6. Rural Emergency Health Care Facilities

Canadian Paediatric Triage and Acuity Scale:
Implementation Guidelines for Emergency Departments

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 Managementof Rural, Remote, and Isolated Emergency Health Care Facilities in Canada [policy document]. Ottawa: Canadian Association of Emergency Physicians; 1997. Available: www.caep.ca).

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, patients have the same diseases and injuries with the same needs for timely and appropriate care. All triage personnel in REHCFs must receive training in paediatric assessment, triage and family-centred health care delivery. They must have available charts and other resource materials on the normal range of physiological parameters and the early signs and symptoms of critical illness in children.

The intent of the PaedCTAS 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 EDs regardless of the size or location of the facility.

The PaedCTAS scale definitions are disease- and physiologic-assessment 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 PaedCTAS time frames. REHCFs can use non-physician assessment protocols and communication of information necessary for medical diagnosis and initiation of treatment protocols.

Although the PaedCTAS 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 must cover all the common paediatric symptom complexes and facilitate immediate detailed assessment and initiation of therapy by the non-physician heath care providers on duty at REHCFs. Such protocols need to provide for the following.

  • 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 evidence-based and, wherever possible, validated in REHCFs. Compliance with 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 PaedCTAS in REHCFs with respect to

  • fractile response measures;
  • provider compliance with protocols and care maps;
  • patient outcome in REHCFs using the PaedCTAS guidelines with enabling protocols and care maps;
  • patient satisfaction in REHCFs using the PaedCTAS guidelines with enabling protocols and care maps;
  • comparison between the PaedCTAS 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 PaedCTAS guidelines and coupled with appropriate training and ongoing audit will allow rural communities to develop systems that meet community needs for paediatric emergency care.

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