Improving delivery of care in rural emergency departments: a qualitative pilot study mobilizing health professionals, decision-makers and citizens in Baie-Saint-Paul and the Magdalen Islands, Québec, Canada.

BACKGROUND: Emergency departments (EDs) in rural and remote areas face challenges in delivering accessible, high quality and efficient services. The objective of this pilot study was to test the feasibility and relevance of the selected approach and to explore challenges and solutions to improve delivery of care in selected EDs. METHODS: We conducted an exploratory multiple case study in two rural EDs in Québec, Canada. A survey filled out by the head nurse for each ED provided a descriptive statistical portrait. Semi-structured interviews were conducted with ED health professionals, decision-makers and citizens (n = 68) and analyzed inductively and thematically. RESULTS: The two EDs differed with regards to number of annual visits, inter-facility transfers and wait time. Stakeholders stressed the influence of context on ED challenges and solutions, related to: 1) governance and management (e.g. lack of representation, poor efficiency, ill-adapted standards); 2) health services organization (e.g. limited access to primary healthcare and long-term care, challenges with transfers); 3) resources (e.g. lack of infrastructure, limited access to specialists, difficult staff recruitment/retention); 4) and professional practice (e.g. isolation, large scope, maintaining competencies with low case volumes, need for continuing education, teamwork and protocols). There was a general agreement between stakeholder groups. CONCLUSIONS: Our findings show the feasibility and relevance of mobilizing stakeholders to identify context-specific challenges and solutions. It confirms the importance of undertaking a larger study to improve the delivery of care in rural EDs.

Through the big top: An exploratory study of circus-based artistic knowledge translation in rural healthcare services, Québec, Canada.

BACKGROUND: The conventional methods and strategies used for knowledge translation (KT) in academic research often fall short in effectively reaching stakeholders, such as citizens, practitioners, and decision makers, especially concerning complex healthcare issues. In response, a growing number of scholars have been embracing arts-based knowledge translation (ABKT) to target a more diverse audience with varying backgrounds and expectations. Despite the increased interest, utilization, and literature on arts-based knowledge translation over the past three decades, no studies have directly compared traditional knowledge translation with arts-based knowledge translation methods. Thus, our study aimed to evaluate and compare the impact of an arts-based knowledge translation intervention-a circus show-with two traditional knowledge translation interventions (webinar and research report) in terms of awareness, accessibility, engagement, advocacy/policy influence, and enjoyment. METHODS: To conduct this exploratory convergent mixed method study, we randomly assigned 162 participants to one of the three interventions. All three knowledge translation methods were used to translate the same research project: "Rural Emergency 360: Mobilization of decision-makers, healthcare professionals, patients, and citizens to improve healthcare and services in Quebec's rural emergency departments (UR360)." RESULTS: The findings revealed that the circus show outperformed the webinar and research report in terms of accessibility and enjoyment, while being equally effective in raising awareness, increasing engagement, and influencing advocacy/policy. Each intervention strategy demonstrates its unique array of strengths and weaknesses, with the circus show catering to a diverse audience, while the webinar and research report target more informed participants. These outcomes underscore the innovative and inclusive attributes of Arts-Based Knowledge translation, showcasing its capacity to facilitate researchers' engagement with a wider array of stakeholders across diverse contexts. CONCLUSION: As a relevant first step and a complementary asset, arts-based knowledge translation holds immense potential in increasing awareness and mobilization around crucial health issues.

Impact of telemedicine on diagnosis, clinical management and outcomes in rural trauma patients: A rapid review.

INTRODUCTION: Rural trauma patients are at increased risk of morbidity and mortality compared to trauma patients treated in urban facilities. Factors contributing to this disparity include differences in resource availability and increased time to definitive treatment for rural patients. Telemedicine can improve the early management of these patients by enabling rural providers to consult with trauma specialists at urban centres. The purpose of this study was to assess the impact of telemedicine utilisation on the diagnosis, clinical management and outcomes of rural trauma patients. MATERIALS AND METHODS: A rapid review of the literature was performed using the concepts 'trauma', 'rural' and 'telemedicine'. Fifteen electronic databases were searched from inception to 29th June 2018. Manual searches were also conducted in relevant systematic reviews, key journals and bibliographies of included studies. RESULTS: The literature search identified 187 articles, of which 8 articles were included in the review. All 8 studies reported on clinical management, while the impact of telemedicine use on diagnosis and outcomes was reported in 4 and 5 studies, respectively. Study findings suggest that the use of telemedicine may improve patient diagnosis, streamline the process of transferring patients and reduce length of stay. Use of telemedicine had minimal impact on mortality and complications in rural trauma patients. CONCLUSIONS: The evidence identified by this rapid review suggests that telemedicine may improve the diagnosis, management and outcomes of rural trauma patients. Further research is required to validate these findings by performing large and well-designed studies in rural areas, ideally as randomised clinical trials.

Résumé Introduction: Les traumatisés en région rurale présentent un risque accru de morbidité et de mortalité comparativement aux traumatisés des établissements en région urbaine. Les facteurs qui contribuent à cette disparité sont les différences quant à la disponibilité des ressources et un délai prolongé avant d'accéder au traitement définitif chez les patients des régions rurales. La télémédecine améliore la prise en charge précoce de ces patients en permettant aux fournisseurs en milieu rural de consulter des spécialistes en traumatologie des centres urbains. Cette étude avait pour but d'évaluer l'impact de la télémédecine sur le diagnostic, la prise en charge clinique et les résultats chez les patients traumatisés en milieu rural. Méthodologie: Un examen rapide de la littérature a été effectué à l'aide des mots-clés anglais "trauma", " rural " et "telemedicine". La recherche a eu lieu dans 15 banques de données électroniques à compter de leur lancement jusqu'au 29 juin 2018. Des recherches manuelles ont également été effectuées dans les revues systématiques et publications scientifiques pertinentes et dans les bibliographies des études incluses. Résultats: La recherche de la littérature a donné lieu à 187 articles, dont 8 ont été inclus dans la revue. Les 8 études portaient sur la prise en charge clinique, alors que l'impact de la télémédecine sur le diagnostic et les résultats a fait l'objet de 4 et de 5 études, respectivement. Les résultats des études laissent croire que la télémédecine améliorerait le diagnostic, simplifierait le processus de transfert des patients et raccourcirait le séjour. La télémédecine a eu un effet minime sur la mortalité et les complications chez les patients traumatisés en milieu rural. Conclusions: Les données probantes relevées par cet examen rapide laissent croire que la télémédecine améliorerait le diagnostic, la prise en charge et les résultats chez les patients traumatisés en milieu rural. D'autres recherches sont nécessaires pour valider ces conclusions par l'entremise d'études d'envergure bien conçues menées en régions rurales, idéalement sous forme d'études cliniques à répartition aléatoire. Mots-clés: rural, télémédecine, patients traumatisés en milieu rural, diagnostic des patients en milieu rural.

Profile of trauma mortality and trauma care resources at rural emergency departments and urban trauma centres in Quebec: a population-based, retrospective cohort study.

OBJECTIVES: As Canada's second largest province, the geography of Quebec poses unique challenges for trauma management. Our primary objective was to compare mortality rates between trauma patients treated at rural emergency departments (EDs) and urban trauma centres in Quebec. As a secondary objective, we compared the availability of trauma care resources and services between these two settings. DESIGN: Retrospective cohort study. SETTING: 26 rural EDs and 33 level 1 and 2 urban trauma centres in Quebec, Canada. PARTICIPANTS: 79 957 trauma cases collected from Quebec's trauma registry. PRIMARY AND SECONDARY OUTCOME MEASURES: Our primary outcome measure was mortality (prehospital, ED, in-hospital). Secondary outcome measures were the availability of trauma-related services and staff specialties at rural and urban facilities. Multivariable generalised linear mixed models were used to determine the relationship between the primary facility and mortality. RESULTS: Overall, 7215 (9.0%) trauma patients were treated in a rural ED and 72 742 (91.0%) received treatment at an urban centre. Mortality rates were higher in rural EDs compared with urban trauma centres (13.3% vs 7.9%, p<0.001). After controlling for available potential confounders, the odds of prehospital or ED mortality were over three times greater for patients treated in a rural ED (OR 3.44, 95% CI 1.88 to 6.28). Trauma care setting (rural vs urban) was not associated with in-hospital mortality. Nearly all of the specialised services evaluated were more present at urban trauma centres. CONCLUSIONS: Trauma patients treated in rural EDs had a higher mortality rate and were more likely to die prehospital or in the ED compared with patients treated at an urban trauma centre. Our results were limited by a lack of accurate prehospital times in the trauma registry.

Organisation des services dans une urgence rurale éloignée : réflexions autour du cas de Fermont, Québec.

INTRODUCTION: The goal of this study was to meet a small, remote emergency department's need to reflect on the minimum threshold of services to offer. The study's main objectives were to 1) provide a statistical profile of the emergency services in Fermont, Quebec, 2) assess the staff's and users' perception of the threshold of services offered and 3) propose solutions for improving care and services. METHODS: This case study was conducted with a participatory approach and a mixed methodology. We compared the results from a questionnaire on the emergency services that was validated during a previous study with the results concerning the other rural emergency services in Quebec as well as with national and provincial recommendations. The questionnaire concerned users' sociodemographic characteristics, the hospital's and the emergency services' descriptors, the services available locally, and the physician and nurse staff. Interviews were also carried out with 33 people (health care professionals, policy-makers and citizens). RESULTS: Fermont's emergency department is smaller than the average rural emergency department in Quebec. They have resources that are in some respects comparable to those of other emergency departments and in line with the recommendations; in other respects, their resources are rather limited. Respondents emphasized how important it is to take into account the environment's specific features when establishing the minimum threshold of services. The proposed solutions would promote collaboration, break down silos within professional practice and focus on training. CONCLUSION: Fermont's case aside, this exploratory case study highlights how important it is to adopt a pluralistic, participatory and local approach in order to support reflection on the minimum threshold of services in remote emergency departments and to improve their overall performance.

INTRODUCTION: Cette étude visait à répondre au besoin d'une petite urgence éloignée d'assoir sa réflexion autour d'un seuil minimum de services à offrir. Les principaux objectifs de l'étude étaient de : 1) dresser le portrait statistique de l'urgence de Fermont, Québec, 2) évaluer la perception du personnel et des usagers en lien avec le seuil de services offert et 3) énoncer des solutions permettant d'améliorer les soins et les services. METHODS: Cette étude de cas a été réalisée avec une approche participative et une méthodologie mixte. Nous avons comparée les données d'un questionnaire sur l'urgence qui a été validé lors d'une étude précédente aux données des autres urgences rurales québécoises et à des recommandations nationales et provinciales. Le questionnaire portait sur les caractéristiques sociodémographiques des usagers, les descripteurs du centre hospitalier et de l'urgence, les services disponibles localement et les effectifs médicaux et infirmiers. Des entrevues ont aussi été réalisées auprès de 33 personnes (professionnels de la santé, décideurs et citoyens). RESULTS: L'urgence de Fermont est plus petite que la moyenne des urgences rurales québécoises et dotée de ressources à certains égards comparables aux autres urgences et aux recommandations et à d'autres égards limités. Les répondants ont souligné l'importance de tenir compte des particularités du milieu dans l'établissement d'un seuil minimum de services. Les solutions proposées concernent l'importance de favoriser la collaboration, de décloisonner la pratique professionnelle et de miser sur la formation. CONCLUSION: Au-delà du cas de Fermont, cette étude de cas exploratoire a permis de souligner l'importance d'adopter une approche pluraliste, participative et locale pour soutenir la réflexion autour du seuil minimum de services à offrir dans les urgences éloignées et pour améliorer la performance générale des urgences rurales.

Lack of CT scanner in a rural emergency department increases inter-facility transfers: a pilot study.

OBJECTIVE: Rural emergency departments (EDs) are an important gateway to care for the 20% of Canadians who reside in rural areas. Less than 15% of Canadian rural EDs have access to a computed tomography (CT) scanner. We hypothesized that a significant proportion of inter-facility transfers from rural hospitals without CT scanners are for CT imaging. Our objective was to assess inter-facility transfers for CT imaging in a rural ED without a CT scanner. RESULTS: We selected a rural ED that offers 24/7 medical care with admission beds but no CT scanner. Descriptive statistics were collected from 2010 to 2015 on total ED visits and inter-facility transfers. Data was accessible through hospital and government databases. Between 2010 and 2014, there were respectively 13,531, 13,524, 13,827, 12,883, and 12,942 ED visits, with an average of 444 inter-facility transfers. An average of 33% (148/444) of inter-facility transfers were to a rural referral centre with a CT scan, with 84% being for CT scan. Inter-facility transfers incur costs and potential delays in patient diagnosis and management, yet current databases could not capture transfer times. Acquiring a CT scan may represent a reasonable opportunity for the selected rural hospital considering the number of required transfers.