering Committee should be minimized, and only on the approval of the Committee. Delegates are expected to be members of their Authority’s Executive Committee to ensure access to rapid review and decision making on major policy issues.

4.7 Corresponding Members: As determined by the Committee.

short term task group progress report – april 2003 72 APPENDIX 3 SHORT-TERM TASK GROUP MEMBERSHIP LIST

Brian Schmidt (Chair) Vice President, Strategic Health Development & Performance Management Provincial Health Services Authority

Dr. William Cunningham Emergency Physician, Cowichan District Hospital Vancouver Island Health Authority

Dr. Graham Dodd Clinical Director, Emergency Department & Clinical Director, Trauma Services Royal Inland Hospital Interior Health Authority

Sue Fuller-Blamey Patient Care Manager, Emergency Department Royal Columbian Hospital Fraser Health Authority

Dr. Urbain Ip Clinical Director, Emergency Surrey Memorial Hospital Fraser Health Authority

Barb Kinnon Director, bcbedline

Dr. Tom Lee Clinical Director, Emergency Department Vancouver General Hospital Vancouver Coastal Health Authority

Catherine MacKay Regional Director, Emergency Services (South Island) Vancouver Island Health Authority

Fred Platteel Assistant Executive Director, Emergency Health Services Commission B.C. Ambulance Service Regions 3 & 4

Jessie Reid Project Leader, Riverview Hospital (Mental Health Services) Provincial Health Services Authority

Dr. John Ryan Clinical Department Chief of Emergency Prince George Regional Hospital Northern Health Authority

short term task group progress report – april 2003 73

Marg Querin Patient Care Coordinator, Emergency Department Royal Inland Hospital Interior Health Authority

Susie Wai (Secretariat) Transition Director, Strategic Planning Provincial Health Services Authority

Jennifer MacKenzie (PHSA Staff Support) Corporate Director, Special Projects Provincial Health Services Authority

Nichola Manning (MoH/S Staff Support) Manager, Priority Issues Program Issues & Resolution Ministry of Health Services

Alex Berland (Consultant and Progress Report author) SRG – Strategic Resource Group

short term task group progress report – april 2003 74 APPENDIX 4 INFORMATION MANAGEMENT SUB-COMMITTEE MEMBERSHIP LIST

Brian Schmidt (Chair) Vice President, Strategic Health Development & Performance Management Provincial Health Services Authority

Dr. William Cunningham Emergency Physician, Cowichan District Hospital Vancouver Island Health Authority

Sue Fuller-Blamey Patient Care Manager, c/o Emergency Department Royal Columbian Hospital Fraser Health Authority

Dr. Eric Grafstein Associate Research Director (Providence Health Care) Vancouver Coastal Health Authority

Dr. Urbain Ip Clinical Director, Emergency Surrey Memorial Hospital Fraser Health Authority

Catherine MacKay Regional Director, Emergency Services (South Island) Vancouver Island Health Authority

Don Henkelman Chief Information Officer Provincial Health Services Authority

Liz Carter (Consultant)

Jennifer MacKenzie (PHSA Staff Support) Corporate Director, Special Projects Provincial Health Services Authority

short term task group progress report – april 2003 75

APPENDIX 5 STAKEHOLDERS, CONTACTS AND OTHER CONTRIBUTORS

David Babiuk Provincial Director, Strategic Health Provincial Health Services Authority

Martha Burd Senior Manager, Person-Based Records BC Ministry of Health Services

Ken Burrows COO, Okanagan Interior Health Authority

Michael Chang Information Analyst, Information Support BC Ministry of Health Services

Barry Cheal Executive VP & COO, Northern Interior Northern Health Authority

John Cheung Executive Director Information Support BC Ministry of Health Services

Dr. Doug Cochrane Vice President, Medical Affairs & Quality Provincial Health Services Authority

Dr. Jeff Coleman COO, Richmond Vancouver Coastal Health Authority

Dr. Fred Dennis Los Angeles Regional Director California Emergency Physicians

Terry Feser Information Consultant Information Support, Corporate Services & Financial Accountability Ministry of Health Services

Dr. Joe Haegert Emergency Room Physician Royal Columbian Hospital Fraser Health Authority

short term task group progress report – april 2003 76

Bruce Harber COO, Vancouver Acute Vancouver Coastal Health Authority

Kathy Kinloch COO, Fraser North Fraser Health Authority

Marian Knock Executive Director, Primary Health Care BC Ministry of Health Services

Linda Lemke Program Manager bcbedline

Dr. Kevin McMeel Emergency Room Physician Nanaimo Regional Hospital

Doug Marrie Executive Director, North Island Vancouver Island Health Authority

Ellen Pekeles COO, North Shore/Coast Garibaldi Vancouver Coastal Health Authority

Dr. Howard Platt Senior Medical Consultant, MSP, Utilization Management BC Ministry of Health Services

Andrew Pringle Information Analyst, Regional Programs, Information Support BC Ministry of Health Services

Marilyn Rook COO, South Island Vancouver Island Health Authority

Dr. Alan Thomson Executive Director, Standards & Performance Development, Performance Management & Improvement BC Ministry of Health Services

Dr. Les Vertesi Medical Director, Royal Columbian Hospital/Eagle Ridge Hospital Fraser Health Authority

short term task group progress report – april 2003 77

APPENDIX 6 DATA SOURCES

Emergency Departments, source: bcbedline 2003

Name of Facility Health Phone City No. Beds Comments Authority (ER) Queen Elizabeth II Alberta- 780-538- Grande 12 24 hours Mistahia 7100 Prairie Health R. Burnaby Hospital Fraser 604-434- Burnaby 18 (4 24 hours 4211 closed) =14 Chilliwack Hospital Fraser 1-604- Chilliwack 17 24 hours 795-4141 Delta Hospital Fraser 604-946- Delta 8 + 5 24 hours 1121 treatment rms/hallway Eagle Ridge Hospital Fraser 604-461- Port Moody 15 24 hours 2022 Fraser Canyon Hospital Fraser 1-604- Hope 8 24 hours 869-5656 Langley Hospital Fraser 604-534- Langley 16 24 hours 4121 Mission Hospital Fraser 1-604- Mission 9 24 hours 826-6261 MSA Fraser 1-604- Abbotsford 17 (3 24 hour +7 operating 853-2201 sitting as inpatient beds for space) fast track to ER Peace Arch Hospital Fraser 604-531- White Rock 10 (10 24 hours 5512 stretchers in front, 5 in back = 15) Ridge Meadows Fraser 604-463- Maple Ridge 7 plus 5 24 hours Hospital 4111 overflow = 12 Royal Columbian Fraser 604-520- New 49 (plus 24 hours (In a disaster, Hospital 4253 Westminster chairs) could put some stretchers into psych and a nurse, although no equipment there). Saint Mary's Fraser 604-521- New 0 1881 Westminster Surrey Memorial Fraser 604-581- Surrey 19 24 hours Hospital 2211 100 Mile District Interior 250-395- 100 Mile 4 + one suture room General 7600 House Arrow Lakes Interior 250-265- Nakusp 4 24 hours , + trauma 3622 room and EDR (suture room) Ashcroft & District Interior 250-453- Ashcroft 4 open 0830 to 1700 2211 Barriere & District Interior 250-672- Barriere 8 open 24 hours Health Centre 9731 Boundary Interior 250-443- Grand Forks 10 open 24 hours 2100 Cariboo Memorial Interior 250-392- Williams 5 open 0800 - 2000 4411 Lake Castlegar & District Interior 250-365- Castlegar 5 open 0800 - 2000 7711 Chase & District Health Interior 250-679- Chase 6 open 0800 - 1730 - Centre 3312 physician on-call 24 hrs short term task group progress report – april 2003 78

Name of Facility Health Phone City No. Beds Comments Authority (ER) Creston Valley Interior 250-428- Creston 8 (2 trauma beds) open 2286 24 hrs Dr. Helmcken Memorial Interior 250-674- Clearwater 6 6 Acute/ER beds 2244 (serve as both) open 24 hours East Kootenay Regional Interior 250-426- Cranbrook 14 open 24 hours Hospital 5281 Elkford D&T Interior 250-865- Elkford 5 outpatient ER beds 2247 Hours M-F 0830 - 1830. Saturday, Sunday and Stats 1000 - 1400 Enderby & District Interior 250-838- Enderby CLOSED Memorial 6441 Fernie District Interior 250-423- Fernie 4 open 24 hours 4453 Golden & District Interior 250-344- Golden 8 open 24 hours 5271 Invermere & District Interior 250-342- Invermere 5 (1 trauma bed, 4 9201 stretchers plus chairs) open 24 hours Kelowna General Interior 250-862- Kelowna 18 (2 trauma bays) open 4000 24 hours Kimberley & District Interior 250-427- Kimberley 0 ER is now closed 2215 Kootenay Lake District Interior 250-352- Nelson 8 open 24 hours 3111 Lillooet District Interior 250-256- Lillooet 3 open 24 hours 4233 Logan Lake Health Interior 250-523- Logan Lake 2 open 0830 to 1600 Centre 6515 Nicola Valley General Interior 250-378- Merritt 5 open 24 hours 2242 Penticton Regional Interior 250-492- Penticton 16 open 24 hours 4000 Princeton General Interior 250-295- Princeton 3 open 24 hours 3233 Queen Victoria Interior 250-837- Revelstoke 6 open 24 hours 2131 Royal Inland Interior 250-374- Kamloops 16 (4 trauma beds) open 5111 24 hours Shuswap Lake General Interior 250-833- Salmon Arm 7 (2 trauma beds) open 3600 24 hrs Slocan Community Interior 250-358- New Denver 3 open 24 hours, no Hospital 7911 acute care South Okanagan Interior 250-498- Oliver 7 (1 trauma bed) open General 5000 24 hours South Similkameen Interior 250-499- Keremeos 2 open Mon-Sat 0900 - Health Centre 3000 1700 Sparwood General Interior 250-425- Sparwood 3 open Mon-Fri 1200 - 6212 2200 - Sat & Sun 1200 - 1930 St. Bartholomew's Interior 250-455- Lytton 3 open 100 - 2200 2221 Summerland Outpatient Interior 250-404- Summerland 0 No ER Department Health Centre 8000 Vernon Jubilee Interior 250-545- Vernon 12 open 24 hours (+ 1 2211 crib) Victoria Hospital of Interior 250-353- Kaslo 0 (RN and physician on- Kaslo 2211 call 24hours for ER cases)

short term task group progress report – april 2003 79

Name of Facility Health Phone City No. Beds Comments Authority (ER) West Kootenay Interior 250-368- Trail 6 open 24 hours Regional Hospital 3311 Bulkley Valley District Northern 250-847- Smithers 5 24 hours 2611 Chetwynd General Northern 250-788- Chetwynd 6 24 hours 2236 Dawson Creek and Northern 250-782- Dawson 6 24 hours District 8501 Creek Fort Nelson General Northern 250-774- Fort Nelson 3 24 hours 6916 Fort St. John General Northern 250-262- Fort St. 6 24 hours 5200 John Fraser Lake D&T Northern 250-699- Fraser Lake 4 (short 9-5 M-F (go to Centre 7742 stay) Vanderhof if outside of those hours) GR Baker Memorial Northern 250-992- Quesnel 8 24 hours 0600 Houston D&T Centre Northern 250-845- Houston 1 0830 to 2030 2294 Hudson's Hope Health Northern 250-783- Hudson's 1 0830 to 1630 Centre 9991 Hope Kitimat General Northern 250-632- Kitimat 4 24 hours 2121 Lakes District Northern 250-692- Burns Lake 13 24 hours 2400 Mackenzie and District Northern 250-997- Mackenzie 4 24 hours 3263 Massett Site Hospital Northern 250-626- Massett 4 24 hours 4700 McBride and District Northern 250-569- McBride 2 24 hours 2251 Mills Memorial Northern 250-635- Terrace 7 24 hours 2211 Nisga'a Valley D&T Northern 250-633- New 2 0830 - 1700 (go to 5000 Aiyanish Terrace if outside of those hours) Prince George Regional Northern 250-565- Prince 12 24 hours 2000 George Prince Rupert Regional Northern 250-624- Prince 7 24 hours (their ICU is 2171 Rupert in the ER) Queen Charlotte Islands Northern 250-559- Queen 4 24 hours (their ICU is General 4300 Charlotte in the ER) St. John Northern 250-567- Vanderhoof 6 24 hours (their ICU is 2211 in the ER) Stewart General Northern 250-636- Stewart 5 lab runs out of 2221 emergency Stuart Lake Northern 250-996- Fort St. 3 24 hours 8201 James Tumbler Ridge D&T Northern 250-242- Tumbler 3 8-5pm M-F doctors Health Centre 5271 Ridge there, otherwise on call Valemount D&T Health Northern 250-566- Valemount 3 (out 8-4:30 pm M-F doctors Centre 9138 patient) ther, otherwise on call Wrinch Memorial Northern 250-842- Hazelton 5 24 hours (stabilize ICU 5211 pt and always send out) (single unit hospital) BC Women's Hospital Provincial 604-875- Vancouver Not Health 2424 applicable Services BC Cancer Agency Provincial 604-877- Vancouver Not Health 6000 applicable Services short term task group progress report – april 2003 80

Name of Facility Health Phone City No. Beds Comments Authority (ER) BC’s Children's Hospital Provincial 604-875- Vancouver Not Health 2345 applicable Services Riverview Hospital Provincial 604-524- Coquitlam Not Health 7000 applicable Services Bella Coola General Vancouver 250-799- Bella Coola 2 24 hours Coastal 5311 Lions Gate Vancouver 604-988- North 26 24 hours Coastal 3131 Vancouver Mount Saint Joseph Vancouver 604-874- Vancouver 12 Closes at 2000 Coastal 1141 Pemberton D&T Centre Vancouver 1-604- Pemberton 5 RN on call after 9 pm Coastal 894-6633 Powell River General Vancouver 1-604- Powell River 9 24 hours Coastal 485-3211 Richmond Hospital Vancouver 604-278- Richmond 12 24 hours Coastal 9711 RW Large Memorial Vancouver 250-957- Waglisla/Bella 3 Doctor on call after 5. Coastal 2314 Bella Squamish General Vancouver 604-688- Squamish 5 24 hours Coastal 9854 St. Mary's Vancouver 1-604- Sechelt 8 24 hours Coastal 885-2224 St. Paul's Vancouver 604-682- Vancouver 34 24 hours Coastal 2344 St. Vincent's Hospital Vancouver 604-876- Vancouver 6 Closed at 8 pm Coastal 7171 UBC Health Sciences Vancouver 604-822- Vancouver 11 24 hours Coastal 7121 Vancouver General Vancouver 604-875- Vancouver 28 24 hours Coastal 4111 Whistler Health Care Vancouver 1-604- Whistler 12 Closes at 10:00 pm Centre Coastal 932-4911 Campbell River & Vancouver 250-287- Campbell 10 24 hours District Island 7111 River Chemainus Health Care Vancouver 250-246- Chemainus 5 24 hours. Feb 15/03 Centre Island 3291 will be closing from 10:30 pm to 7:30 am Cowichan District Vancouver 250-746- Duncan 14 24 hours Island 4141 Ladysmith & District Vancouver 250-245- Ladysmith 4 2 RN's on through the Island 2221 night. Closed from 10:30 pm to 07:30 am. No admits at night. Nanaimo Regional Vancouver 250-754- Nanaimo 16 And will bring in more General Island 2141 beds if needed. Port Alice Vancouver 250-284- Port Alice see Port Island 3555 McNeill Port Hardy Vancouver 250-949- Port Hardy 4 24/7 No ICU or CCU Island 6161 Port McNeill & District Vancouver 250-956- Port McNeill 5 24 hours (would Island 4461 normally tsf cut CCU/ICU but can deal with them. Queen Alexandra Center Vancouver 250-477- Victoria 0 No ER Department - for Children's Health Island 1826 Mental Health Facility Royal Jubilee Vancouver 250-370- Victoria 21 24 hours Island 8000 short term task group progress report – april 2003 81

Name of Facility Health Phone City No. Beds Comments Authority (ER) Saanich Peninsula Vancouver 250-652- Saanichton 7 24 hours Island 3911 St. George's Vancouver 250-974- Alert Bay 4 24 hours No ICU/CCU Island 5585 St. Joseph's General Vancouver 250-339- Comox 11 24 hours Island 2242 Tofino General Vancouver 250-725- Tofino 5 24 hours No ICU/CCU Island 3212 Victoria General Vancouver 250-727- Victoria 20 24 hours Island 4212 West Coast General Vancouver 250-723- Port Alberni 6 24 hours Island 2135 Whitehorse General YUKON 1-867- Whitehorse 9 24 hours (no CCU - Hospital TERRITORY 393-8700 stabilize and transfer patient only)

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Emergency Room Visits for BC Hospitals by Health Authority and Health Service Delivery Area 2000/01, 2001/02 and 2002/03, source MOH/S 2003

2000/2001 2001/2002 2002/2003 Scheduled Non Scheduled Non Scheduled Scheduled Non Non Sched. Sched. Schedul Scheduled ed Visits Visits Visits Visits Visits Visits Visits Visits To Date Projected To Date Projected

Interior East 409 Golden and 1,018 5,237 795 5,259 328 542 2,865 4,732 Health Kootenay District General Authority Hospital Interior East 654 Creston Valley 2,323 7,117 2,640 6,346 2,924 4,829 3,067 5,065 Health Kootenay Hospital Authority Interior East 752 Kimberley and 1,315 4,062 Health Kootenay District Hospital Authority Interior East 753 Fernie District 6,247 4,157 4,152 5,229 1,729 2,856 2,340 3,865 Health Kootenay Hospital Authority Interior East 754 Sparwood 3,439 2,444 2,430 2,535 1,029 1,699 900 1,486 Health Kootenay General Authority Hospital Interior East 755 Invermere and 312 8,443 333 8,911 1,063 1,756 4,117 6,800 Health Kootenay District Hospital Authority Interior East 756 Cranbrook 7,365 5,770 16,823 1,609 2,657 2,431 4,015 Health Kootenay Regional Authority Hospital Interior East 757 Elkford and 524 1,768 1,058 1,351 358 591 750 1,239 Health Kootenay District D and T Authority Centre East 13,863 36,531 18,493 50,516 9,040 14,930 16,470 27,202 Kootenay Interior Kootenay 651 Kootenay Lake 3,854 13,400 3,100 11,488 1,317 2,175 5,834 9,635 Health Boundary District Hospital Authority Interior Kootenay 652 Slocan Interm 524 393 816 694 472 780 670 1,107 Health Boundary Care Authority Interior Kootenay 655 Arrow Lakes 2,432 1,934 793 1,310 1,194 1,972 Health Boundary Hospital Authority Interior Kootenay 801 Trail Regional 3,708 10,741 3,250 10,044 489 808 2,240 3,700 Health Boundary Hospital Authority Interior Kootenay 803 Boundary 1,371 10,392 1,572 8,501 761 1,257 4,525 7,473 Health Boundary Hospital Authority Interior Kootenay 804 Castlegar and 1,442 9,848 1,260 8,725 505 834 2,720 4,492 Health Boundary District Hospital Authority Kootenay 13,331 44,774 11,932 39,452 4,337 7,163 17,183 28,379 Boundary Interior Okanagan 301 Vernon Jubilee 157 30,376 4 26,119 492 813 14,636 24,173 Health Hospital Authority Interior Okanagan 302 Kelowna 3,332 47,815 3,191 45,546 28,587 47,214 Health General Authority Hospital Interior Okanagan 303 Penticton 4,805 26,089 5,377 24,654 16,748 27,661 Health Regional Authority Hospital Interior Okanagan 305 Princeton 7,507 309 7,326 211 348 3,812 6,296 Health General Authority Hospital Interior Okanagan 307 Pleasant Valley 308 255 460 760 Health Health Centre Authority Interior Okanagan 308 Summerland 1,337 5,058 1,287 4,503 207 342 524 865 Health General Authority Hospital Interior Okanagan 309 South Okanagan 3,178 14,083 3,662 14,205 1,941 3,206 9,390 15,508 Health General Authority Hospital

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Interior Thompson/Ca 403 Nicola Valley 6,206 7,520 6,628 7,333 Health riboo General Authority Hospital Interior Thompson/Ca 404 Shuswap Lake 15,504 3,333 15,473 10,394 17,167 Health riboo General Authority Hospital Interior Thompson/Ca 405 St. 191 884 194 845 Health riboo Bartholomew's Authority Interior Thompson/Ca 406 Cariboo 23,354 22,918 Health riboo Memorial Authority Hospital Interior Thompson/Ca 408 Ashcroft and 748 2,470 1,043 2,410 Health riboo District General Authority Hospital Interior Thompson/Ca 417 Lillooet District 1,360 2,820 952 2,491 Health riboo Hospital Authority Interior Thompson/Ca 419 Dr. Helmcken 608 3,340 1,758 2,292 Health riboo Memorial Authority Hospital Interior Thompson/Ca 423 Logan Lake D 2,044 327 2,375 327 Health riboo and T Centre Authority Interior Thompson/Ca 424 Barriere D and 1,161 1,126 852 739 Health riboo T Centre Authority Interior Thompson/Ca 426 Chase and 4,400 6,185 4,777 6,501 Health riboo District Health Authority Centre Interior Thompson/Ca 708 100 Mile 1,615 8,307 Health riboo General District Authority Hospital Thompson/C 43,560 75,983 49,320 82,199 1,424 2,352 13,038 21,533 ariboo

Interior 83,563 288,21 93,883 298,09 18,102 29,897 122,92 203,024 Health 6 9 7 Authority

Fraser Fraser Valley 601 Chilliwack 38,551 33,170 Health General Authority Hospital Fraser Fraser Valley 602 Mission 5,299 22,106 5,289 20,809 Health Memorial Authority Hospital Fraser Fraser Valley 603 Matsqui-Sumas- 42,993 38,541 Health Abbotsford Authority General Hospital Fraser Fraser Valley 606 Fraser Canyon 666 6,660 545 6,587 Health Hospital Authority Fraser 5,965 110,31 5,834 99,107 Valley 0 Fraser Simon Fraser 109 Royal 125,501 50,311 Health Columbian Authority Hospital Fraser Simon Fraser 130 Burnaby 54,597 48,228 Health Hospital Authority Fraser Simon Fraser 136 Eagle Ridge 31,712 Health Authority Fraser Simon Fraser 604 Ridge Meadows 24,545 Health Hospital and Authority Health Care Centre Simon 180,09 154,796 Fraser 8 Fraser South Fraser 115 Langley 5,097 39,741 3,097 33,952 Health Memorial Authority Hospital Fraser South Fraser 116 Surrey 71,830 65,088 Health Memorial Authority Hospital

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Fraser 17,410 451,05 170,530 242,54 0 0 0 0 Health 3 1 Authority

Vancouver Richmond 121 Richmond 2,801 42,671 3,024 39,257 Coastal Hospital Health Authority Richmond 2,801 42,671 3,024 39,257 0 0 0 0 Vancouver Vancouver 101 Vancouver 953 71,653 1,201 62,384 2,670 4,410 63,079 104,180 Coastal General Health Hospital Authority Vancouver Vancouver 17650 Providence 2,608 71,628 7,844 60,179 1,476 2,438 41,411 68,394 Coastal Health Authority Vancouver 3,561 143,28 9,045 122,56 4,146 6,847 104,49 172,574 1 3 0 Vancouver North Shore / 111 Powell River 20,294 19,349 Coastal Coast General Health Garibaldi Hospital Authority Vancouver North Shore / 112 Lions Gate 43,177 38,381 27,336 45,148 Coastal Coast Hospital Health Garibaldi Authority Vancouver North Shore / 113 St. Mary's 12,354 12,154 Coastal Coast Hospital, Health Garibaldi Sechelt Authority Vancouver North Shore / 128 Squamish 11,913 11,903 7,031 11,612 Coastal Coast General Health Garibaldi Hospital Authority Vancouver North Shore / 422 Pemberton D 152 4,719 125 5,706 77 127 3,253 5,373 Coastal Coast and T Centre Health Garibaldi Authority Vancouver North Shore / 425 Whistler D and 392 22,464 597 21,775 369 609 11,063 18,271 Coastal Coast T Centre Health Garibaldi Authority Vancouver North Shore / 904 R.W. Large 2,315 2,276 Coastal Coast Memorial Health Garibaldi Hospital Authority North Shore 544 117,23 721 111,54 446 737 48,683 80,404 / Coast 6 4 Garibaldi

Vancouver 6,906 303,188 12,790 273,364 4,592 7,584 153,173 252,978 Coastal Health Authority

Vancouver South 202 Greater Victoria 7,441 84,826 7,533 77,388 Island Vancouver Hospital Society Health Island Authority Vancouver South 203 Cowichan 27,078 26,054 16,962 28,014 Island Vancouver District Hospital Health Island Authority Vancouver South 206 Lady Minto Gulf 883 6,100 815 6,409 Island Vancouver Islands Hospital Health Island Authority Vancouver South 217 Saanich 19,477 17,658 Island Vancouver Peninsula Health Island Hospital Authority South 8,324 137,48 8,348 127,50 16,962 28,014 Vancouver 1 9 Island 2000/2001 2001/2002 2002/2003

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Scheduled Non Scheduled Non Scheduled Scheduled Non Non Sched. Sched. Schedul Scheduled ed Visits Visits Visits Visits Visits Visits Visits Visits To Date Projected To Date Projected

Vancouver Central 851 West Coast 2,362 21,840 2,795 20,894 3,372 5,569 11,157 18,427 Island Vancouver General Health Island Hospital Authority Vancouver Central 854 Tofino General 375 3,019 627 2,849 312 515 2,264 3,739 Island Vancouver Hospital Health Island Authority Central 14,465 90,006 15,648 87,893 10,861 17,938 57,846 95,538 Vancouver Island Vancouver North 507 St. George's 288 1,497 2,472 Island Vancouver Hospital Health Island Authority Vancouver North 508 Campbell River 1,670 7,602 5,283 24,259 3,792 6,263 14,018 23,152 Island Vancouver and District Health Island General Authority Hospital Vancouver North 510 Port Hardy 7,308 623 3,542 5,850 Island Vancouver Hospital Health Island Authority Vancouver North 511 Port McNeil and 3,614 232 2,423 4,002 Island Vancouver District Hospital Health Island Authority Vancouver North 859 Port Alice 74 653 1,078 Island Vancouver Hospital Health Island Authority Vancouver North 860 Gold River 464 1,986 1,051 2,277 566 935 1,682 2,778 Island Vancouver Health Clinic (D Health Island and T) Authority Vancouver North 861 Tahsis Health 872 474 1,208 216 956 1,579 72 119 Island Vancouver Centre Health Island Authority North 3,006 20,984 7,542 27,969 5,314 8,777 23,887 39,451 Vancouver Island

Vancouver 25,795 248,471 31,538 243,371 16,175 26,714 98,695 163,003 Island Health Authority

Northern North West 15871 Stikine 1,367 313 4,342 1,740 Health Community Authority Health Council Northern North West 901 Wrinch 3,907 3,885 2,712 4,479 Health Memorial Authority Hospital Northern North West 902 Prince Rupert 4,685 17,245 4,429 10,504 2,598 4,291 6,772 11,185 Health Regional Authority Hospital Northern North West 910 Stewart General 367 382 61 101 Health Hospital Authority Northern North West 912 Mills Memorial 17,052 16,104 10,552 17,428 Health Hospital Authority Northern North West 917 Kitimat General 6,537 6,230 3,818 6,306 Health Hospital Authority North West 6,052 45,421 8,771 38,845 2,659 4,392 23,854 39,397 Northern Northern 702 St. John 2,874 5,376 2,459 Health Interior Hospital Authority 2000/2001 2001/2002 2002/2003 Scheduled Non Scheduled Non Scheduled Scheduled Non Non Sched. Sched. Schedul Scheduled ed Visits Visits Visits Visits Visits Visits Visits Visits To Date Projected To Date Projected

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Northern Northern 718 Valemount 554 Health Interior Health Centre Authority (D and T) Northern Northern 758 Fraser Lake D 2,139 3,715 1,902 Health Interior And T Centre Authority Northern 7,149 77,276 6,689 12,922 Interior Northern Northeast 701 Fort St. John 1,434 26,423 1,456 25,500 15,532 25,652 Health General Authority Hospital Northern Northeast 704 Dawson Creek 1,570 19,925 1,144 21,019 1,083 1,789 12,314 20,338 Health And District Authority Hospital Northern Northeast 714 Fort Nelson 203 5,958 140 5,394 205 339 3,755 6,202 Health General Authority Hospital Northern Northeast 716 Chetwynd 126 5,882 101 5,941 42 69 3,843 6,347 Health General Authority Hospital Northern Northeast 720 Tumbler Ridge 1,812 2,653 1,572 2,596 Health Health Care Authority Centre (D and T) Northern Northeast 759 Hudson's Hope 980 1,441 795 1,313 Health Gething D And Authority T Centre Northeast 3,333 60,980 2,841 61,948 1,330 2,197 37,811 62,448

Northern 16,534 183,677 18,301 113,715 3,989 6,588 61,665 101,845 Health Authority

Provincial PHSA 105 BC Children's 199 34,452 265 32,355 152 251 18,859 31,147 Health Hospital Services Authority Provincial PHSA 412 Blue River Health Services Authority Provincial PHSA 416 Alexis Creek Health Services Authority Provincial PHSA 656 Edgewood Health Services Authority Provincial PHSA 855 Bamfield Health Services Authority Provincial PHSA 857 Kyuquot Health Services Authority Provincial PHSA 914 Atlin Health Services Authority

Provincial 199 34,452 265 32,355 152 251 18,859 31,147 Health Services Authority

Total 150,407 1,509,0 327,307 1,203,4 43,010 71,035 455,31 751,997 57 45 9

Non Scheduled Emergency Room Visits for 2000-01 and 2001-02

Important Note: that indicates which geographic region each visit was from, therefore there is not necessarily a direct relationship between that population and its utilization of emergency room visits. This is especially true in regions where there might be high inter-regional flow, such as tourist areas, the lower mainland, and those areas in close proximity to HSDA boundaries

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2000/2001 Population Visits / 2001/2002 Population Visits / Non 2001 HSDA Pop. Non 2002 HSDA Scheduled Scheduled Pop. Visits * 10,000 Visits * 10,000

Interior Health East Kootenay 49,031 79,011 6,206 50,516 79,275 6,372 Authority Interior Health Kootenay 44,774 80,773 5,543 39,452 80,432 4,905 Authority Boundary Interior Health Okanagan 130,928 309,031 4,237 125,932 311,935 4,037 Authority Interior Health Thompson/Cariboo 103,983 215,687 4,821 102,199 215,021 4,753 Authority Fraser Health Fraser Valley 110,310 245,658 4,490 99,107 248,906 3,982 Authority Fraser Health Simon Fraser 180,098 532,342 3,383 154,796 541,597 2,858 Authority Fraser Health South Fraser 160,645 591,570 2,716 143,434 602,520 2,381 Authority Vancouver Richmond 42,671 169,267 2,521 39,257 172,260 2,279 Coastal Health Authority Vancouver Vancouver 143,281 575,333 2,490 122,563 581,511 2,108 Coastal Health Authority Including 177,733 575,333 3,089 154,918 581,511 2,664 Childrens Vancouver North Shore / 117,236 264,907 4,426 111,544 267,027 4,177 Coastal Health Coast Garibaldi Authority Vancouver South Vancouver 137,481 397,607 3,458 127,509 400,468 3,184 Island Health Island Authority Vancouver Central Vancouver 90,006 238,099 3,780 87,893 239,742 3,666 Island Health Island Authority Vancouver North Vancouver 20,984 57,148 3,672 27,969 56,525 4,948 Island Health Island Authority Northern North West 45,421 85,834 5,292 38,845 84,396 4,603 Health Authority Northern Northern Interior 77,276 152,519 5,067 73,296 150,859 4,859 Health Authority Northern Northeast 34,557 64,047 5,396 36,448 63,460 5,743 Health Authority

1,523,134 4,058,833 3,753 1,413,115 4,095,934 3,450

Where data is missing or believed to be incorrectly coded, an estimation or adjustment has been made based on previous reporting and other emergency room statistics. Where data is incomplete, annualizations have been made.

Source of Population Statistics are: BC Stats, PEOPLE27 ; Source of Emergency Room Non Scheduled Visits is: HAMIS/OASIS as of January 21 2003 ; Prepared by Information Support, BC Ministry of Health Services, Project # 2002_595 January 22 2003, Source: HAMIS/OASIS

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APPENDIX 7 SURVEY QUESTIONNAIRE TEMPLATE & LIST OF SURVEY PARTICIPANTS

SURVEY QUESTIONNAIRE TEMPLATE

PROVINCIAL EMERGENCY SERVICES STEERING COMMITTEE (PESSC)

SURVEY OF HOSPITAL BASED EMERGENCY SERVICES−INTERVIEW TOOL

DECEMBER 11, 2002

SECTION 1: BASELINE FACILITY DATA (To be completed by one or mare HA Contact Person(s))

Location: (complete for EACH emergency department)

Contact Person: (include telephone #, fax #, and email address)

HA Executive Responsible for this ED Facility:

Annual Visits (2001/2002): (include pediatric separately, if available)

Annual Inpatient Admissions via ED (2001/2002): (include pediatric separately, if available)

ED Data Routinely Collected (above & beyond ER visits/inpatient admissions): Yes or No If Yes, Manual or Electronically.

Distance (km) to Next Higher Level Referral Centre from each ED:

Usual Point of Referral or Transfer Centre for each ED:

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SECTION 2: CONTEXT OF EMERGENCY SERVICES (To be collected by telephone survey between HA Contact Person and Surveyor)

GENERAL “GUIDED” QUESTION BY SURVEYOR: PLEASE ADVISE WHICH OF THE “EMERGENT ISSUES” IMPACT YOUR ED.

ISSUE NO YES DESCRIPTION (Note: Surveyor will be provided with detailed information to explore each issue.) Geography and demographics Prehospital transport Prehospital crews Ambulance service regions Interhospital transport Initial patient nursing contact in hospital Nurse staffing Emergency physician availability Specialist availability Diagnostic facilities Rate of encountering major emergencies Options for referral Procedures required of family physicians Practice focus Library resources Community life Extra ED support staff Collegial critical mass Medical education Continuing education Research base skill linking Other issues

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SECTION 3: SUMMARY OF BEST PRACTICE INITIATIVES (To be collected by telephone survey between HA Contact Person and Surveyor)

GENERAL “GUIDED” QUESTION BY SURVEYOR: WHAT ARE THE CONTEMPLATED AND IMPLEMENTED IMPROVEMENT INITIATIVES WITHIN EACH HA? (THE OVERALL INTENT IS TO COLLECT INFORMATION FROM A HA PERSPECTIVE, BUT COULD INCLUDE EXAMPLES OF SPECIFIC INITIATIVES IN EDS.

(Note: The Exhibit summary of tactics, below, is only intended to provide a framework to guide the interview process by the Surveyor and does not reflect an exhaustive list of initiatives. Other tactics/initiatives to be identified, via telephone survey process.)

Some tactics to improve emergency health services

Preventing hospital Accessing Managing Improving admissions specialist care unscheduled demand community linkages

Standardizing Rapid Nurse First Call or Case management to triage-screening assessment other protocols improve flow, systems. clinics. especially during Diagnosing an ED in surges. (e.g. Quick Improving the Expanded scope trouble (e.g. linked response Teams) linkages for acute of nursing hospital bed and primary care. practice. management systems) Anticipatory management for Promoting CME for GPs in Building “surge “frequent attenders”. telephone help specialized protection” into acute lines. skills. care. Providing better information about Streaming methods Availability of Improving IT for services. for assessment and senior doctors or emergency response treatment of minor specialists (e.g. systems. injuries. shared care). Tighter links with Emergency demand ambulance service. focused preventive initiatives. Coordinated planning for rapid assessment and treatment of medical patients.

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List of Survey Contacts and Participants Linda Basran Chief Operating Officer, East Kootenay (IHA) Stella Black Director, Acute Care, Royal Inland Hospital (IHA) Betty-Ann Busse Chief Operating Officer, Fraser East (FHA) Joanne Cozac Patient Care Manager, Ambulatory Services (NHA) Peter du Toit Community Administrator, Oliver & Osoyoos, South Okanagan General Hospital (IHA) Sharon Fekete Nurse Manager, Penticton Regional Hospital (IHA) Diane Gagnon Director, Kootenay Lake Hospital (IHA) Vivian Giglio Health Services Administrator, Abbotsford/Mission (FHA) Laurie Gould Director, Planning & Development - Primary Care & Chronic Disease Management (FHA) Marilyn Harkness Community Administrator, Princeton & Keremeos, Princeton General Hospital (IHA) Beverly Hazzard Acute Care Director, East Kootenay Health Service Area (IHA) Leanne Heppell Director, ED, Vancouver General Hospital (VCHA) Linda Herman Director of Health Services, Chilliwack General Hospital (FHA) Kirstine Hill Manager, Shuswap Lake General Hospital (IHA) Chris Histed Community Administrator, Vernon, Armstrong & Enderby, Vernon Jubilee Hospital (IHA) Suzanne Johnston A/Chief Operating Officer, Northwest HSDA (NHA) Joanne Konnert Chief Operating Officer, Fraser South (FHA) Linda Latham Area Director of Acute Services, Campbell River (VIHA) Michael Leisinger Regional Director, Health Information (NHA) Dr. Glen Lowther Executive VP & Chief Medical Officer (VIHA) Tracy MacDonald Director, Health Services, 100 Mile House, Williams Lake (IHA) Carol Markowsky Community Administrator, Central Okanagan, Kelowna General Hospital (IHA) Andrew Neuner Chief Operating Officer, Northeast HSDA (NHA) Tess Orlando Director, Acute & Home/Community Care, Powell River & Sunshine Coast, North Shore/Coast Garibaldi (VCHA) Pierre Ozolins Manager, Revelstoke HSA, Queen Victoria Hospital (IHA) Raelene Shea Director, Rural & Community Health (Thompson), Thompson Cariboo Shuswap HSA (IHA) Marg Querin Patient Care Coordinator, Emergency, Royal Inland Hospital (IHA) Nancy Rigg Director, Acute & Chronic, North Shore/Coast Garibaldi (VCHA) Carl Roy President & CEO, Providence Health Care (VCHA) Chuck Rowe Executive Director, Central Island (VIHA) Allison Ruault Director, Health Services (Shuswap & Revelstoke), Shuswap Lake General Hospital (IHA) Linda Sawchenko Site Director, Kootenay Boundary Regional Hospital (IHA) Charles Taylor Health Services Administrator, Robson Valley (NHA) Anne Troelsen Manager of EMS & ICU, Richmond Health Services (VCHA) Jean Wheeler Area Director of Rural Health Services, Mt. Waddington (VIHA)

Consultant Alex Berland Strategic Resource Group Surveyor Michael Beseau Strategic Resource Group

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APPENDIX 8 JOINT PLANNING WORKSHOP

Strategic Resource Group SandR AssociatesG

February 19, 2003

To: Provincial Emergency Services Project, Short-Term Task Group

Please find attached a summary of the discussion at the workshop. This summary is for your review and discussion at the Short-term Task Group meeting, February 25, 2003.

We have organized the material for flow of ideas rather than exactly in chronological order. It seemed helpful to cluster ideas from both the break-out sessions as well as the general discussion under consistent headings.

The intent is to provide a basis for moving on to short-term action planning by building agreement around accessible issues. We have also tried to build a bridge to the work of the Long-term Task Group by capturing some of the more complex suggestions for future reference.

I hope this is helpful and look forward to the discussion.

Alex Berland SRG – Strategic Resource Group

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PROVINCIAL EMERGENCY SERVICES PROJECT

WORKSHOP NOTES

“How would we know when things are going well?” “What are the hallmarks of a well-functioning ED?”

Quality Care – we satisfy patient care needs (provider definition) Evidence-based medicine Identify the sickest patients, those who need care first

Patient Satisfaction (patient definition)

Staff Satisfaction

System Effectiveness Appropriate use (how the system uses the ER) Due diligence in the use of resources Appropriate balance of resources in large and small centres We use meaningful indicators to explain variance.

“How should we measure performance?”

“We need to select data points for action, not for research.”

Acknowledge that “one size does not fit all” & selected system competency measurements need to be customized to reflect realistic expectations for rural & remote, rural & community, rural/urban, urban settings

Assessing inputs to the ED CTAS should be applied consistently in all EDs For effective triage To predict level of acuity, admissions, resources, etc. We need to educate staff on how to use it properly and need the right systems in place to use it effectively and to sustain application

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Assessing practice within the ED Best Practices should be identified (need to decide priorities and how to measure) Examples of high volume/high risk: pneumonia-antibiotics; thrombolytics and management of chest pain; trauma; asthma; head injury; meningitis, etc.)

Assessing outputs from the ED Percentage admitted patients and length of time to admission Patient left without being assessed Time to see specialists and diagnostics Time to discharge/home care with appropriate support at home Re-admission to ER (defined as return in 48 hours same diagnosis) Linkage to GPs – appropriate follow-up – getting information to them Use of Critical Care Bypass or Redirect

Indicators for Small Hospitals Transportation (time to transport, inability to return patient) How long patients are held awaiting move to nearest ‘appropriate’ centre

Getting started with indicators Ensure surrogate measures for each indicator can be easily and readily collected in a timely manner Ensure indicator development aligns & enhances the accreditation requirements Use the concept of a balanced score card

“What are some solutions?”

Applying better practices consistently Need to identify priorities. See Jim Thomson’s recommendations for Best Practices guidelines. Utilization management [e.g. monitoring LOS; e.g. specific tools like MCAP] and accountability are inconsistent across HAs. Regional models for accountability of ER services so that key stakeholders with decision making authority can effect policy change & resource sharing.

System Planning “The problem isn’t how patients use the ED; it’s how the system uses the E.D.” Need to ensure that 24/7 community support is available The “Winter Action Planning” concept is helpful for joining up many agencies. This is also a transition strategy, to ensure that system-wide planning processes and impacts are considered while the HAs are reconfiguring services. BC Bedline is improving all the time. HAs should address cross-boundary access in a more integrated fashion.

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“No refusal” policy at the referral centres is important, but it will require that the HA has the organization to commit and support. This will certainly require a collaborative agreement with the specialists. Seasonal Funding allocations are less useful as there is now less seasonal flux with unpredictable workload constant all year. It would be helpful to have flex funding and management tactics for “rogue waves”. Modeling could be used more to adjust resources based on the seasonal change. This might mean for instance switching from winter’s medical focus [respiratory] to summer’s higher trauma, and so on. We should improve our predictive capacity and anticipatory planning [How many are expected? How many are coming? What specialties?] so as to start the planning dialogue further and further “upstream and downstream”. BCAS feedback should be built into HA planning and policies and vice versa. [For instance, a transfer fleet could be used to reduce “Taxi service” demand, or paid commercial flights for patient returns.] Anticipatory planning leads to action after the planning, whether on an individual basis [e.g. anticipate who may be a short admission] or on a program basis [e.g. develop an internal quick response] or facility-wide [e.g. Access Coordinators]. Agreed directives and policies must be applied consistently ER Physician recruitment, retention, & incentives must be aligned with service and system goals

Upstream impacts “The biggest problem in the system is communication.” Unregulated walk-ins do not decrease demand for ED, they merely lead to duplication of resources. Some just refer CTAS level 4 and 5 to the ED anyway. The Nurseline is working well for some conditions. Perhaps addition of a physician [as in Montreal] could serve even more patient callers. BCAS could consider advanced practice roles to avoid an ED visit [e.g. protocols for diabetes]. There is noticeable improvement for care of Mental Health clients in some areas, due to central intake away from the hospital (links with GP offices, psychiatrist, etc., especially after-hours). However improvements are still needed where there is an A&D component, as this usually cannot be referred to central intake. Engaging differently with Primary Care is key. “At-Risk Registry” systems for high-users should be simple and practical, then it would not be difficult to establish a basic system as the home care nursing and ED staff know the clientele. Such Registries could include care plans, protocols, contact names and discharge plans for specific individuals. Some services could be sent out from the hospital [e.g. IV starts in LTC facilities]. Or a hospital/community partnership might ensure 24/7 support to long term care facilities to assess residents before transferring to ED. Rapid access clinics could improve response time for specialists and diagnostics.

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There are several ways to improve home nursing, including cluster care centred in the community, or in the ED. Providing more advanced nursing skills and GP support to enhance home support, assisted living and respite would be useful [e.g. rapid response geriatric rehab team; e.g. community respiratory therapy]. So would community nurses taking on the task of facilitating access and managing resources [e.g. beds and daycare spaces]. Education of the public should: Be targeted [e.g. Nurseline]. Focus on specific groups [e.g. to advise seniors about alternatives to ED use]. Often patients perceive that the ED is their only option. Focus on issues related to client satisfaction [e.g. regarding “what to expect” when arriving at the ED].

Solutions within the ED Short-term training could be enhanced. For example, Nurse First Call protocols could be expanded. [The liability issue needs to be addressed centrally and decisively.] EDs need to set priorities to address local problems. For instance, medical directives for blood work could improve care and job satisfaction for both nurses and physicians. For instance, critical incident protocols that take skilled staff away from the ED. This could in turn lead to use of different personnel, such as Clinical Nurse Specialists to supplement EPs. Having nurses in these roles would increase satisfaction for level 4 and 5 patients, while increasing quality of care for patients and families, due to the nurses’ education capabilities. There is also a retention component if nurses are provided education and increased responsibilities. “Unbundle” ED functions to find opportunities for process improvement. Address non-nursing duties re: perceived productivity improvements with 24/7 admitting clerks or Porters or 24/7 access to social worker or discharge planner. Explore Emergency Medical Technicians as a potential resource in the ED.

Solutions related to patient discharge and “downstream” impacts. Hospitals need systems so that can they discharge patients at any time. This would require improved communication (electronic), possibly dedicated hospitalists, “fast-track” linkages to other services, and effective methods to give patients instructions and to provide information to caregivers (including GPs). Establish Geriatric Assessment and Treatment Units for the elderly. Provincial guidelines to enable admissions to residential care beds 24/7.

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“What does an outside expert see as our opportunities?” “Although there are many excellent innovations, there is a tendency to look outward rather than what can be done with what you have. This means applying your own critical thinking about whether you have achieved maximum improvements in your own EDs.” “This is basically still about communication. Your real strength is your collective energy to address the issues creatively. How will you maintain this communication and liaison after the workshop?” “Training is a constant theme. How will you identify the priorities and resources?” “Collectively the HAs are joining together to address these issues. Where will the linkage occur? What are your collective goals, especially for consistency and standardization?”

“How should we move forward to system-wide action?” The new culture emerging in the HAs suggests that there is a collective will to make improvements. “More planning; less crisis management.” We need to look beyond the ED alone; we need to consider system issues to improve throughput. EDs should not be used as the only contingency plan. “Usually the system prevents the provision of good care.” Recognize the good work already, build on that, and enhance it. “But don’t be too prescriptive.” We need consistency across HAs, need to use standard [national] nomenclature, and apply plans consistently. “It would be helpful to achieve consensus on a few key priorities.”

“What should be included in our short-term plan?” Prepare a communication plan to get information out to people working in the system so they understand the process and plans. “Emergency docs are used to uncertainty - resuscitating and diagnosing at the same time – but everyone prefers information.” Develop a process to identify and share information about “better practice” sites. “Consistency of practice – measured”. Move ahead with developing “the essential few” indicators and a data collection system using a small group of experts led by a consultant. “Meaningful data related to key objectives”. Develop guidance for HAs to use to implement system-wide action plans. “Join up all community systems.” Plan the transition to the longer-term planning work.

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APPENDIX 9 TOP FIVE LIST

Provincial Emergency Services Project – Short Term Task Group “Top 5 laundry list” of issues & solutions: February 6, 2003

SOLUTIONS ISSUES SHORT TERM LONG TERM 1. Nursing Staff Shortage i) Locum nurses, acute care dual i) Address burnout, training programs, flexible compensation, & qualification schedules, incentives, issues enhanced LPN function ii) Improve effectiveness of ii) Review how RN staff is used, current strategies in managing identify opportunities to best manpower shortage. utilize this limited resource, and develop 3 year manpower plan • RN/full scope LPN staff mix • adjust support staff, e.g. clerical, aides, porters • advanced nurse practice iii) Develop plan for training and ongoing education 2. Physician ER & Other i) On call premiums, beds, Specialty Coverage Shortage operating room access ii) Address burnout, compensation, & qualification issues iii) Improve effectiveness of current strategies in managing manpower shortage. Re: Potential Destinations i) Financial Implications limited • In province vs out of province or out of country • Physician compensation • Maintenance of Mass at tertiary sites ii) Hospital policies • Need for no refusal policies • Repatriation – Patient in kind returns iii) Transfer Ability • BCAS Resource availability • Weather issues impacting travel (land/air) • Geography • CCT Training • Timing of needs 3. Inter-Hospital Transfer re: i) Enhanced coordination, complicated, no incentive, training, & medical oversight lack optimal utilization & ii) Timely transport between movement hospitals (particularly important in our area of regionalized services) and mode of transport as no dedicated rotary air ambulance exists outside of the south island/lower mainland but could be a big asset to our area, particularly in conjunction with the new Critical Care Transport short term task group progress report – april 2003 99

SOLUTIONS ISSUES SHORT TERM LONG TERM Program in Kamloops. iii) Role of Bedline, no refusal policy and patient repatriation issues. 4. Pre-Hospital Care 5. Overcrowding in ED, e.g., i) Further review of “best i) Hard data must be obtained first lack of flow through into practices” to determine what in order to take the political acute care, lack of access to approaches have been most rhetoric out of the equation. inpatient acute beds for successful The reality of walk in clinics admitted patients ii) Review impact of volume of and urgent care centers needs AAP patients in acute care to be addressed at the same beds time and standards set for iii) Develop plan for “surge” them. capacity during peak activity ii) Services to assume responsibility iv) Review “best practices” related for patients at point of to reducing unnecessary admission, enhanced home admissions: e.g. for frail care. elderly: expanded Geriatric iii) Concentrate on stretcher Evaluation and Management patients, not the “walking teams (acute care, community, wound' e.g., create a process and ED based), enhanced to identify in real time where community supports, is the 'flex' in the system & alternative community based find a simplified way to options for caregiver burnout redirect these stretcher patients. iv) Geriatric Transitional Units (GTU) where geriatric patients are assessed in a short stay environment and do not get lost in the acute centre. This population is assessed in the ER by staff that determines if they can return to their home, go to GTU or require a medical bed in an acute hospital. v) Access Service where staff moves the flow of patients through the hospital and out the back door back to facilities. vi) The optimal occupancy rate for acute beds should be 85% to ensure patient safety and efficient delivery of emergency care. [This issue is a combination of funded beds and capacity of staffing the beds.] vii) Access to the community resources 7 days a week (Resources need to include respite, palliative, home care or home IV). Many community homes do not take patients before noon on Monday or after noon on Friday) viii) More education to physicians, nurses and families on end of life issues. ix) A physician (on call for HA or HSDA) that could go out to the LTC homes and assesses the patient prior to moving the patients to an acute hospital. x) DNR issues discussed and signed off at all facilities caring for the frail and elderly. xi) Discharge planning to begin with admission (Geriatric or Medical Critical Pathway). xii) Standards of practice and guidelines be established to promote consistencies within short term task group progress report – april 2003 100

SOLUTIONS ISSUES SHORT TERM LONG TERM HA’s and the Province. xiii) Standardized policies (i.e. MRSA, dehydration care and Norwalk virus). xiv) With the decrease in surgical stays hospitals need to revisit the surgical beds and increase the medical beds as the boomers age. A centralized Geriatric ER with GTU attached with all support services would be valuable and innovative. 6. Flow within emergency i) 24/7 availability and timely access to the following services •Diagnostic imaging. •Consultant/attending physician to expedite admission, treatment and discharge ii) Technicians, point of care testing, tele-radiology 7. Flow out into community i) Improve community resources including patient education programs, home care and readily accessible outpatient clinics, such as stroke clinics, CHF clinics, diabetic clinics, asthma clinics, home IV antibiotic clinics, etc. ii) Improve availability and access to Community Health Services to address the following issues: •Home care services (including Home IV) are not available for new referrals on evenings and weekends. •The reduction of home support hours can jeopardize safe discharge to the community. •Access to LTC services and facilities (including rehab and respite care), and to discharge support aids (e.g. OT aids, medical devices, oxygen) is not well coordinated.

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SOLUTIONS ISSUES SHORT TERM LONG TERM 8. Inadequate throughput from i) Hospital policy regarding going i) Patient outflow from care units the ED creates bottlenecks over census on floors or to create capacity or room for and reduced ED capacity re: specialty areas patients from ED contributed to lost 50 • Collective agreement •Long Term Care space ambulance unit hours daily issues availability in GVRD • Corporate philosophy and •Available community support direction such as home care • Physician responsibilities, •Repatriation of patients from hospitalist access specialty areas • Patient expectations •Repatriation of patients to sub-acute ii) Bed allocation practices for specialties •Hospitals hold specialty beds (e.g. CCU) for internal potentials vs collective requirements •Predictable volumes for ED admits not planned for in bed allocation process •Elective surgery beds blocked preferentially to ED patients 9. Procedures within the ED i) Specialist time to assess organizational structure patients to determine if admit slow patient process within required the ED • On-call rostering i) Too long for patient • Specialist compensation to be seen by issues appropriate staff • Specialist availability ii) Staffing Issues for ED • Teaching hospital/intern iii) Diagnostic/Procedural dual assessment process approaches ii) Nursing Staffing • Nursing shortages • Nurse training availability • Vacation/Scheduling • Attractiveness of workplace for career nurses Physician Staffing • Physician shortages • Compensation issues • Attractiveness of workplace for Physicians iii) Time from procedure request to report • Who can order • Time to make decision to order test • Ordering processes • Necessity of tests • External department processes and staffing • Proximity of diagnostic areas

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SOLUTIONS ISSUES SHORT TERM LONG TERM 10. Standard of care at triage & i) Further review of “best i) Emergency physicians should waiting room delays (when practices” to determine what be encouraged to obtain their ED congested with Admitted processes/approaches have CCFP(EM) qualification and Patients) been most successful in meet their minimum improving patient care at maintenance of competency triage and patient flow through requirements. CPGs and their the ED use should be encouraged. ii) Develop recertification for Provincial CQI programs CTAS should be implemented. 11. Lack of Data Base & i) Identify key data elements for i) Funding to train and implement Information Systems re: tracking and monitoring ED’s CTAS and EDIS inconsistency province wide ii) Accountability must be ii) Review how ER’s are being introduced into the system. used and identify opportunities This is based on data. BC is a to reduce ED activity: e.g. veritable tower of Babel when admissions sent to ED due to it comes to data systems and no beds, elderly patients sent data reporting making to ED for admission due to interpretation and inadequate community comparisons impossible and supports I would assume therefore appropriate allocation of resources. CEDIS (and other data systems)should be implemented across the whole system. Reporting should be to a central authority so that the health care system can move away from the unhealthy competition between hospitals and decisions can be based on facts not on self reported impossible to compare data. 12. Client/Public Satisfaction i) Identify opportunities for public education ii) Identify best practice related to specific patient populations: e.g. child life workers in ED, Elder Friendly initiatives in the ED

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SOLUTIONS ISSUES SHORT TERM LONG TERM 13. Rural Health Care Delivery i) Tools like Telehealth Capacity especially in Nursing Stations and small rural hospitals should be made available Re: Availability of Initial Care i) Financial Implications - Staffing Issues • Budget processes • Commitment to resource ii) Staff Implications • RN Availability • Physician Availability • Interfacility transfer/CCT staff to reduce need for hospital staff iii) Sufficiency of mass • Need to maintain skills • Need to maintain equipment and meds iv) BCAS as proxy or alternative • Staffing levels in rural communities • BCAS training and skills retention • Financial capacity • Travel time impact to local vs more distant 14. High number of psychiatric i) Standards of care for patients inpatient, out patient and transfers for the HA’s and the Province ii) Guidelines for transfer and referral within HA and outside of HA iii) Increase the number of beds in the Province (Bc Bedline referrals exceed the number of available beds) iv) Not enough adolescent psych beds therefore designated centres need to be named v) Quiet rooms for the ER’s where the substance abuse psych patients prior to transfer for patient and staff safety vi) Increase the number of detox beds and access to these in large centres vii) Employ psych nurses in the ER viii) Increase community resources to balance the closure of Riverview beds 15. Capacity issues

SHORT → LONG TERM SOLUTIONS i) Provide an Access Service that is responsible for access and not looking for ways of keeping patients out of hospital if emergency care is required. Access Service is constantly decompressing the ER. The Access Service has a global vision of the hospital and the patient transfers that can be made to accommodate patients coming into the ER after hours and on weekends. This position needs to be given the responsibility and the authority to make difficult decisions. Access must be able to prioritize, problem solve, use critical thinking with all members of the health care team. ii) Centralize the bedbooking offices in the HA’s to increase efficiencies and to decrease redundancies. iii) Use BC Bedline for acute and higher level of care patients to increase efficiencies, co-ordinate transfers and increase utilization at all sites short term task group progress report – april 2003 104

SOLUTIONS ISSUES SHORT TERM LONG TERM within the HA’s. iv) Decrease or stop gatekeepers “never take no from someone who was authorized to give you a Yes”. 16. Inconsistencies amongst and i) Standardize all emergency and between ERs Urgent Care Centres in the Province to use CTAS Triage Scale. Education must be provided

SHORT → LONG TERM SOLUTIONS i) Standardize the minimum educational standard for nurses and physicians working in the ER. ii) Collect comparable and reliable data from ER’s. iii) Set guidelines that eliminate the improper use of the ER (i.e.) extension of the Physicians office iv) Establish direct admit policies and standards that can be implemented at hospitals that admit to ER instead of the wards. v) Set a reasonable time frame for admitted patients to be in an ER (6 hours) vi) Clearly establish the roles of each hospital within the HA. vii) Improve the co-ordination of the transfers into and out of hospitals. (I.e.) ambulance sitting in ER with medical patient while the medical floor is waiting for ambulance to take a medical patient out which will give them a free bed for patient in ER.

17. Lack of co-ordination Centralize a social worker on call Multiskilled workers that can do between support services for a number of sites after hours portering and housekeeping or unit and on weekends. clerk or admitting functions.

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APPENDIX 10 WINTER ACTION PLANS

The purpose of this project is to develop a planning process that will lead to all HAs completing their Winter Action Plans by September 15, 2003. This will lead to better patient care through coordination across all care sectors and between HAs and PHSA. The following project outline sets out four key tasks:

1. Providing strategic support and guidance for joint PHSA and HA actions to prepare for this winter.

2. Assisting HAs to develop plans for operational projects to deal with this winter’s pressures.

3. Developing communications systems to support improved system performance this winter

4. Developing longer-term projects to support improved system performance in future years.

Winter Action Plans

1.0 Project Purpose The purpose of this project is to develop a planning process that will lead to all HAs completing their Winter Action Plans by September 15, 2003.

2.0 Background Winter is a season of extreme pressures for Health Authorities (HAs) for a variety of reasons: children and people with chronic illness suffer from the weather as well as flu and other communicable diseases; staff experience higher rates of absence due to illness, and weather-related trauma also increases. It is an especially difficult time for managers and clinicians as they struggle, often isolated within their own agency’s resources.

If not well managed, winter pressures lead to poor patient care and higher costs. Media reports of emergency room waits, cancelled operations and ambulance diversions create public anxiety and political pressure to “do something”. All of these could undermine perceptions about progress towards New Era commitments.

These factors warrant a special focus on coping with winter pressures. While the action planning has to be the responsibility of HAs, there are some system- wide coordination issues. In addition, in the first few years, some better- practice guidance would be helpful.

An initiative of this complexity will mature over several years. To some extent it will likely become a permanent fixture of the HA planning cycle, and of the MoH/S monitoring program. Because of its strategic importance, it will require resources and commitment from MoH/S, PHSA and other HAs.

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3.0 Objectives The objectives of the project are to identify mechanisms that MoH/S and HAs can use to: 1. Reduce the frequency of cancelled procedures and operations for scheduled [elective] patients. 2. Reduce delays in treatment and transfer of patients needing critical care services. 3. Reduce waits for patients needing hospital admission from Emergency Departments. 4. Increase use of alternative levels of care to reduce unnecessary hospitalization. 5. Develop ways to manage escalation of winter pressures so as to prevent negative effects for patients and staff. 6. Improve communication among HAs and with the general public.

4.0 Scope The scope of the project includes:

1. Providing strategic support to HAs about better practices for health system performance this winter. a. Planning joint PHSA and HA actions. b. Developing “Better Practice” guidance on Winter Action Planning [WAP] for use by HAs. A key recommendation will cover the process for forming Winter Action Planning Groups within each HA. c. Supporting HAs as requested in defining roles, responsibilities and tasks for their WAP Groups. d. Initiating discussions with BCAS to promote local and provincial participation in HA Winter Action Planning.

2. Assisting HAs to developing plans for operational projects to deal with this year’s winter pressures as requested. PHSA would develop expertise in this area if HAs were willing to collaborate in resourcing this capacity.

3. Developing communications systems to support improved system performance this winter a. Setting up a process to assist HAs in sharing good practice, tracking trends and improving communication. b. Developing briefing materials for HA and MoH/S communications staff on the WAP Project.

4. Longer-term initiatives to improve health system performance during future winter periods a. Identifying HA-level indicators that can be used to identify “hot spots” where pressures are building. b. Defining resources (staff and systems) required to monitor critical indicators and develop situation reports. short term task group progress report – april 2003 107

c. Defining requirements for developing on-going modeling capacity to analyze the impact of winter pressures and emergency workload on scheduled services. d. Working with BCAS, the Bedline and Nurseline programs to ensure that they are well-linked to the WAP work.

5.0 Major Deliverables

The major deliverable results for this project are:

1. Providing strategic direction a. Briefing note for the initial discussion at the Leadership Council and Provincial Emergency Services Project Workshop. b. Research report on “Better Practices for Winter Action Planning” for use by HAs. c. Report on discussions with BCAS to promote their participation in Winter Action Planning.

2. Providing operational support in the form of written guidance or coaching sessions with HA staff to support them in defining roles, responsibilities and tasks for their WAP Groups. [See next section. Actual requirement to be defined based on HA preference and resources.]

3. Developing communications systems a. A mechanism for regular information-sharing among HAs. b. Briefing materials and a briefing session for communications staff on the Winter Action Planning Project.

4. A report on longer-term initiatives for improving health system performance, evaluating work to date and recommending next steps.

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GUIDELINES FOR WINTER ACTION PLANS

Planning Process and Timetable HSDAs would develop Winter Action Plans by June 15 for implementation by HAs starting in September 2003. These Plans would be developed according to an outline or checklist developed by PHSA in collaboration with HAs. Planning would be through collaborative Winter Action Planning Groups (WAPG) within each HSDA, with linkages to the HA, to other HAs and to PHSA as required. Each WAPG would include representatives from all care sectors, plus social services, BCAS, and others. There would be an identified executive lead and project manager to support each WAPG.

Assessing the State of Readiness HA assessments of capacity for winter 2003/04 should take into account how each health management area managed pressures in 2002/03 as well as year round elective/emergency activity. Plans should demonstrate that actual performance has been taken into account in planning for this year and that clear action plans are in place to address any shortfalls or pressure points.

Monitoring MoH/S staff will review HA Winter Action Plans not only to support consistency and coordination across all HAs, but also to advise Ministers about system readiness and potential problem areas. During the winter, regular reporting by HAs will enable provincial coordination of resources necessary to avoid any major escalation problems or incidents affecting patient care.

Checklist A detailed checklist will provide a guide to issues that each WAPG should consider when planning (main headings and sample below). This is not intended to be an exhaustive list. While it sets out a broad framework, local planning will be much more operationally focused around local and regional issues.

D Winter Planning Action Group Charters (for project management) D ‘Flu Immunization Programme D Hospital Services D Mental Health Services D Ambulance Services D Home and Community Care D Ministry of Human Resources, Ministry for Children and Family Development (including Housing & wider Local Government) D Primary Care D Escalation D Staffing and Human Resources D Communications

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Sample of checklist detail – Hospital services

Critical Care Services 1. Is there a plan to manage critical care services across the HA? 2. Is there an identified HA executive level staff member responsible for the organization and provision of critical care services? 3. Is there a critical care network across the HA with an agreed critical care capacity including additional capacity to meet peaks of pressure and robust staffing plans to ensure capacity can be maintained? 4. Are each hospital’s critical care plans derived from the overall HA plans? Do they include a project plan for improvements with implementation dates against which progress can be monitored? 5. Has the HA critical care network agreed common admission and transfer standards and protocols? 6. Are arrangements in place to ensure critical care transfers outside the local clinical network are agreed by specialists and responsible executives in both hospitals? Is there a system to inform the sending and host HA Chief Executive of pending patient transfer? 7. Have postoperative facilities been reviewed to maximize capability to provide critical care for the first 24 hours post operatively and arrangements put in place to manage potential cancellation of urgent elective surgery?

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APPENDIX 11 BIBLIOGRAPHY

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2 Ardagh MW, Wells JE, Cooper K, Lyons R, Patterson R, O'Donovan P. Effect of a rapid assessment clinic on the waiting time to be seen by a doctor and the time spent in the department, for patients presenting to an urban emergency department: a controlled prospective trial. N Z Med J 2002 Jul 2; 115(1157): U28

3 Audit Commission (1996) By Accident or Design: Improving A&E Services in England and Wales. London: HMSO.

4 Athey S. and Stern, S. The Impact of Information Technology on Emergency Health Care Outcomes http://www-cepr.stanford.edu/papers/pdf/01-22.pdf (20/11/02)

5 bcbedline. Graphic Summaries of Calls by Service/by Sending Hospital/by Receiving Hospital/by Priority/by Transport Method/by Transfer Reason/by Time of Day/by YTD Total Calls for Period 08 (October 11 – November 7, 2002), Period 09 (November 8 – December 5, 2002) & Period 10 (December 6, 2002 – January 2, 2003).

6 B.C. Ministry of Health & B.C.’s Children’s Hospital. Report of the Provincial Pediatric Hospital Utilization Study Steering Committee. October 1990.

7 B.C. Ministry of Health & B.C.’s Children’s Hospital. Report of the Provincial Pediatric Hospital Utilization Study Steering Committee. Analysis of Greater Vancouver Hospital Regional District: Survey of Emergency Department Utilization by Children. January 1990.

8 B.C. Ministry of Health Services. Performance Agreement between The Ministry of Health Services and The Fraser Health Authority – April 1, 2002 to March 31, 2003.

9 B.C. Ministry of Health Services. Performance Agreement between The Ministry of Health Services and The Northern Health Authority – April 1, 2002 to March 31, 2003.

10 B.C. Ministry of Health Services. Performance Agreement between The Ministry of Health Services and The Interior Health Authority – April 1, 2002 to March 31, 2003.

11 B.C. Ministry of Health Services. Performance Agreement between The Ministry of Health Services and The Provincial Health Services Authority – April 1, 2002 to March 31, 2003.

12 B.C. Ministry of Health Services. Performance Agreement between The Ministry of Health Services and The Vancouver Coastal Health Authority – April 1, 2002 to March 31, 2003.

13 B.C. Ministry of Health Services. Performance Agreement between The Ministry of Health Services and The Vancouver Island Health Authority – April 1, 2002 to March 31, 2003.

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14 Bristow DP, Herrick CA. Emergency department case management: the dyad team of nurse case manager and social worker improve discharge planning and patient and staff satisfaction while decreasing inappropriate admissions and costs. Lippincotts Case Manag 2002 May-Jun; 7(3): 121-8.

15 BC Medical Association (BCMA). Appendix C: Overcrowding Responses.

16 British Columbia Medical Association (BCMA) Section of EM. ED Crowding – Presentation Slides.

17 British Columbia Medical Association (BCMA). Examples of Morbidity and Mortality in the past 6 months at RCH ED due to ED crowding.

18 Brookstone, A. “Emergency room doctors lead the way for wireless, mobile computing”. Canadian Health Technology, (September 2002). (http://www.canhealth.com)

19 Canadian Association of Emergency Physicians (CAEP). Backgrounder - A National Forum on Emergency Health Care.

20 Canadian Association of Emergency Physicians (CAEP). Media Release: Emergency physicians call for national forum on emergency health care.

21 Canadian Association of Emergency Physicians (CAEP). Proposal for a National Forum on Emergency Health Services. September 3, 2002.

22 Canadian Association of Emergency Physicians (CAEP). Recommendations for the Management of Rural, Remote and Isolated Emergency Health Care Facilities in Canada. (March 1, 1997).

23 Canadian Association of Emergency Physicians (CAEP) and National Emergency Nurses Affiliation. “Joint Position Statement on emergency department overcrowding”. Canadian Journal of Emergency Medicine, (April 2001; 3(2)), pp. 82-84.

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25 Canadian Association of Emergency Physicians (CAEP) and Working Group on the Future of Emergency Medicine in Canada. “The future of emergency medicine in Canada: submission from CAEP to the Romanow Commission. Part 2.” Canadian Journal of Emergency Medicine, (November 2002; 4(6)), pp. 431-432.

26 Caro DHJ and D Angelis. Federal Governance in Emergency Management in Canada: Quo Vadis? http://www.cchse.org/Forum/Caro%20Angelis%20corr.pdf

27 Child Health Network of the Lower Mainland & Fraser Valley of BC. Child Health Network Project: Phase 2 Survey Report. October 2000.

28 Coleman EA, Eilertsen TB, Kramer AM, Magid DJ, Beck A, Conner D. Reducing emergency visits in older adults with chronic illness. A randomized, controlled trial of group visits. Eff Clin Pract 2001 Mar-Apr; 4(2): 49-57

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29 College of Physicians & Surgeons of British Columbia. External Review of the Diagnostic Accreditation Program (DAP): Final Report. November 2002.

30 Cooke MW, Wilson S, Pearson S. The effect of a separate stream for minor injuries on accident and emergency department waiting times. Emerg Med J 2002 Jan; 19(1): 28- 30.

31 Department of Health, UK. Long term planning for hospitals and related services – consultation document on the National Beds Inquiry. 2000 http://www.doh.gov.uk/nationalbeds.htm

32 Drummond, A.J. “No room at the inn: overcrowding in Ontario’s emergency departments”. Canadian Journal of Emergency Medicine, (March 2002; 4(2)), pp.91- 96.

33 Emergency Demand Coordination Group. Victorian Government Department of Human Services. Hospital Admission Risk Program (HARP) Background Paper. www.health.vic.gov.au/hdms/harpbgpap.pdf (20/11/02)

34 “Emergency Department Overcrowding: An Action Plan”. Academic Emergency Medicine, (February 2001, Vol. 8, No. 2), pp. 185-189.

35 Emergency Nurses Association of NSW Inc. Response to ACEM Policy Documents: Guideliens for Implementation of the Australian Triage Scale in Emergency Departments & The Australian Triage Scale. February 2001.

36 Flintoft VF, Williams JI, Williams RC, Basinski AS, Blackstein-Hirsch P, Naylor CD. The need for acute, sub-acute and non-acute care at 105 general hospital sites in Ontario. CMAJ 1998; 158(10): 1289-96

37 Fortune T. Telephone triage: an Irish view. Accid Emerg Nurs 2001 Jul; 9(3):152-6

38 Grafstein, E., Coleman, J., and Innes, G. Bridges to Health – Closing the Gap Between Researchers and Policy-Makers in B.C. Health Care – Presentation Slides. November 2002.

39 Groll, D. and Henry, B. “Can a universal influenza Immunization program reduce emergency department volume?” Canadian Journal of Emergency Medicine, (July 2002; 4(4)), pp. 245-250.

40 HIT Report. “Emergency department Systems Study – Focus: Eight ED Vendor Products Compared. Study Provides Valuable Insight into the Success of ED Systems.” ElectronicHealthcare, (Vol. 1, No. 4, 2002), pp. 53-56.

41 Hong Kong Government. Government Flying Performance Statistics. February 2003.

42 Hunt RC. Emerging communication technologies in emergency medical services. Prehosp Emerg Care 2002 Jan-Mar; 6(1): 131-6

43 Innes, G., Murray, M., and Grafstein, E “A consensus-based process to define standard national data elements for a Canadian emergency department information system”. Canadian Journal of Emergency Medicine, (Vol. 3, No. 4, October 2001). (http://www.caep.ca/004.cjem-jcmu/004-00.cjem/vol-3.2001/v34-277.htm).

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44 Insight Information Co. Hallway Medicine: Strategies for Eliminating Emergency Room Backlogs, Toronto, June 28-29, 2000. A Canadian Success Story: How Capital Health Did It – Dr. Robert Bear, Executive Vice President, Chief Clinical Officer, Capital Health (Toronto).

45 Insight Information Co. Hallway Medicine: Strategies for Eliminating Emergency Room Backlogs, Toronto, June 28-29, 2000. Ambulance Services and Hallway Medicine – Ronald L. Kelusky, General Manager, Toronto Ambulance Services.

46 Insight Information Co. Hallway Medicine: Strategies for Eliminating Emergency Room Backlogs, Toronto, June 28-29, 2000. Crisis in the Emergency Department: Contributing Factors and Potential Solutions - Laura Van de Bogart, Principal Consultant, PricewaterhouseCoopers LLP (Toronto).

47 Insight Information Co. Hallway Medicine: Strategies for Eliminating Emergency Room Backlogs, Toronto, June 28-29, 2000. Impact of Emergency Shortages on Chronic Healthcare Consumer – Durhane Wong-Rieger, PhD, President & CEO, Anemia Institute for Research and Education (Toronto).

48 Insight Information Co. Hallway Medicine: Strategies for Eliminating Emergency Room Backlogs, Toronto, June 28-29, 2000. Modernizing Medicare for the Twenty-First Century – Dr. Michael M. Rachlis, Health Policy Analyst (Toronto).

49 Insight Information Co. Hallway Medicine: Strategies for Eliminating Emergency Room Backlogs, Toronto, June 28-29, 2000. Ontario’s Health Critic Provides Her Perspective – Lyn McLeod, MPP Thunder Bay-Atikokan (Toronto).

50 Insight Information Co. Hallway Medicine: Strategies for Eliminating Emergency Room Backlogs, Toronto, June 28-29, 2000. Some Practical Solutions: Case Studies from Kaiser Permanent and St. Michael’s Hospital – Taylor Cuthbertson, Program Director, Minimal Access Therapeutics and Diseases of the Digestive System (Toronto).

51 Insight Information Co. Hallway Medicine: Strategies for Eliminating Emergency Room Backlogs, Toronto, June 28-29, 2000. The Consumer’s Perspective – Dale McMurchy, Senior Consultant, PricewaterhouseCoopers LLP (Toronto).

52 Jaklevic MC. Making room for more. New admission and discharge center at Ill. hospital relieves chronic overcrowding in the emergency room and gets patients care quicker. Mod Healthc 2002 Sep 23; 32(38):30-2, 34, 36

53 KPM Consulting. Provincial Health Services Authority: Developing a Province-wide Health System. July 29, 2002.

54 Lower Mainland/North Shore/Fraser Valley Emergency Services Co-ordinating Committee: Project Report and Recommendations. August 1998.

55 Lower Mainland/North Shore/Fraser Valley Emergency Services Co-ordinating Committee: Summary of Recommendations. August 1998.

56 Lower Mainland/North Shore/Fraser Valley Emergency Services Co-ordinating Committee: Recommendations: Planning and Progress. September 1998.

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57 Martin A, Martin C, Martin PB, Martin PA, Green G, Eldridge S. 'Inappropriate' attendance at an accident and emergency department by adults registered in local general practices: how is it related to their use of primary care? J Health Serv Res Policy 2002 Jul; 7(3): 160-5

58 McLeod NR. Healthcare organizations and patient transfers: a transportation industry perspective. Hosp Q 2002 Summer; 5(4): 81-4, 4

59 McManus, M. Issue Brief: The Massachusetts Health Policy Forum. Emergency Department Overcrowding in Massachusetts: Making Room in Our Hospitals. Boston, June 7, 2001.

60 MedAmerica Consulting. Emergency Medicine Proposal. August 13, 2002.

61 Metropolitan Toronto District Health Council. MTDHC Hospital Restructuring Project: Emergency Services Patient Service Group Task Force – Summary of Deliberations. November 1994.

62 Monash Institute of Health Services Research. Consistency of Triage in Victoria’s Emergency Departments http://www.health.vic.gov.au/hdms/litrev.pdf (20/11/02)

63 Nicholl J, Munro J. Systems for emergency care: Integrating the components is the challenge. British Medical Journal 2000 320:955-6.

64 Nova Scotia Department of Health, Emergency Health Services (EHS). Annual Report 2001-2002. (http://www.gov.ns.ca/health/ehs)

65 Ontario Ministry of Health & Long-Term Care. Hospital Report 2001: ED System Integration & Change. (http://www.gov.on.ca/health)

66 Ontario Ministry of Health & Long-Term Care. Hospital Report 2001: Emergency Department Care. (http://www.gov.on.ca/health)

67 Ontario Ministry of Health & Long-Term Care. Hospital Report 2001: Complex Continuing Care & Emergency Department Care. (http://www.gov.on.ca/health)

68 Ota FS, Muramatsu RS, Yoshida BH, Yamamoto LG. GPS computer navigators to shorten EMS response and transport times. Am J Emerg Med 2001 May; 19(3): 204-5

69 Providence Health Care. Report of The Regional Working Group on Emergency Overcrowding. January 18, 2002.

70 Reeder TJ, Garrison HG. When the safety net is unsafe: real-time assessment of the overcrowded emergency department. Acad Emerg Med 2001 Nov; 8(11): 1070-4

71 Richardson, L., Asplin, B., and Lowe, R. “Emergency Department Crowding as a Health Policy Issue: Past Development, Future Directions”. Annals of Emergency Medicine, (October 2002, Vol. 40, No. 4), pp. 388-393.

72 Roberts E, May N. Can primary care and community-based models of emergency care substitute for the hospital accident and emergency (A&E) department? Health Policy 1998 44:191-214.

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73 Schneider, S., et al. “Rochester, New York: A Decade of Emergency Department Overcrowding”. Academic Emergency Medicine, (November 2001, Vol. 8, No. 11), pp.1044-1050.

74 Schull, M.J., et al. “Emergency Department Overcrowding Following Systematic Hospital Restructuring: Trends at Twenty Hospitals over Ten Years”. Academic Emergency Medicine, (November 2001, Vol. 8, No. 11), pp. 1037-1043.

75 Schull, M.J., Slaughter, P.M., and Redelmeier, D.A. “Urban emergency department overcrowding: defining the problem and eliminating misconceptions”. Canadian Journal of Emergency Medicine, (March 2002; 4(2)), pp. 76-82.

76 Strategic Resource Group. Emergency Health Services in BC: Challenges, Opportunities and Best Practices. January 2003.

77 Strategic Resource Group. Emergency Health Services in BC: Diversity in Abundance. February 2003.

78 Strategic Resource Group and Associates. Improving BC’s Emergency Health Services – a brief assessment of published research. November 2002.

79 Strategic Resource Group and Associates. Winter Action Plans. December 13, 2002.

80 Tink, W. Profiling Patients Who Use The Emergency Department for Primary Care in a Multicultural Urban Setting.

81 Vancouver Coastal Health Authority. VCESPP: Phase One – Appendix B: Vancouver Coastal Emergency Services Planning Project (VCESPP).

82 Vancouver Richmond Health Board. Review of Acute/Rehab Services: Emergency Services Clinical Program Team Report (Final Draft). October 1997.

83 Vedsted P, Sorensen HT, Nielsen JN, Oleson F. The association between daytime attendance and out-of-hours frequent attendance among adult patients in general practice. British Journal of General Practice 2001 51:121-124.

84 Washington DL, Stevens CD, Shekelle PG, Henneman PL, Brook RH. Next-day care for emergency department users with nonacute conditions. A randomized, controlled trial. Ann Intern Med 2002 Nov 5; 137(9): 707-14

85 Wilson S, Cooke M, Morrell R, Bridge P, Allan T. Emergency Medicine Research Group (EMeRG). A systematic review of the evidence supporting the use of priority dispatch of emergency ambulances. Prehosp Emerg Care 2002 Jan-Mar; 6(1): 42-9

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Relevant reviews from other Canadian jurisdictions

Performance Evaluation of Nova Scotia Emergency Health Services. (November 2001) http://www.gov.ns.ca/health/downloads/Nova_Scotia_Final_Report.pdf

EHS Ground Ambulance Operations in Nova Scotia http://www.gov.ns.ca/health/ehs/

After Hours Medical Clinics http://www.gov.pe.ca/infopei/Health/Medical_Clinics/After_Hours_Medical_Clinics/

Health Services Review: Report of the Committee (February 1999) http://www.gnb.ca/hw-sm/hw/pub/hsrc/5/hospcare.htm

Extra-Mural Hospital http://www.gnb.ca/hw-sm/hw/pub/hsrc/5/longterm.htm

Improving Emergency Services for Ontarians (November 2001) http://www.gov.on.ca/MOH/S /english/news/media/media_faq_5.html

Redirect/ Critical Care Bypass Working Group Recommendations (March 2001) http://www.gov.on.ca/MOH/S /english/pub/ministry/rdc_ccb.pdf

Hospital Report 2001 – Acute Care http://www.gov.on.ca/MOH/S /english/pub/ministry/hosp_rep01/hosp_rep_mn.html

Hospital Report 2001 – Emergency Department Care Hospital Report Research Collaborative, University of Toronto http://www.oha.com/OHA/ohawebpg.nsf/0c50ec800018f04e0525652b00114fb8/48ba 09a95a842b2185256b28004b4a86/$FILE/ED_Report_2001.pdf

Backgrounder on Demand Management. The Change Foundation for the Demand Management Think Tank, Toronto, Ontario January 2002 http://www.changefoundation.com/tcf/TCFBul.nsf/dea2e13875b9d7cb052565e4007faa a0/05b7fbdb14695dcd85256b43005c0512/$FILE/FINALDemandManagement.pdf

Quebec's Bill 114. CMAJ 2002 Sep 17; 167(6): 617, 619 Montreal Regional Board. The 1998-2002 ‘’Accent on Access’’ improvement plan http://www.santemontreal.qc.ca/index.asp?url=en/planamelioration/plan_9802_12m _santp.htm

Saskatchewan EMS Development Project http://www.health.gov.sk.ca/info_center_pub_EMSFinalReport.pdf

Patient-Focused Emergency Medical Services – MLA Review of Ambulance Service Delivery 2001 Draft Report http://www.gov.ab.ca/home/news/dsp_feature.cfm?lkFid=150

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