The Quebec rural emergency department project: a cross-sectional study of a potential two-pronged strategy in the knowledge transfer process

Rural emergency care 360°: mobilising healthcare professionals, decision-makers, patients and citizens to improve rural emergency care in the province of Quebec, Canada: a qualitative study protocol

INTRODUCTION

Emergency departments (EDs) are an important safety net for rural populations. Results of our earlier studies suggest that rural Canadian hospitals have limited access to advanced imaging services and intensive care units and that patients are transferred over large distances. They also revealed significant geographical variations in rural services. In the absence of national standards, our studies raise questions about inequities in rural access to emergency services and the risks for citizens. Our goal is to build recommendations for improving services by mobilising stakeholders interested in rural emergency care. With help and full engagement of stakeholders, we will (1) identify solutions for improving quality and performance in rural EDs; (2) formulate and prioritise recommendations; (3) transfer knowledge of the recommendations to rural EDs and support operationalisation and (4) assess knowledge transfer and explore further impacts of this participatory action research project.

METHODOLOGY

We will use a participatory action research approach. We will plan for a governance structure that includes all stakeholders’ representatives, so throughout this project, stakeholders are fully engaged at every step. Our sample will be 26 EDs in rural Quebec. We will conduct semistructured individual and focus group interviews with relevant and representative participants, including patients and citizens (estimated n=200). Interviews will be thematically analysed to extract potential solutions and other qualitative information.An expert panel (±15) will use an analysis grid to develop consensus recommendations from solutions suggested and will evaluate feasibility, impacts, costs, conditions for implementation and establish monitoring indicators. Recommendations will be transferred to stakeholders using tailored knowledge translation strategies (web platform, meetings and so on).

DISCUSSION AND EXPECTED RESULTS

This study will result in a comprehensive consensus list of feasible and high-priority recommendations enabling decision-makers in emergency care to implement improvements in rural emergency care in Quebec.

ETHICS AND DISSEMINATION

This protocol has been approved by the CSSS Alphonse-Desjardins research ethics committee (Project number: MP 2017-009). The qualitative material will be kept confidential and the data will be presented in a way that respects confidentiality. The dissemination plan for the study includes publications in scientific and professional journals. We will also use social media to disseminate our findings and activities such as communications in public conferences.

Portrait of trauma care in Quebec's rural emergency departments and identification of priority intervention needs to improve the quality of care: a study protocol

INTRODUCTION

Trauma remains the primary cause of death in individuals under 40 years of age in Canada. In Quebec, the Trauma Care Continuum (TCC) has been demonstrated to be effective in decreasing the mortality rate among trauma victims. Although rural citizens are at greater risk for trauma and trauma death, no empirical data concerning the effectiveness of the TCC for the rural population in Quebec are available. The emergency departments (EDs) are important safety nets for rural citizens. However, our data indicate that access to diagnostic support services, such as intensive care units and CT is limited in rural areas. The objectives are to (1) draw a portrait of trauma services in rural EDs; (2) explore geographical variations in trauma care in Quebec; (3) identify adaptable factors that could reduce variation; and (4) establish consensus solutions for improving the quality of care.

METHODS AND ANALYSIS

The study will take place from November 2015 to November 2018. A mixed methodology (qualitative and quantitative) will be used. We will include data (2009-2013) from all trauma victims treated in the 26 rural EDs and tertiary/secondary care centres in Quebec. To meet objectives 1 and 2, data will be gathered from the Ministry's Database of the Quebec Trauma Registry Information System. For objectives 3 and 4, the project will use the Delphi method to develop consensus solutions for improving the quality of trauma care in rural areas. Data will be analysed using a Poisson regression to compare mortality rate during hospital stay or death on ED arrival (objectives 1 and 2). Average scores and 95% CI will be calculated for the Delphi questionnaire (objectives 3 and 4).

ETHICS AND DISSEMINATION

This protocol has been approved by CSSS Alphonse-Desjardins research ethics committee (Project MP-HDL-2016-003). The results will be published in peer-reviewed journals.

Portrait of rural emergency departments in Québec and utilization of the provincial emergency department management Guide: cross sectional survey

Background

Rural emergency departments (EDs) constitute crucial safety nets for the 20 % of Canadians who live in rural areas. Pilot data suggests that the province of Québec appears to provide more comprehensive access to services than do other provinces. A difference that may be attributable to provincial policy/guidelines “the provincial ED management Guide”. The aim of this study was to provide a detailed description of rural EDs in Québec and utilization of the provincial ED management Guide.

Methods

We selected EDs offering 24/7 medical coverage, with hospitalization beds, located in rural or small towns. We collected data via telephone, paper, and online surveys with rural ED/hospital staff. Data were also collected from Québec’s Ministry of Health databases and from Statistics Canada. We computed descriptive statistics, ANOVA and t-tests were used to examine the relationship between ED census, services and inter-facility transfer requirements.

Results

A total of 23 of Québec’s 26 rural EDs (88 %) consented to participate in the study. The mean annual ED visits was 18 813 (Standard Deviation = 6 151). Thirty one percent of ED physicians were recent graduates with fewer than 5 years of experience. Only 6 % had residency training or certification in emergency medicine. Teams have good local access (24/7) to diagnostic equipment such as CT scanner (74 %), intensive unit care (78 %) and general surgical services (78 %), but limited access to other consultants. Sixty one percent of participants have reported good knowledge of the provincial ED management Guide, but only 23 % of them have used the guidelines. Furthermore, more than 40 % of EDs were more than 300 km from levels 1 to 2 trauma centers, and only 30 % had air transport access.

Conclusions

Rural EDs in Québec are staffed by relatively new graduates working as solo physicians in well-resourced and moderately busy (by rural standards) EDs. The provincial ED management Guide may have contributed to this model of service attribution. However, the majority of rural ED staff report limited knowledge or use of the provincial ED management Guide and increased efforts at disseminating this Guide are warranted.