Section 2: One System, With Many Access Points
Section Editor: David Petrie
This section is defined by the orienting question: how do we optimize the number, distribution, capabilities, connections, and staffing of emergency departments (and other access points) to turn it into an integrated system and network of emergency care? It could also be more informally titled: “ED Closures, and What to do About Them.” Four chapters follow: ED Categorization, Quality, and Standards (Chapter 3): Competencies, Certification, and Teamwork (Chapter 4): System Integration (Chapter 5); and Emergency Physician Resource Planning (Chapter 6).
Chapter 3: ED Categorization, Quality, and Standards is about the categorization of EDs (and urgent care centres) within a network and geographic area. A plain-language, four-level nomenclature for EDs in Canada is recommended, based on population-weighted distances, and other system level goals. It discusses the potential for peer-to-peer virtual care to impact clinical services planning—the siting, sizing, and synergizing of EDs. We strongly advocate for EDs to meet minimum quality standards around equipment, staffing, and transition-of-care pathways. Without standards, a system with extreme capacity and fiscal pressures may be tempted to blur some quality lines in the name of access.
Chapter 4: Competencies, Certification, and Teamwork explores the issue of staffing, the importance of competencies, the role of certification, and how we can optimize scopes of practice to improve care. There are several pathways in emergency medicine to ensure physicians have the requisite (relative to the level of ED categorization) competencies in a rapidly evolving discipline; likewise for nurses, paramedics, and advanced care providers, such as nurse practitioners and physician assistants. The art and science of fostering high-performance teams is also discussed, with an emphasis on clear goals and roles, core values, leadership, and simulated practice. Finally, this chapter expands on the concept of communities of practice, and what they can do to advance quality, recruitment, retention, and morale.
Chapter 5: System Integration emphasizes the key principles for successful health system integration and coordination. The focus is placed on the relationships between three levels of care in system redesign: primary, urgent, and emergency. This chapter develops the concept of multi-option EMS, and the essential role that pre-hospital care and expanded-scope paramedicine can play in the future. The availability of on-call specialists in an integrated network of emergency care is also emphasized, which is especially true for large rural expanses of Canada. Also highlighted are the importance of systems that deal with trauma, poison-care, myocardial infarction/stroke, etc. in improving patient and population outcomes.
Chapter 6: Emergency Physician Resource Planning synthesizes the recommendations of the preceding three chapters into a practical and immediately relevant emergency physician resource planning framework (the Savage Model) that can, and should, be implemented at a national level. This approach builds on previous work that emphasizes a more demand-based (i.e., what do our populations need?), behaviour-informed (e.g., how do MD career decisions impact the workforce?), iteratively implemented and adjusted approach to HHR (Health Human Resources) planning for the future.