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ObjectivesAs Canada’s second largest province, the geography of Quebec poses unique challenges for trauma management. Our primary objective was to compare mortality rates between trauma patients treated at rural emergency departments (EDs) and urban trauma centres in Quebec. As a secondary objective, we compared the availability of trauma care resources and services between these two settings.DesignRetrospective cohort study.Setting26 rural EDs and 33 level 1 and 2 urban trauma centres in Quebec, Canada.Participants79 957 trauma cases collected from Quebec’s trauma registry.Primary and secondary outcome measuresOur primary outcome measure was mortality (prehospital, ED, in-hospital). Secondary outcome measures were the availability of trauma-related services and staff specialties at rural and urban facilities. Multivariable generalised linear mixed models were used to determine the relationship between the primary facility and mortality.ResultsOverall, 7215 (9.0%) trauma patients were treated in a rural ED and 72 742 (91.0%) received treatment at an urban centre. Mortality rates were higher in rural EDs compared with urban trauma centres (13.3% vs 7.9%, pConclusionsTrauma patients treated in rural EDs had a higher mortality rate and were more likely to die prehospital or in the ED compared with patients treated at an urban trauma centre. Our results were limited by a lack of accurate prehospital times in the trauma registry.

Introduction Rural emergency departments (EDs) are important safety nets for the 20% of Canadians who live there. A serious problem in access to health care services in these regions has emerged. However, there are considerable geographic disparities in access to trauma center in Canada. The main objective of this project was to compare access to local 24/7 support services in rural EDs in Quebec and Ontario as well as distances to Levels 1 and 2 trauma centers. Materials and Methods Rural EDs were identified through the Canadian Healthcare Association's Guide to Canadian Healthcare Facilities. We selected hospitals with 24/7 ED physician coverage and hospitalization beds that were located in rural communities. There were 26 rural EDs in Quebec and 62 in Ontario meeting these criteria. Data were collected from ministries of health, local health authorities, and ED statistics. Fisher’s exact test, the t-test or Wilcoxon-Mann-Whitney test, were performed to compare rural EDs of Quebec and Ontario. Results All selected EDs of Quebec and Ontario agreed to participate in the study. The number of EDs visits was higher in Quebec than in Ontario (19 322 ± 6 275 vs 13 446 ± 8 056, p = 0.0013). There were no significant differences between Quebec and Ontario’s local population and small town population density. Quebec’s EDs have better access to advance imaging services such as CT scanner (77% vs 15%, p < .0001) and most the consultant support and ICU (92% vs 31%, p < .0001). Finally, more than 40% of rural EDs in Quebec and Ontario are more than 300 km away from Levels 1 and 2 trauma centers. Conclusions Considering that Canada has a Universal health care system, the discrepancies between Quebec and Ontario in access to support services are intriguing. A nationwide study is justified to address this issue.

Approximately 20% of Canadians live in rural areas. Compared to their urban counterparts, rural citizens are in poorer health and are at greater risk for trauma and trauma death. There are great challenges providing and accessing rural emergency care in Canada due to inherent greater distances and limited resources. However, few studies have described the level of resources available in rural emergency departments (EDs) in Canada and the challenge this represents for providing safe patient care. There is minimal information on ED use in Canada, and comparison between provinces is limited by differences in the types of data collected. We present the situation in a rural ED in Nelson, British Columbia, after major service cuts took place. The issue of reasonable access to emergency services is discussed in the context of the Canada Health Act (CHA). We argue that with budgetary constraints and rising costs, service attribution may not be evidence based and outcomes will not be compared to established benchmarks. Considerable variability in access to timely patient care may result; further research is required to determine the impact of service cuts prior to their implementation. In 2001, health care services to BC rural populations were reduced. In the region served by Kootenay Lake Hospital in Nelson, services were centralized in a community 74 km away. The intensive care unit, general surgical service, and inpatient mental health ward were closed, and laboratory and radiography services were reduced. As a result, over 1,500 patients per year required transfer for workups, consultations, or a higher level of care, frequently on an emergency basis. This transfer process resulted in delays in obtaining definitive care. A recent report also suggested that the service cuts coincided with worse outcomes. Using data from the Discharge Abstract Database and the Canadian Institute for Health Information, the Fraser Institute published its British Columbia hospital report card in 2011. For example, residents in Nelson fell from fourth place (4 of 47 municipalities in 2001–2002, prior to health cuts) to last in the province in 2008–2009 with respect to ‘‘failure to rescue,’’ which is considered among the most important health quality indicators and describes mortality from complications that arose while a patient was hospitalized. For many, Canada’s universal health care system is a defining feature of this country. Rural citizens may be tempted to look toward the CHA as a safeguard because one of the central components of the CHA is ‘‘reasonable access’’ to care. The ‘‘intent of accessibility criterion’’ of the CHA is set to ensure that Canadians ‘‘have reasonable access to insured hospital, medical and surgical-dental services on uniform terms and conditions, unprecluded or unimpeded, either directly or indirectly, by charges (user charges or extra-billing) or other means (e.g., discrimination on the basis of age, health status or financial circumstances).’’ Yet reasonable access in terms of physical availability of medical services has been interpreted under the CHA using the ‘‘where and as available’’ rule. Thus, residents of a province or territory are entitled to have access to insured health services at the facility where the services are provided and as the services are available in that setting. Moreover, Canadian emergency medical service systems are not part of the CHA; emergency transportation times and direct costs to patients to where services are available will demonstrate great variation across the country. Hence, the ‘‘where and as available’’ nuance confers significant powers to provinces with respect to service

Efforts at cost containment through regionalization have led to reduced services in several rural emergency departments (EDs) in Canada. As a result, questions have been raised about patient safety and equitable access to care, compelling physicians to advocate for their patients. Few published reports on physicians' advocacy experiences pertaining to rural EDs exist. We describe our experience of patient advocacy after major service cuts at Kootenay Lake Hospital in Nelson, BC. Despite mixed results, we suggest increased physician involvement in patient advocacy.

Introduction Trauma remains the primary cause of death in individuals under 40 years of age in Canada. In Quebec, the Trauma Care Continuum (TCC) has been demonstrated to be effective in decreasing the mortality rate among trauma victims. Although rural citizens are at greater risk for trauma and trauma death, no empirical data concerning the effectiveness of the TCC for the rural population in Quebec are available. The emergency departments (EDs) are important safety nets for rural citizens. However, our data indicate that access to diagnostic support services, such as intensive care units and CT is limited in rural areas. The objectives are to (1) draw a portrait of trauma services in rural EDs; (2) explore geographical variations in trauma care in Quebec; (3) identify adaptable factors that could reduce variation; and (4) establish consensus solutions for improving the quality of care. Methods and analysis The study will take place from November 2015 to November 2018. A mixed methodology (qualitative and quantitative) will be used. We will include data (2009–2013) from all trauma victims treated in the 26 rural EDs and tertiary/secondary care centres in Quebec. To meet objectives 1 and 2, data will be gathered from the Ministry9s Database of the Quebec Trauma Registry Information System. For objectives 3 and 4, the project will use the Delphi method to develop consensus solutions for improving the quality of trauma care in rural areas. Data will be analysed using a Poisson regression to compare mortality rate during hospital stay or death on ED arrival (objectives 1 and 2). Average scores and 95% CI will be calculated for the Delphi questionnaire (objectives 3 and 4). Ethics and dissemination This protocol has been approved by CSSS Alphonse-Desjardins research ethics committee (Project MP-HDL-2016-003). The results will be published in peer-reviewed journals.

Background Point-of-care ultrasound (POCUS) can be used to provide rapid answers to specific and potentially life-threatening clinical questions, and to improve the safety of procedures. The rate of POCUS access and use in Canada is unclear. The objective of this study was to examine access to POCUS and potential barriers/facilitators to its use among rural physicians in Quebec. Methods This descriptive cross-sectional study used an online survey. The 30-item questionnaire is an adapted and translated version of a questionnaire used in a prior survey conducted in rural Ontario, Canada. The questionnaire was pre-tested for clarity and relevance. The survey was sent to non-locum physicians working either full- or part-time in rural emergency departments (EDs) (n = 206). All EDs were located in rural and small towns and provided 24/7 medical coverage with acute care hospitalization beds. Results In total, 108 surveys were completed (participation rate = 52.4 %). Of the individuals who completed surveys, ninety-three percent were family physicians, and seven percent had Canadian College of Family Physicians – Emergency Medicine (CCFP-EM) certification. The median number of years of practice was seven. A bedside ultrasound device was available in 95 % of rural EDs; 75.9 % of physicians reported using POCUS on a regular basis. The most common indications for POCUS use were to rule out abdominal aortic aneurysm (70.4 %) and to evaluate presence of free fluid in trauma and intrauterine pregnancy (60 %). The most common reason (73 %) for not using POCUS was limited access to POCUS training programs. Over 40 % of POCUS users received training in POCUS during medical school or residency. Sixty-four percent received training from the Canadian Emergency Ultrasound Society, 13 % received training from the Canadian Association of Emergency Physicians, and 23 % were trained in another course. Finally, 95 % of respondents reported that POCUS skills are essential for rural ED practice. Conclusions POCUS use in rural EDs in the province of Quebec appears to be relatively widespread. Access to training programs is a barrier to greater use.