6. Rural Emergency Health Care Facilities
Canadian Emergency Department Triage and Acuity Scale Implementation Guidelines
The CAEP Rural Committee published detailed recommendations for the management of rural emergency health care facilities (REHCFs) that should be used as a reference guide for examining facility design and operation in rural and remote communities (Recommendations for the Management of Rural, Remote and Isolated Emergency Health Care Facilities in Canada [policy document]. Ottawa: Canadian Association of Emergency Physicians; 1997).
There are a variety of rural context factors that affect the design and operation of health care systems in rural communities. For example in rural or remote communities it may not be reasonable or possible to have in-hospital physician coverage. Even though patient volumes may be lower than in urban centres the patients have the same diseases and injuries with the same needs for timely and appropriate care.
The intent of the CTAS is to both measure case mix and ensure timely access to intervention. To address case mix comparisons and understand access issues across regions, all patients should be assigned a CTAS triage level in all emergency departments regardless of the size or location of the facility.
The CTAS scale definitions are disease-based, and time to assessment should be the same for REHCFs as it is for urban facilities. Timely intervention may not always require on-site physician assessment within the CTAS time frames. REHCFs can use non-physician assessment protocols and communication of information necessary for medical diagnosis and initiation of treatment protocols.
Although the CTAS triage levels and time to patient assessment are the same in REHCFs, managers will need to write enabling protocols and care plans to modify the time to on-site physician assessment when physicians staff the REHCF by on-call systems off-site. These protocols need to provide for: dence-based and wherever possible validated in REHCFs. Compliance to care guidelines and evaluation of patient outcomes will be necessary for quality improvement monitoring and protocol validation. Research should be undertaken to assess the implementation of the CTAS in
- REHCFs that do not have a separate triage area.
- Situations where the triage nurse and the nurse performing the full assessment are the same person, as is common in low-volume REHCFs.
- Initial management and investigation by appropriately trained, qualified and experienced non-physician health care providers.
- Telephone review, fax, email, videoconferencing or other communication methods between the provider and on-call physician for deciding how soon the physician must see the patient, or whether treatment can be started before the physician arrives on site.
- More urgent physician attendance on site when the nurse’s evaluation of the patient’s condition changes.
The enabling protocols and care plans should be evi-REHCFs with respect to:
- Fractile response measures.
- Provider compliance with protocols and care maps.
- Patient outcome in REHCFs using the CTAS with enabling protocols and care maps.
- Patient satisfaction in REHCFs using the CTAS with enabling protocols and care maps.
- Comparison between the CTAS and formal triage systems already used in REHCFs.
Well-developed on-line and off-line protocols, guidelines and care plans that are designed based on the CTAS and coupled with appropriate training and ongoing audit will allow rural communities to develop systems which meet community needs for emergency health care.
