Erie St. Clair LHIN – Small Community Hospital ED Study Questions for Dr. Isser Dubinsky from the ESC LHIN Board (February 2009)

Prepared by Dr. Dubinsky March 23, 2009 

The answers to the following questions are those of Dr. Dubinsky. The responses provided in no way reflect the opinions of the Erie St. Clair LHIN or its staff.  

Question 1
What options are there for the maintenance of the CEE ED? What would it take to move an ED from "unsustainable" to "sustainable"? Why did Dr. Dubinsky only make a single recommendation?

Question 2 
What other options are we going to consider [if any]?

Question 3 
What are the job impacts of the proposed changes in each of Petrolia and Wallaceburg?

Question 4
The Observer (January 30) article cites the Jim Whaley report: "the recommendation for maintaining a 24/7 emergency department is consistent with the long-standing Ministry of Health policy for rural hospitals including the Rural and Northern Healthcare Framework which was released in 1997". We have looked at this and the JPPC report. How does the Hay report account for these?

Question 5 
What are the physician remuneration issues? What are the potential impacts of these on the community? Can we address these?

Question 6 
Leamington has a history of being on the bubble with respect to ED physician staffing. How will this be addressed going forward? For that matter, how can CKHA be expected to handle the additional traffic with their doc shortage?

Question 7 
What impact does the closure of the ED at both hospitals have on the remainder of the services offered at the hospital, and specifically on the acute care beds that are located there?

Question 8
Can Bluewater and CKHA handle the increasing ED and acute-care volume the closure would produce?

Question 9 
The "data war" is concerning. Shadow billing used by docs to support their point of view contrasts starkly with the CIHI CTAS data used in the Hay report. Even though we (the LHIN) assert that the CIHI data is "gold standard", this will not be accepted by the community. Are there additional data sources that can be accessed, such as EMS logs that will shed additional light? Is there any time of day reporting that we can review to get a handle on the overnight ED "closure" at CEE?

Question 10 
Dubinsky states that CEE will need to add "one staff position to both the daytime and evening shifts" and goes on to equate this into a need to recruit 10 FTE nurses. While we can accept that we need a ratio of something higher than 1:1 for a staffing position, how does this translate into a five to one hiring ratio?

Question 11 
Dubinsky does not describe "Urgent Care Centre" except in terms of what it is not. Can we have more information on Urgent Care Centers and especially in instances where an UCC has replaced an ED and the impacts on care in the affected community? 

Question 12
The debate on travel times is problematic. If there is evidence of bias in the Hay report, it is here -- it is specious to limit the calculation of travel time as hospital door to hospital door. The patient will have to travel from the site of the actual emergency event to the ED, and in the case of folks from the outer reaches of CEE or Sydenham’s catchment, it would have been more honest to put a range of these actual travel times in the report.


 

 

Question 1

What options are there for the maintenance of the CEE ED? What would it take to move an ED from "unsustainable" to "sustainable"? Why did Dr. Dubinsky only make a single recommendation? 

Answer

As outlined in the Hay Group report to the Erie St. Clair LHIN, the assessment of the viability of any emergency department is multifactorial. Amongst other factors, for an emergency department to be sustainable, it needs to have an appropriate:

  • physical plant,
  • infrastructure, and
    • complement of human resources
    • as well as sufficient visit volume
    • to make the cost of care delivery efficient, and
    • to maintain the quality of care provided by the physician and nursing staff.

When feasible, we recommend that emergency departments operate only in hospitals which are full service organizations. Specifically, the hospital should have not only an Emergency Department, but the array of diagnostic services, consultants for the provision of medical, surgical, pediatric, gynecologic and psychiatric services, inpatient beds, critical care services and operating rooms necessary to support the ED. The Sarnia hospital is only a short distance away offers all of these services and will, at the completion of its construction project, have the capacity to provide all of these services to residents of Sarnia, Petrolia and other communities in the area.

With specific reference to the CEE ED, the physician human resource currently needs to be supplemented (and will need further supplementation in the near future), the nursing resource needs to be augmented, and there is no consultant, critical care, or operating room services available. Additionally, there are only a small number of inpatient beds.

Importantly, the hospital already operates "de facto" as an urgent care center rather than an Emergency Department. It is only staffed during the day and evening hours. The emergency department doors are locked at night, no physician is present on site, and nursing staff are not located in the emergency department after hours.

Additionally, the total volume of emergency department visits is low, and the number of patients in need of urgent and emergent care is exceptionally low, with less than 60 patients per year requiring CTAS level 1 or 2 care.

As outlined in the Hay Group report, there are an array of options available to the hospital. These include, but are not limited to,
  1. Continuing to operate in the current physical plant for a limited number of hours (12-16 per day is suggested), and formally designating the facility as an urgent care rather than emergency department.
  1. A second option is to develop a comprehensive primary care facility which is community-based and contains an urgent care facility within it.
  1. A third opportunity would be to create a comprehensive primary care facility within the hospital, and utilize the existing physical plant of the emergency department as the urgent care facility which is operated by the family physicians.

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Question 2 

What other options are we going to consider [if any]?

Answer

The Hay Group report, as outlined above, identifies the options available. The option which is not recommended is to attempt to establish/re-establish a full-service emergency department at CEE. To do so will require an investment in physical plant renovation, the addition of a significant number of operating dollars into a hospital's budget to provide 7 day per week, 24 hour per day nurse staffing in the ED ($800,000 at a minimum), the recruitment of several more physicians to the community who will be willing to provide emergency care and who are willing to attend in the ED 7 days per week, 24 hours per day (or, alternatively, having physicians provide service on an "ad hoc" basis while, potentially, underwriting physician agency fees necessary to provide 7/24 physician coverage of the ED).

Even if this option is pursued, patients who are seriously ill or injured will still require transfer to the Sarnia hospital for treatment

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Question 3 

What are the job impacts of the proposed changes in each of Petrolia and Wallaceburg? 

Answer

We expect that the net impact will be nil; assuming that staff currently employed in the emergency departments of the sites will be employed in the urgent care or primary care facilities suggested in the report. 

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Question 4

The Observer (January 30) article cites the Jim Whaley report: "the recommendation for maintaining a 24/7 emergency department is consistent with the long-standing Ministry of Health policy for rural hospitals including the Rural and Northern Healthcare Framework which was released in 1997". We have looked at this and the JPPC report. How does the Hay report account for these? 

Answer 

The Rural and Northern Healthcare Framework, released in 1997, does not represent Ministry of Health policy, guidelines, or recommendations. Rather, it is a discussion document reflecting some of the key elements necessary for the maintenance of viable hospitals in rural and remote locations. It emphasizes the need for coordination and integration of services and speaks to the need to ensure that services are available in a timely way, but not the necessity that all hospitals deliver all services.

With specific reference to the maintenance of emergency services, while very small rural hospitals may be defined by visit volumes, they also need to be viewed in the context of proximity to larger facilities which can offer an array of services to patients living in the rural community.

With specific reference to Petrolia, there is a hospital with a comprehensive array of services available a very short distance away.

Additionally, as mentioned elsewhere in this report, and confirmed in Mr. Whaley's document, the number of people seeking urgent and emergent care at CEE is extremely small as a percentage of the total visits and small in absolute terms as well. The time sensitive emergent and urgent care for those patients who continue to present themselves at CEE will continue to be provided the majority of time (12- 16 hours per day) by the facility which is recommended for Petrolia. As is currently the case, most of these patients will, after assessment and stabilization, be transferred to the hospital in Sarnia. Only the extremely small number of patients currently presenting on the night shift will, in the future need to be transported by ambulance, or expected to transport themselves, directly to Sarnia for care.

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Question 5

What are the physician remuneration issues? What are the potential impacts of these on the community? Can we address these? 

Answer 

The physicians providing service in the emergency department in the CEE ED are currently compensated in an alternative fee arrangement. As stated by the physicians, the extremely low visit volume on nights, with the provision of a competitive hourly stipend, "compensates them" for the sacrifice of office hours for the provision of service during the day. Thus, the provision of physician services on the night shift is not seen as “cost effective”. The hospital is prohibited, by virtue of the OMA/Ministry of Health agreement, from supplementing physician incomes for clinical activity.

Given the current, and anticipated future worsening physician human resource situation in the community, it is distinctly possible that the hospital will have to pay physician agency fees in order to staff the department 24 hours per day/ 7 days per week. This will place a significant burden on Bluewater Health. If the hospital was to opt to pay this supplement, the money would be taken out of the operating budget, thus interfering with the hospital's ability to continue to provide the array of services that it does.

It is, however, noteworthy that there is, at this time, no model of compensating physicians for the provision of urgent care, other than the fee-for-service model.

Ultimately, the physicians providing service in the facility will have to examine the income generating potential of an urgent care or comprehensive primary care facility. This may require entering into discussion with the Ministry of Health to negotiate the development of an AFA or other remuneration model specific to physicians providing care in such facilities.

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Question 6 

Leamington has a history of being on the bubble with respect to ED physician staffing. How will this be addressed going forward? For that matter, how can CKHA be expected to handle the additional traffic with their doc shortage? 

Answer 

Currently, the staffing situation in Leamington is stable. Specific recommendations have been made to augment this staffing even further.

Recommendations regarding the need to enhance the CKHA emergency department staffing have been made in the Hay Group report. Specifically, the need to ensure a stable staffing model in CKHA as a prerequisite to the reconfiguration of the Wallaceburg emergency department has been identified.

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Question 7 

What impact does the closure of the ED at both hospitals have on the remainder of the services offered at the hospital, and specifically on the acute care beds that are located there? 

Answer  

The Chatham-Kent Health Alliance is undergoing a strategic review which will examine the future of acute care at the Wallaceburg site. As mentioned above, we believe that emergency departments should only operate in facilities that have the array of inpatient and support services necessary to manage the acute inpatient needs of patients presenting to the emergency department. The Wallaceburg site currently does not offer this array of services.

The array and designation of inpatient services to be offered at the CEE site is also under review. The reconfiguration of urgent and emergent services at the site, other than the considerations above, should have no impact on this process.

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Question 8

Can Bluewater and CKHA handle the increasing ED and acute-care volume the closure would produce? 

Answer 

Given the extremely low visit volumes at both sites, the incremental number of admitted patients anticipated will be minimal. Furthermore, many of the patients requiring admission are already transferred from Wallaceburg to Chatham or from Petrolia to Sarnia. We believe that more rapid access to consultation will, in fact, enhance the quality of care received by patients in need of emergent and urgent inpatient care.

The specific concerns regarding the impact on the emergency departments have been addressed both in the report and in the answers to questions above.

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Question 9 

The "data war" is concerning. Shadow billing used by docs to support their point of view contrasts starkly with the CIHI CTAS data used in the Hay report. Even though we (the LHIN) assert that the CIHI data is "gold standard", this will not be accepted by the community. Are there additional data sources that can be accessed, such as EMS logs that will shed additional light? Is there any time of day reporting that we can review to get a handle on the overnight ED "closure" at CEE? 

Answer

The CIHI NACRS and embedded CTAS data is, in fact, the "gold standard". These are provided by the hospital based on the clinical record of visits to the hospital ED. It would be concerning if there are visits to the ED for which there is no clinical record.

Unless there are a significant number of emergency department visits which are not being tracked or recorded, it is hard to conceive of a situation in which there can be significant disparities between the CIHI data and the actual number of emergency department visits.

The only alternative to using the CIHI NACRS data would be to create a parallel data collections scheme wherein there would be an independent manual count of all emergency department visits including assignment of a CTAS level, ideally performed by an experienced triage nurse.

EMS records will only provide information on the number of patients transported by ambulance.

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Question 10

Dubinsky states that CEE will need to add "one staff position to both the daytime and evening shifts" and goes on to equate this into a need to recruit 10 FTE nurses. While we can accept that we need a ratio of something higher than 1:1 for a staffing position, how does this translate into a five to one hiring ratio? 

Answer 

The report is insufficiently clear on this point. The addition of one nurse on each of the daytime and evening shifts will require the completion of an additional 14 nursing shifts per week. Providing 14 shifts per week will require 5 full-time equivalent positions.

If, in fact, the department were to operate as a true emergency department, it would also be necessary to have an additional two nurses working the night shift, which would require a further five full-time equivalents, resulting in a total cost of $800,000 per year or more.

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Question 11 

Dubinsky does not describe "Urgent Care Centre" except in terms of what it is not. Can we have more information on Urgent Care Centers and especially in instances where an UCC has replaced an ED and the impacts on care in the affected community? 

Answer 

A discussion of emergency department and urgent care facilities is found in section 2.2 of the report. Other hospitals which have transitioned emergency departments to urgent care facilities include Women's College and Branson Hospitals in Toronto.

The Branson Hospital urgent care now operates 12 hours per day, and provides care focused on CTAS 3, 4 and 5 patients. It operates in cooperation and collaboration with North York General Hospital, to which patients in need of urgent or urgent admission or consultation are transferred. There have been no reports of untoward outcomes as a consequence of this transition.

Women's College Hospital has operated an urgent care center for many years. Patients in need of higher levels of care are not transported there by ambulance, as prehospital care providers preferentially take patients to other full-service departments geographically nearby, such as St. Michael's, University Health Network (Toronto General site), or Mount Sinai hospitals.

Again, no untoward outcomes of this model have been reported.

In the city of Kingston, the Hotel Dieu Hospital also transitioned its emergency department into an Urgent Care Centre. Patients in need of acute admission are transferred to the Kingston General Hospital, and ambulances preferentially transfer patients from “the field” to this site. Since the closure of the Hotel Dieu emergency department, no untoward outcomes have been reported.

The St. Catherine's General Hospital also closed one of its two emergency departments, with one continuing to operate as an urgent care center, providing services at 16 hours a day. Again, no untoward outcomes have occurred as a consequence of this redistribution of services.

The Willet Hospital in Paris also now operates an Urgent Care Centre and emergency patients are cared for in the Brantford Hospital again with no reported untoward outcomes.

The Niagara Health System is currently planning the reconfiguration of the emergency departments in both Port Colbourn and Fort Erie as Urgent Care Centers as well.

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Question 12

The debate on travel times is problematic. If there is evidence of bias in the Hay report, it is here -- it is specious to limit the calculation of travel time as hospital door to hospital door. The patient will have to travel from the site of the actual emergency event to the ED, and in the case of folks from the outer reaches of CEE or Sydenham’s catchment, it would have been more honest to put a range of these actual travel times in the report.

Answer

The report identifies the incremental travel times which would be necessary should the emergency departments in Wallaceburg and Petrolia cease to operate as full-service departments. There are, however, a number of other factors which need to be considered.

It is important to bear in mind that for most patients, no incremental travel will be required. On the day and evening shifts, with the exception of emergently ill ambulance bound patients, (a maximum of 52 patients per year in Petrolia and 847 patients per year in Wallaceburg assuming that all CTAS 1 and 2 patients are transported by ambulance) patients will continue to receive care as they have in the past. Bearing in mind that not all patients are transferred by ambulance, and only a small number of CTAS 1 and 2 patients present on the night shift, the actual numbers of patients subjected to additional transfer or travel distances will be small.

Additionally, those patients currently transferred, even from outlying areas of the region to the existing emergency departments, will ultimately be transferred to another site for admission. There is an incremental time element inherent in first transferring the patient to either the CEE or Sydenham emergency department, having him or her be assessed, stabilized, and have transfer arrangements made, which already adds to the total travel time experienced by the patient. Importantly, this intermediate step delays the time to assessment and treatment by the physician who will ultimately be responsible for the care of the patient.

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