title: Use of the emergency room in Elliot Lake, a rural community of Northern Ontario, Canada.
abstract: BACKGROUND
  There is ample documentation that use of hospital emergency facilities for reasons other than urgencies/emergencies results in clogged services in many urban centers. However, little has been published about similar misuse of emergency rooms/departments in rural and remote areas, where the situation is usually compounded by a scarcity of healthcare professionals. In Canada there is a shortage of physicians in rural and remote areas as a consequence of misdistribution (most physicians staying in southern urban centers after residence), and there is a chronic misuse of facilities meant for urgencies/emergencies to cope with primary healthcare needs. We address the problem in Elliot Lake, a rural Northern Ontario community of 12,000 people. The economy of Elliot Lake was based on uranium mining until the mid-1990s, when it drastically changed to become a center for affordable retirement and recreational tourism. As a consequence, at the present time the proportion of seniors in Elliot Lake doubles the Canadian average. Our objectives are to elucidate the demographics of emergency room (ER) clients and the effect of the elderly population; the nature of ER use; the perceived level of urgency of clients versus health professionals; and possible alternatives offered to non-urgent/emergency visits. This is the first study of the kind in Northern Ontario, a region the size of France.
  
  
  METHODS
  The study, conducted in July 2001, used a prospective survey, completed by patients and attending clinicians at the time of a patient's presentation to the ER of St Joseph's General Hospital. This hospital is staffed by family physicians, a nurse practitioner, and registered nurses (RNs). The catchment area population (town plus surrounding areas) of the hospital is approximately 18,000 people. ER clients were interviewed verbally, and the attending health professionals responded to written questionnaires. Demographics were recorded (age, sex, employment and marital status), as was each client's reason for making an ER visit. Clients were asked if they had a family physician and if they had contacted him/her before visiting the ER, and if they would use another agency to address their health problem. Each client's, nurse's, and physician/nurse practitioner's perceived urgency level was recorded on a scale from 1 (non-urgent) to 5 (extremely urgent/life threatening). The attending physician/nurse practitioner and attending nurse were also asked to recommend appropriate alternatives, in their judgment, to each ER visit.
  
  
  RESULTS
  Of a total of 1472 ER cases, 1096 (74.5%) verbal interviews with clients were conducted, as well as 1298 (88.2%) and 1013 (68.8%) questionnaires were completed respectively by attending nurses and physicians/nurse practitioner. The age of the clients was roughly proportional to their cohorts in the catchment area. Males and females were equally represented in the sample. Only 28.8% of the clients contacted their family physicians before visiting the ER, although 80.9% of them had a family physician. The reasons for visiting the ER are mostly typical of a primary care practice in Canada, and ER clients considered 19.4% of their visits non-urgent/non-emergency. In contrast, 45.2% of the physicians/nurse practitioner and 63.7% of the nurses considered the visits non-urgent/non-emergency. To reduce ER misuse, two-thirds of the recommendations by staff were to recruit more family physicians and nurse practitioners, and another one-fifth of the recommendations suggested the creation of a walk-in clinic. Other alternatives, such as the use of a variety of agencies available in town, were minimally recommended by healthcare professionals.
  
  
  CONCLUSIONS
  The core of the problem identified by this research is that more physicians, nurse practitioners, and other health care professionals are needed in Elliot Lake to provide continuity of care. A new medical school is being created for the region, but the first family physicians from this initiative will only be available in 2012. In the meantime, healthcare professionals may need to take more preventive and educational measures to reduce ER misuse, and the use of other town's agencies, Telehealth, case-management of recurrent clients, and collaboration with local pharmacists need to be maximized. Further research is urgently needed into the effects on health outcomes in rural communities that may result from health services having to function beyond their capacity. Rural health clinicians, communities, researchers, and policy makers must work together to design, implement, and evaluate, both immediate and longer term solutions to the problems identified in this study.
authors.affiliation: Laurentian University, Sudbury, Ontario, Canada.
authors.forename: L
authors.initials: L
authors.lastname: Harris
authors.forename: M
authors.initials: M
authors.lastname: Bombin
authors.forename: F
authors.initials: F
authors.lastname: Chi
authors.forename: T
authors.initials: T
authors.lastname: DeBortoli
authors.forename: J
authors.initials: J
authors.lastname: Long