Asking for Help from Afar: The Value of Peer-To-Peer Support in Rural and Remote Emergency Departments in British Columbia

Dr. Kassandra McFarlane, UBC Family Medicine PGY-1

Patients in isolated communities in Canada encounter difficulty accessing healthcare services.1 This inequity includes urgent and emergent care in rural and remote emergency departments (ED) in all provinces and territories.1 Many challenges exist for health care providers (HCPs) in these low-resource settings and such issues are prevalent throughout British Columbia (BC).

A lack of provider experience, education, or skillset is contributing to a decreasing number of physicians who are interested and confident in providing rural and remote emergency medical care and this is especially prevalent among some cohorts of recently trained physicians.2 In particular, more experienced physicians have noted reluctance among recent graduates to pursue work in a rural or remote ED without further training.2

Rural and remote physicians in BC face complex barriers to accessing higher levels of care for their patients as a result of patient transfer obstacles ranging from a lack of available staff to accompany patients, receiving-physicians refusing the transfer, a lack of transport vehicles, or hazardous weather and rugged geography.2 Difficulties in arranging transfer to higher levels of care can result in frustration for the rural provider and potentially create system-based risks for patient safety.2

As a result of the inherent problems rural and remote providers face in these low-resource settings, there is a greater risk of mental and emotional cost which contributes to burnout and career dissatisfaction3 and is potentially a contributing factor to historic recruitment and retention issues in these isolated EDs. It is well-known that there is a disproportionate lack of health care providers in rural and remote BC communities4, which only furthers the healthcare inequities faced by the patients who reside within them.

One method of addressing the disparity in access to emergency medical care in these communities throughout BC has been by establishing a virtual peer-to-peer support platform for ED HCPs known as Real-Time Virtual Support (RTVS).4 This program, launched during the COVID-19 pandemic in April 2020, facilitates access to decision support in a virtual format using Zoom™ technology.5 Generally, this program aims to support on-site HCPs by employing a cohort of physicians with expertise in emergency medicine, as well as prior experience in similar environments, who serve as colleague-consultants to improve clinical decision making and provider confidence in these low-resource settings.4,5 In particular, RTVS has multiple resources available for HCPs, with two that are specific for urgent and emergent consults: Rural Urgent Doctors in-aid (RUDi) and Child Health Advice in Real-Time Electronically (CHARLiE).6 The goal of this technology is to enhance the availability and quality of health services throughout British Columbia by providing support for rural and remote communities.4

Additionally, the use of virtual peer-to-peer platforms can expedite access to patient transfer services by coordinating directly with patient transport organizations on behalf of the rural and remote HCP.4 Similarly, access to these virtual clinical support services can reduce avoidable utilization of patient-transfer services by providing patient management support that allows the on-site provider to safely care for the patient in their local ED and thereby permits the patient to stay in their home community.7 As a result, there is a reduction in costs associated with contracting transfer services, and it also prevents an unnecessary dispersion of resources.7,8

By fostering a collegial, relationshipbased environment, virtual peer-to-peer platforms provide support to individuals in an otherwise isolating role, potentially contributing to both the positive recruitment and retention of HCPs in these regions.4 While this technology has been helpful in creating connection to valuable knowledge resources in many distributed communities, there are still those where a lack of internet infrastructure provides hurdles to implementation of these solutions.5 However, telephone assistance is offered within the RTVS framework and allows those without reliable internet to access its services9 thereby providing accessible options for providers and supporting relationships between professionals across the farthest reaches of the province.4

There is no doubt that, regardless of the implementation of this technology, challenges still remain in rural and remote emergency departments throughout the province. However, there is hope for the future as a more interconnected community of physicians and allied healthcare workers becomes empowered by access to a virtual network of supportive and knowledgeable colleagues. It is clear that teamwork and collegiality is the basis of a sustainable model for rural and remote emergency medicine in British Columbia.

References

1. Wilson CR, Rourke J, Oandasan IF, Bosco C. Progress made on access to rural health care in Canada. Canadian Family Physician. 2020 Jan 1;66(1):31-6. https://www.cfp.ca/ content/66/1/31.short

2. Wilkinson T, Bluman B. Rural Emergency Medicine Needs Assessment-British Columbia, Canada-2014-2015-Final Report. UBC Continuing Professional Development (UBC CPD).2015. https://ubccpd.ca/sites/ubccpd.ca/files/2015Report-Rural-EM-Needs-Assessment.pdf

3. Canadian Medical Association. 2022. “National Physician Health Survey 2021.” https://www.cma.ca/sites/default/ files/2022-08/NPHS_final_report_EN.pdf

4. Lauscher HN, Stewart K, Markham R, Pawlovich J, Mah J, Hunt M, Williams K, Christenson J, Graham S, Bepple K, Pritchard E. Real-time virtual supports improving health equity and access in British Columbia. InHealthcare Management Forum 2023 Sep (Vol. 36, No. 5, p. 285). SAGE Publications. https://journals.sagepub.com/ doi/10.1177/08404704231183177

5. Falk, W. 2021. The state of virtual care in Canada as of wave three of the COVID-19 pandemic: An early diagnostic and policy recommendations https://www.canada.ca/en/health-canada/corporate/ transparency/health-agreements/bilateral-agreement-pancanadian-virtual-care-priorities-covid-19/wave-three-earlydiagnostic-policy-recommendations.html

6. Emergency Care BC. Real Time Virtual Support – A network of information. 2023. https://emergencycarebc.ca/ rtvs/

7. University of British Columbia Digital Emergency Medicine. Real-time virtual support: year one evaluation report. 2021. https://www.bcemergencynetwork.ca/wpcontent/ uploads/2022/06/2021-07-09-RTVS-Year-1-EvaluationReport-v4.0.pdf

8. Ward MM, Carter KD, Ullrich F, Merchant KA, Natafgi N, Zhu X, Weigel P, Heppner S, Mohr NM. Averted transfers in rural emergency departments using telemedicine: rates and costs across six networks. Telemedicine and e-Health. 2021 May 1;27(5):481-7.

9. Rural Coordination Centre of British Columbia. Real-Time Virtual Support. 2023. https://rccbc.ca/initiatives/rtvs/