A new way to deliver emergency services was presented to the Sydenham District Hospital board on Monday.
Willi Kirenko, vice president and chief nursing executive at the Chatham-Kent Health Alliance, provided a presentation during the SDH board meeting about a trip she and Sherri Saunders, executive director with the Chatham-Kent Community Health Centre, took to Nova Scotia.
During the trip at the beginning of last month, Kirenko said she learned about how the maritime province transformed eight small hospitals into eight Collaborative Emergency Centres (CECs).
“CECs are like nothing we have in Ontario,” Kirenko said during the meeting. “They are very unique and new.”
Although not referring directly to Kirenko’s presentation or the details presented on Monday, Sheldon Parsons, the chair of the SDH board, said there is information available to the board that hasn’t been discussed publicly at this point.
“There are reports we are skirting around that are not public… we are having a members meeting on the 19th,” Parsons said. “We’re going to endeavour to do the best we can to provide as much information as we can to the membership and to the general public.”
Why Nova Scotia switched to CECs
Kirenko said one of the main reasons why Nova Scotia changed over to CECs was a lack of physicians and nurses to staff their “low volume” emergency rooms.
“They had these rolling closures of emergency departments,” she said.
“A community of say 5,000 or 10,000 people might read in the newspaper or hear on the news or even have to make a telephone call to find out if their emergency department was open that day. It would be open one day, closed the next, open this weekend, closed another weekend.”
Kirenko said there was “poor access to primary care” with often six to eight week long waits to have a doctor’s appointment.
“If a physician or staff was working in the emergency department overnight, most often that physician would be from that community, and they were not able to see patients in their clinic or by appointment the next day because they need to rest,” she said. “It didn’t seem very efficient.”
What are the CECs?
Kirenko said the daytime model at the Nova Scotia CECs, is a primary healthcare centre with access for urgent care and walk-in type care.
She said most of the people who are going there have an appointment.
The practicing emergency physicians and specialists also organized and implemented a system-wide on-call support model.
“They put themselves on-call so that each of these eight CECs can call into one number to speak with a physician who is on-call to give advice about what to do,” Kirenko said. “They have physicians, RNs, RPNs and nurse practitioners and they practice from 8 a.m. until 8 p.m.”
“At each of these sites at 8 p.m. they transition to care from an RN and a paramedic. An RN does not have a scope of practice that allows prescription or treatment and release, but each one of those patients who are seen after 8 p.m. a call is made out to that regional doctor on-call, who gives advice about what to do with the patient.”
Kirenko added: “There is no ambulance that goes to the CECs at night time, unless they are going past and they need another pair of hands from the paramedic who is on site.”
Kirenko said in terms of access to diagnostic or lab services, if the existing small hospital had it before it turned into a CEC, they kept it. This included some ultra-sounds, x-rays and labs.
“If they didn’t have it before they transitioned to a CEC, they didn’t have it afterwards,” she said.
“The night time, the premise is if they need lab tests or x-rays at night time, those patients are shipped or transported to a regional centre, rather than kept overnight waiting for care in the morning.”
Kirenko said before the CECs started, community paramedics were already embedded into practice.
“A different way of using paramedics in Nova Scotia than we do here,” she said. “There is an all-encompassing health authority for Nova Scotia, it is not fragmented or put in pieces like it is in Ontario either.”
There is a service expectation within the CEC model that there is a two-hour length of stay, Kirenko added.
“The requirement is if there is a health problem that can be resolved, treated and released within a two-hour period,” she said. “If it is going to take longer than that, then those patients should be moved to an emergency department.”
The CECs were also not built, they were small hospitals that were transitioned into a new model.
“20% of the urgent care visits, those who walk into CECs, are transported to the regional emergency department,” Kirenko said. “That is still quite a high number, but again these CECs are not shock, trauma centres that you might expect in a teaching hospital. 50% get next day appointments and 30% are treated and released.”
Kirenko said they some experienced a 22% decline in the emergency department visits at the nearest regional hospital, while others had the same numbers.
“There is a reduced reliance on the emergency department because of improved access to primary healthcare,” Kirenko said. “They have a different way of practicing.”
The first CEC opened in Nova Scotia back in 2011.
Lots of feedback was gathered
Kirenko said focus groups, surveys, meetings and a number of ways of collecting information was completed as part of an evaluation since the CECs were put in place in Nova Scotia.
Referring to the feedback they received in Nova Scotia, Kirenko said at all sites, patients now have better access to primary healthcare services.
“Rather than the 9 a.m. to 5 p.m., Monday to Friday service, maybe on or off service that they had in the past,” she said. “Now they had service seven days a week, for access to primary healthcare, most often from 8 a.m. to 8 p.m.”
“They found just improving access to primary healthcare at these centres really, really dropped the need for people to visit an emergency department. As you can imagine, if you don’t have access most often during the week, you call with a sore throat or an earache and it takes two weeks to get in… what alternative do you have, most people would generally visit an emergency department. Now, because they had same day or next day access 12 hours a day, seven days a week, they really found access to primary healthcare improved and really reduced the need for urgent and emergency care.”
Kirenko said other feedback they received included the feeling that the ‘H’ signage on these buildings contributed to “misinformation.
“People in the community don’t necessarily know about what services are available and which services are not,” she said.
Kirenko added a recurring concern from the focus groups in Nova Scotia was the fear of the unknown and anticipating the worst case scenario.
“As the model becomes more mainstream and has a longer track record of performance some of this anxiety will diminish, but there is still some folks who are very anxious about that a true emergency service staffed 24/7 is not available and they think something very bad is going to happen or worst case scenario,” she said.
“I asked if they had any risk or quality concerns that have come forward because of the change over of these CECs and there are none documented. There are a few minor incident reports that happened at some of the CECs but there has not been a big disastrous ‘anything’ as part of the evaluation.”
Lessons learned in Nova Scotia
Kirenko said the senior administration and EMS officials in Nova Scotia recommended that Chatham-Kent start with a 12-18 hour daytime and evening model.
“As we would likely find the same things happening and that is, as daytime primary care healthcare access improves, the need for night time coverage would decrease,” she said.
“If activated, we would experience a tremendous shift in behaviour in patients once established. They are rightly accessing primary care more regularly and reducing reliance on the CECs and emergency departments. They would experience more satisfaction and the healthcare providers would increase their scope of practice, that is RNs, nurse practitioners and paramedics. We don’t use paramedic in Ontario like they do in Nova Scotia.”
Kirenko said the open and candid way the senior health service representatives in Nova Scotia shared their experiences and level of support that was offered as the Chatham-Kent Health Alliance explored a new model, was exceptional.
“They shared full agreement in support of all aspects of our proposed model, including the name Emergency Access Centre, they thought that was a terrific name, better than the name they had chosen.”
Kirenko’s thoughts on the model
Kirenko said she thinks improving access to primary healthcare for all Chatham-Kent communities is a priority for the hospital “as the leader in the health system.
“Waiting weeks for an appointment, or being sent to the emergency department because you don’t have access is not acceptable. That is not satisfying. That is not the best possible healthcare,” she said.
Even outside of communities like Wallaceburg, Dresden, Tupperville, Kirenko said they need to look at Blenheim, Ridgetown, Morpeth, Highgate.
“You name it… we need to improve access to primary healthcare in Chatham-Kent,” Kirenko said.
“I think that is the best thing we can do for our community.”
More ‘context’ coming on April 19
Parsons said during the meeting that there are proposals before the hospital boards, but they are very early on in the process.
“Our board has engaged and continues to engage with our membership and the public,” he said.
“We hope to be able to provide fulsome reports and information that would be helpful to the communities at large so that they are informed and aware of these considerations.”
Referring to a recent letter he sent to the SDH membership and the media, Parsons said the SDH board is staying true to a number of core principles.
“These are the principles under which we think we can move forward to look at how healthcare is delivered in our communities and we’re going to share that with the membership and get a little more consent, blessing, agreement in principle… that those are the issues that we think are important, that need to guide how we pursue healthcare changes into the future,” he said. “There is a fairly long process to go through, this doesn’t happen overnight. If it does happen, it doesn’t happen overnight.”
Parsons said much of the details in Kirenko’s presentation will be explained further next week.
“I have a difficulty looking at the information when you reference 1.3 visits per night at one of these CECs… that is nowhere near the experience we are having in Chatham and Wallaceburg,” Parsons said.
“Context… what we’re hearing now might be vastly different to what we’ll hear in terms of metrics at the April 19 meeting.”
Watch for more coverage leading up to the April 19 meeting at the UAW Hall in Wallaceburg fir the SDH board and membership, which is open to the public.
The meeting begins at 5 p.m.
Here is some more background information:
Recap of SDH board meeting on April 11: Wallaceburg hospital board ‘disappointed’ with latest developments
LIVE tweets from April 11 SDH meeting: Board meeting at Sydenham Campus in Wallaceburg, LIVE coverage
SDH Chair doesn’t agree with CKHA report: Proposed hospital changes does ‘not meet our expectations’
Health coalition meeting recap, April 7: New health Coalition fighting for Wallaceburg’s hospital
Advocacy group formed: New hospital advocacy group holding town-hall meeting
Full interview with CKHA CEO: CKHA president discusses Wallaceburg hospital situation
March 23 meeting recap: ‘Everything has to be on the table’
LIVE coverage of March 23 meeting: Wallaceburg hospital meeting at the UAW Hall
MPP bringing concerns to Queen’s Park: MPP: ‘The community spoke loud’
March 23 meeting preview: Doubts arising about Wallaceburg’s ER future
CKHA facing deficit: CKHA board meeting highlights
Imagine project background: New direction for a brand new Wallaceburg hospital