Consensus statement on networks for high-quality rural anesthesia, surgery, and obstetric care in Canada.

OBJECTIVE: To describe the essential components of well-resourced and high-functioning multidisciplinary networks that support high-quality anesthesia, surgery, and maternity care for rural Canadians, delivered as close to home as possible. COMPOSITION OF THE COMMITTEE: A volunteer Writers' Group was drawn from the Society of Obstetricians and Gynaecologists of Canada, the Society of Rural Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, the Canadian Association of General Surgeons, the College of Family Physicians of Canada, and the Association of Canadian University Departments of Anesthesia. METHODS: A collaborative effort over the past several years among the professional stakeholders has culminated in this consensus statement on networked care designed to integrate and support a specialist and non-specialist, urban and rural, anesthesia, surgery, and maternity work force into high-functioning networks based on the best available evidence. REPORT: Surgical and maternity triage needs to be embedded within networks to address the tensions between sustainable regional programs and local access to care. Safety and quality must be demonstrated to be equivalent across similar patients and procedures, regardless of network site. Triage of patients across multiple sites is a quality outcome metric requiring continuous iterative scrutiny. Clinical coaching between rural and regional centres can be helpful in building and sustaining high-functioning networks. Maintenance of quality and the provision of continuing professional development in low-volume settings represent a mutual value proposition. CONCLUSION: The trusting relationships that are foundational to successful networks are built through clinical coaching, continuing professional development, and quality improvement. Currently, a collaborative effort in British Columbia is delivering a provincial program-Rural Surgical Obstetrical Networks-built on the principles and supporting evidence described in this consensus statement.

Improving Access to Safe Anesthetic Care in Rural and Remote Communities in Affluent Countries.

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.

An evidence-based program for rural surgical and obstetrical networks.

CONTEXT: Over the past 25 years, the attrition of small volume rural surgery programs across Western Canada has been significant and sustained. The 'Joint position paper on rural surgery and operative delivery' (JPP) offers a consensus policy framework for the sustainability of rural surgical programs by nesting them within larger regional programs. The many recommendations in the JPP coalesce around the recognition that surgical care should be provided as close to home as possible. To achieve this, surgical care should be delivered within rural and regional surgical programs integrated into well-functioning networks staffed by generalist specialist surgeons trained across surgical disciplines and family physicians with enhanced surgical skills (FPESS). ISSUES: There are important issues to be addressed in the creation of these networks, not the least of which is the sometimes challenging relationships between the stakeholders in these networks and skepticism about the training of FPESS and the safety and quality of low volume surgical programs. Relationships extend from the patient-provider nexus to include interprofessional relationships and those between the pentagram partners (patients/communities, care providers, administrators, researchers and policymakers). Equally important to resolve is the issue of the minimum threshold volume of local surgical activity required for a sustainable professional workforce in a small rural program. LESSONS LEARNED: A collaborative effort by key stakeholders in British Columbia has produced a program designed to overcome these challenges and build effective networks of rural surgical care, based on the synergistic interplay of five key pillars to support small surgical sites. These five pillars include clinical coaching, continuing quality improvement (CQI), remote presence technology to mitigate geographic challenges, sustainable local surgical capacity, and evaluation of dimensions of network function and clinical outcomes. This is the first time that the integration of these five pillars, each derived from best available evidence, have been positioned together as deliberate strategic policy to improve rural surgical care.

Learners' experiences of an enhanced surgical skills training program for family physicians.

BACKGROUND: Family Physicians with Enhanced Surgical Skills (FPESS) have sustained rural operative care, including local access to caesarean section, in many communities across rural Canada and internationally. The contemporary role of FPESS within the health system, however, has not been without challenges. The 12-month Prince Albert Enhanced Surgical Skills (ESS) program intakes two learners a year and is one of only two accredited programs in Canada offering a scope of surgical practice beyond operative delivery. METHODS: This paper highlights the results of an evaluation of graduates' experiences of training and the post-training environment. Graduates were practicing in Western and Northern Canada after completing the ESS training program, specifically in British Columbia, Alberta, Manitoba, and the Northwest Territories. RESULTS: Findings suggest the overall success of the program in meeting learners' needs. There was a close match between the training curriculum and post-training practice. CONCLUSION: The findings from the post training experience suggest that sustainability of ESS is linked to 1) creating pathways to privileges between the ESS community and the Health Authorities, 2) building functional and trusting relationships with surgical specialists, and 3) creating a web of accessible effective rurally appropriate surgical Continuing Professional Development (CDP). Ongoing CPD is identified as essential in increasing the comfort of FPESS.

A proposal for the curriculum and evaluation for training rural family physicians in enhanced surgical skills.

SUMMARY: Rural western Canada relies heavily on family physicians with enhanced surgical skills (ESS) for surgical services. The recent decision by the College of Family Physicians of Canada (CFPC) to recognize ESS as a "community of practice" section offers a potential home akin to family practice anesthesia and emergency medicine. To our knowledge, however, a skill set for ESS in Canada has never been described formally. In this paper the Curriculum Committee of the National ESS Working Group proposes a generic curriculum for the training and evaluation of the ESS skill set.

Joint position paper on rural surgery and operative delivery.

Our professional organizations have prepared this paper as part of an integrated, multidisciplinary plan to ensure the availability of well-trained practitioner teams to sustain safe, effective and high-quality rural surgical and operative delivery services. Without these robust local (or nearby) surgical services, sustaining rural maternity care is much more difficult. This paper describes the "network model" as a health human resources solution to meet the surgical needs, including operative delivery, of rural residents; outlines necessary policy directions for achieving this solution; and poses a series of enabling recommendations.

Nos organisations professionnelles ont préparé cet article dans le cadre d'un plan multidisciplinaire intégré visant à assurer la disponibilité d'équipes soignantes bien formées pour offrir des services obstétricaux interventionnels et chirurgicaux sécuritaires, efficaces et de grande qualité en milieu rural. Sans de tels solides services chirurgicaux locaux (ou de proximité), il est beaucoup plus difficile d'assurer les soins obstétricaux en milieu rural. Cet article décrit le « modèle en réseau ¼ comme une solution au chapitre des ressources humaines en santé pour répondre aux besoins chirurgicaux des populations rurales, y compris pour les services obstétricaux interventionnels. On y décrit aussi les orientations politiques nécessaires à l'application de cette solution et on formule une série de recommandations préparatoires.

Evaluation of Canadian family practice anesthesia training programs: can the Resident Logbook help?

PURPOSE: Without a core curriculum for the training and evaluation of Canada's family practice anesthetists, little is known regarding the training process of these physicians. This article offers a description of the variety of cases and procedures experienced by family practice anesthesiology (FPA) residents during their training year based on records in the Resident Logbook. METHODS: Data were extracted from the Resident Logbook, an online program wherein FPA residents across Canada record their daily activities. Data were extracted for four residents from 2009/2010 and four from 2010/2011 who had recorded the largest number of patient encounters for the academic year. Medians were calculated for cases and procedures relevant to the practice of a family practice anesthetist. RESULTS: Residents in FPA use the Resident Logbook inconsistently. The trainees we selected entered a median of 1,418 encounters for 2009/2010 and 1,074 for 2010/2011. Residents appear to have most of their clinical encounters with cases and procedures relevant to FPA. There is still a need, though, to improve areas previously cited as requiring augmentation, such as trauma management and peripheral nerve blocks. CONCLUSIONS: Although FPA residents use the Resident Logbook inconsistently, the data obtained offer an initial description of the composition of the FPA training year. We believe that the Resident Logbook offers an excellent tool for furthering the goal of a standardized curriculum and assessment program for FPA training.

GP Surgeons' Experiences of Training in British Columbia and Alberta: A Case Study of Enhanced Skills for Rural Primary Care providers.

INTRODUCTION: There has been a steady erosion of family physicians with enhanced surgical skills providing care for rural residents. This has been largely due to the lack of formal training avenues and continuing medical education (CME) opportunities afforded to those interested, and attrition of those currently practicing. METHODS: A qualitative study was undertaken using an exploratory policy framework to guide the collection of in-depth interview data on GP surgeons' training experiences. A purposive sample of GP surgeons currently practicing in rural BC and Alberta communities yielded interviews with 62 participants in person and an additional 8 by telephone. Interviews were audio recorded and transcribed then subjected to a process analysis. RESULTS: Participants thematically identified motivations for acquiring advanced skills training, resources required (primarily in the area of solid mentorship), the most efficacious context for a training program (structured), and differences in mentorship between obstetricians and general surgeons. CONCLUSION: Mentors and role models were the most salient influencing factor in the trajectory of training for the participants in this study. Mentorship between specialists and generalists was constrained at times by inter-professional tensions and was accomplished more successfully within a curriculum-based, structured environment as opposed to a learner-responsive training environment.

Birth in Bella Bella: emergence and demise of a rural family medicine birthing service.

OBJECTIVE: To explore a once successful rural maternity care program and the variables surrounding its closure. DESIGN: Analysis of archived logbook data, reports, and communications with medical staff. SETTING: Bella Bella, a Heiltsuk First Nation community on British Columbia's central coast. PARTICIPANTS: Every patient delivering at the Bella Bella hospital since 1928. METHODS: We extracted delivery rates, cesarean section rates, and local perinatal and maternal mortality rates from the hospital logbooks. In 2003, a consultant's report reviewed the viability of surgical and maternity care services in Bella Bella; this was also reviewed. Finally, several personal communications with past and present medical staff added to an understanding of the issues that initially sustained and, in the end, closed the local maternity care program. MAIN FINDINGS: Bella Bella had an intrapartum service with operative backup, and intervention and perinatal mortality rates were comparable to national data. There was only 1 maternal death in 80 years of intrapartum service. In the 1990 s, with sparse cesarean section coverage, more mothers were obliged to travel to referral centres, until an eventual closure of the intrapartum care service in 2001. CONCLUSION: Bella Bella provided safe and comprehensive maternity care until, in the context of an insufficient supply of family medicine generalists trained in anesthesia, surgery, and maternity care, the service closed.

Utilization rates for surgical procedures in rural and urban Canada.

OBJECTIVE: To investigate whether utilization rates of common surgical procedures are different between urban and rural Canadians in 2 provinces and to examine whether these rates are influenced by the presence and scope of local surgical programs and by the availability of different physician providers. METHODS: Utilization rates for 8 common surgical procedures (appendectomy, carpal tunnel release, closed hip fracture repair, rectal cancer surgery, joint replacement, thyroidectomy, unilateral or bilateral inguinal herniorrhaphy, and cholecystectomy) were identified in rural Alberta and rural Northern Ontario from hospital discharge records. Rural populations were characterized by 3 types of communities, based on availability of local physician and diagnostic resources. Travel time for consultations and surgery were estimated. Age-sex-adjusted rates, their standard errors, and 95% confidence intervals (CIs) were calculated for the purpose of comparisons among residents' locations using the method of direct standardization. To test a possible association between travel times and utilization rates, hierarchical linear and nonlinear modelling was used to analyze a 2-level model, with patients nested within rural hospital catchment areas in the province of Alberta. RESULTS: Utilization rates for appendectomy, cholecystectomy and carpal tunnel release are significantly greater for rural populations compared with urban in both Alberta and Northern Ontario. Rural Northern Ontario had higher rates of utilization than rural Alberta for carpal tunnel release and cholecystectomy (p < 0.01) and closed hip fracture repair (p < 0.05). No statistical differences between the provinces were noted for the remaining procedures. No difference in utilization rates was found between the 3 types of rural centres. The modelling found a significant association between travel time and use for only one procedure--carpal tunnel release. Patients who had to travel < or =1 hour had a 13% higher surgery rate. CONCLUSION: Rates of utilization were higher in rural areas for procedures where greater surgical variability is known to exist. These higher rural rates were not influenced by either the presence or scope of local surgical programs nor by the differences in providers. There was no difference in rates for procedures where previous research has shown little variability.

Rural surgical services in two Canadian provinces.

OBJECTIVE: Contrast alternative health delivery systems and the use of differently trained physician providers in the supply of surgical services to rural residents in 2 Canadian provinces. METHODS: Four surgical procedures (carpal tunnel release, inguinal herniorrhaphy, appendectomy and cholecystectomy) provided to rural residents of Alberta and Northern Ontario were identified between 1997/98 and 2001/02. Surgical staff were identified as specialists or non-specialists. Rural populations were mapped into the catchment areas of rural acute care facilities. Rural surgical programs were characterized by the level of surgical service available locally. RESULTS: Alberta and Northern Ontario have a similar number of rural surgical programs staffed by Canadian-certified general surgeons (10 and 12, respectively). However, Alberta has 27 smaller rural surgical programs staffed by non-specialist surgeons and Northern Ontario has only 4. These non-specialist surgeons play a significant role in Alberta, often in collaboration with specialist surgeons. In Northern Ontario the non-specialist surgeons play a minor role. The small rural surgical programs in Northern Ontario that are staffed by specialist surgeons are significantly more successful in retaining the local surgical caseload compared with similar programs in Alberta. CONCLUSIONS: The principal differences between Alberta and Northern Ontario in the delivery of rural surgical services are the greater number of small rural surgical programs in Alberta, and the substantial role of non-specialist surgical staff in these programs.

Research methodology for the investigation of rural surgical services.

This paper describes a functional approach to the definition of rural populations for purposes of rural health care research. Rather than define "rural" directly, we created a definition of urban populations and our research target became the non-urban component. Using Geographic Information Systems technology, isochrones (drivetime zones) were created that attached suburban populations to urban centres and mapped non-urban populations into rural hospital catchment areas. For population-based analyses, we have proposed a methodology for constructing catchment areas attached to Rural, Regional and Metropolitan services. We have developed a model for calculation of travel time for patients required to travel for care. We successfully applied these methodologies to the disparate regions of rural Alberta and Northern Ontario in 2 papers that investigated the delivery of rural surgical services. This methodology represents a durable and portable designation of "rural" with potential for research applications in other areas of health research. By defining "urban" rather than "rural," we avoided many of the methodological conundrums in this research field.