Rural areas deserve real emergency care, doctors say — and that could mean closing ERs

The same health-care report that suggested closing Winnipeg ERs also recommends getting rid of ineffective small-town emergency departments.

"If it isn't an emergency department, then don't call it an emergency department," says page 63 of the Provincial Clinical and Preventive Services Planning for Manitoba report.

The report refers to a system common in rural Manitoba hospitals: you have to call ahead or look at a flyer your local ER has sent to determine whether your community has emergency care that day.

- READ THE REPORT: Clinical and Preventive Services Planning for Manitoba

"In Virden we receive these flyers in the mail now, that it would be simpler to just put on what days the ER is available," said Ingrid Wilkinson, who lives in the rural municipality of Pipestone. She's seen nearby hospitals reduced to what are effectively senior care facilities.

Medical ethicist Dr. Merril Pauls said in many small communities, the services hospitals claim to provide or want to provide aren't actually being provided.

"So you could even flip that over and say, is it ethical to say I'm going to put an emergency department in your community but not be able to staff it, not be able to provide the things you need, but still try and call it an emergency department?" he said.

"Maybe it's more ethical to call it what it is and to say what we can do within the parameters of the resources that we have to provide."

Wait times task force

In 2010, Nova Scotia started closing 14 rural ERs at night at the suggestion of Dr. John Ross.

Ross is now co-lead of the emergency department wait times committee of Manitoba's wait time reduction task force.

Nova Scotia's example might not be the answer for Manitoba, Ross said, because that province's ambulance network is better. The goal is to keep Manitobans' drives to emergency care under an hour.

He said committee members have travelled to many of Manitoba's small communities and will visit more before recommendations are released, likely in the fall.

That's in line with the Provincial Clinical and Preventive Services Planning report recommendation No. 6: "All rural hospitals in Manitoba be assessed independently to determine the propriety of continuing to be designated as a hospital, the nature of the use of its beds, and the continuing provision of emergency department services."

But is Ross's task force going to recommend the closure of ERs?

"I don't know that's the case, to be honest," Ross said.

"I can't tell you whether that's appropriate.… Trying to keep an emergency department open with a doctor in it is actually not happening today. Places are closing intermittently, so that's obviously not tenable.

"Can it be done with a different care provider mix? I think, certainly. So they may not be 'shuttered,' as you say, but they may be populated or staffed by a different crew than what is currently there and often not there."

Ross said emergency departments in smaller communities often end up providing primary care anyway, because of limited access to family doctors in rural regions. Wait times to see a doctor in some rural areas can climb to four or five weeks, he said.

"That's probably the biggest access problem in non-urban Manitoba right now, and so people end up using emergency departments as the default spot, because they just can't get in somewhere else," he said.

The same rural recruitment problem also makes staffing a challenge for the emergency departments, Ross said.

​"I think the care providers that are currently covering off emergency departments in smaller centres are doing a really good job," he said.

"They know when to call for help, and they end up sending patients to larger regionals or to Winnipeg I think quite appropriately when needed. But they also end up treating and sort of screening out lots of other people that can be treated locally."

Faster care or better?

What is not known, said Dr. Alan Katz, director of the Manitoba Centre for Health Policy, is whether it's better for emergency patients to see a doctor as quickly as possible or to get higher-quality medical care in the city.

"It's a highly relevant factor and we don't really know. It's the kind of thing you can't really do an experiment on and say which is more important," he said.

But there's evidence that doctors who treat trauma more often are better at it, he said.

There's good evidence that medical staff who don't do emergency care regularly have a difficult time providing high-quality emergency care when needed, Katz said.

"So in a serious trauma incident, it's complicated and very difficult to provide that care. And if you do that once every two or three years, I'm not sure that the team in that ER is well-suited to provide the care."

Katz said rural hospitals isn't just provide medical care. People think about them in terms of heart attacks, but much more frequently, the value of a small-town hospital is as a community centre and source of jobs.

"Would they be better off driving an hour to get to the better care? But it's a question that is not commonly looked at in places like Manitoba, because our rural emergency rooms and hospitals are about more than just the care providers."

Sixty-three of Manitoba's 73 hospitals are rural. Manitoba's rural population, at 28 per cent, beats the national average by 10 percentage points.

The Provincial Clinical and Preventive Services Planning report recommends that "some, but not all, communities in the small town category [up to 2,000] maintain facility-based EMS and basic diagnostic services."

It also suggests consolidating 911 to a provincial service, led by a provincial emergency medicine program.

Worth the trip?

Pauls said community members must have a say in the future of their emergency departments, but they might not always get what they want.

For the most part, Pauls said, people understand that they can't live in a remote area and have the same level of care as people in Winnipeg.

"Would I be OK with trading off where I live, the community that I like, with some type of reasonable access to services even if they're not too, too far away?" he posited.

"I think a lot of people would say that they're OK with that, that they understand that they give up certain things by living in certain places in the province, but they get other benefits from living in those places too. So they're constantly making tradeoffs, right, about what they can access."

In making an ethical decision about something as complex as closing rural ERs, Pauls said, it is vital to ensure the following key principles are met: accountability, inclusiveness, transparency, reasonableness and responsibleness. That requires balance.

"The tradeoffs that we're making, that, you know, perhaps you won't have this specific service as close to your home as you'd like, but now we have a better, more robust service and a way to get you there," he said. "Maybe that's a good tradeoff."