Editor’s note: The following is a position paper from The College of Family Physicians of Canada (CFPC) and the Society of Rural Physicians of Canada (SRPC).
Despite the Canada Health Act legislating that all Canadians be given universal and accessible health care, many people living in rural and remote communities do not have access to care close to home. We use the term rural to describe those communities that are geographically located in rural and remote regions of Canada and are distinctly or partly populated by Indigenous people. Access to care implies equitable care and equitable outcomes; this is one important way for us to help end systemic racism in the health-care system. Many people who live in rural communities must be transferred out to receive care and then transferred back home for ongoing care. We describe this process as patient transfers.
Developing strategies for more effective patient transfers requires cooperation and collaboration at a pan-Canadian level. An analysis the College of Family Physicians of Canada commissioned uncovered numerous barriers that exist. The case narratives presented below were collected as part of this work.
The analysis, which will be published in 2021, further revealed that more support is needed to provide care close to home and minimize the need for patient transfers. Community-based care and small rural hospitals must be linked and integrated with a formal network of care affiliated with tertiary institutions. Improvements in inter-institutional and inter-jurisdictional coordination could make a big difference in the care of patients in rural and Indigenous communities, and to their families and caregivers.
Gaps exist in current standards and protocols. Better coordination of patient transfers is needed at a systems level (between organizations), within an organization (site to site), and even at the direct care level for transfers that involve interfacility medical transfers. There is a need for access to better data on rural transport and interfacility transfer delivery so that such findings may be translated into practice to improve health outcomes. End-to-end protocols are needed for those who require patient transfers, distinct from what standards currently describe as interfacility medical transfers.
Ensuring access to rural patient transport
The Rural Road Map Implementation Committee (RRMIC) brings together voices from some of Canada’s leading medical and health organizations to address issues of inequitable access to care close to home for people living in rural and remote communities. To address the need for better patient transfers, RRMIC recommends that: Those who live in rural and remote communities in Canada should expect a high standard of care when patient transfers are required. To achieve this vision, RRMIC emphasizes the following five principles built on the tenets of patient-centered care:
- Safe care: Everyone in rural Canada should expect safe care that reflects end-to-end planning for conditions such as trauma, mental health concerns and obstetrical and neonatal emergencies as well as other emergency conditions.
- Equitable care: Leadership across health professions, health-care institutions, academic institutions, governments and communities must address disadvantages, including those related to systemic racism, experienced by those living in rural and remote communities in order for them to receive an equitable standard of care.
- Accessible care: Guidelines for coordinated rural patient transfers by providers and institutions, supported across jurisdictions, must be developed, implemented and improved continually based on indicators agreed upon by all stakeholders, including rural and Indigenous communities.
- Appropriate care: All those involved in the coordination of patient transfers must be competent in providing culturally safe care.
- Integrated care: A pan-Canadian approach with strong provincial and territorial leadership is required to develop guidelines for patient transfers.
- To achieve these principles, the RRMIC calls for a systems-based approach to planning, implementing, and evaluating patient transfers using:
- Evidence-informed policies: Research to support the optimal use of virtual care technologies should be conducted to ensure high-quality and fiscally efficacious care that reduces reliance on patient transfers.
- Continuous quality improvement: The ongoing evaluation of a systems-based approach to the continuous improvement of patient transfers needs to be prioritized, with data reported annually for use by health-care institutions and jurisdictions.
Leadership action/commitment needed
The RRMIC calls on leaders to support and engage in the following actions:
- Adopt formal patient transfer agreements: Establish formal agreements between referring physicians, nurses, midwives and nurse practitioners from rural clinical settings and accepting regional, provincial and territorial health-care institutions.
- Implement no-refusal policies: No-refusal policies would ensure that accepting institutions agree to take the patient first and sort out which service will be responsible later. Community-based health-care settings should accept transfers back upon agreement that the patient can receive appropriate care in the home community with appropriate and safe infrastructure realities.
- Create supportive intra- and inter-jurisdictional infrastructures: Proper infrastructure is crucial for timely transfers and appropriate consultations between rural health facilities and tertiary hospitals to optimize care when transferring patients out of and back into communities. Systems require policy alignment that will overcome jurisdictional boundaries to ensure the best possible care is provided to patients who must travel to receive care. For example, trauma patients must be transferred to the nearest trauma centre, even if this means crossing a provincial or territorial boundary.
- Leverage the use of virtual care technologies to support more care close to home: Advancements in technology can support point-of-care, urgent, real-time consultations between locally based health-care practitioners and regional specialists. Enhanced broadband capacity is essential to this, and investments in appropriate diagnostic imaging and other services in rural settings are needed.
- Use data to evaluate, improve and reduce the need for patient transfers and enable ongoing end-to-end planning: Enhance the use of established tools and data (e.g., Canadian Institute for Health Information data) that can be mined to support evidence-based policies and decision-making related to patient transfers. Create benchmarks to promote continuous quality improvement for patient outcomes, care delivery approaches, and system efficiencies.
Currently, most health-care standards are developed with individual health care institutions in mind. We encourage every hospital and/or health institution to think not only of the patients within their walls, but also of those in the regions and populations they serve. Together we need to develop standards and protocols that reflect the realities of patient transfers; in turn, this will allow for greater systemic accountability.
Providing equitable access to health care, with a level of quality that should be the same whether a patient lives in an urban, rural, or remote community, is a goal for everyone who values the Canada Health Act. We all have a role to play in supporting a coordinated approach that ensures equitable access to care, including when patient transfers are necessary.
Case narrative #1:
“Called Health Sciences Centre; neurosurgery accepted (the patient) but asked for ER to be contacted as patient would have to go through ER. ER physician declined, stating they didn’t think it was a neurosurgical emergency. Advised that their in-house neurosurgeon felt it was a stat case, (but they) again declined, stating they didn’t think it was and didn’t want to accept an out-of-province transfer. (They) finally relented and accepted when asked for their college # to put on the chart to document that they declined a transfer for a neurosurgical emergency when their own neurosurgeon agreed. Patient ended up being transferred out, diagnosed with lumbar spinal injury, had surgery that morning.
— Rural family physician, Ontario
Case narrative #2:
“I had an experience last year, while doing a locum at a hospital in an Indigenous community, where a tertiary centre sent a very sick patient straight back to his home community (which had only a nursing station) when he would have been much better managed in a stepdown fashion at our hospital. The tertiary centre physicians simply didn’t understand (and clearly didn’t try to understand) what the patient would be returning to.
— Rural specialist
Rural Road Map Implementation Committee members
Association of Faculties of Medicine of Canada
Canadian Association for Rural and Remote Nursing
Canadian Association of Emergency Physicians
Canadian Association of Staff Physician Recruiters
Canadian Federation of Medical Students
Canadian Medical Association
Canadian Nurses Association
College of Family Physicians of Canada
Federation of Canadian Municipalities
Healthcare Excellence Canada
Indigenous Physicians Association of Canada
Resident Doctors of Canada
Royal College of Physicians and Surgeons of Canada
Society of Rural Physicians of Canada