Brydon Blacklaws is an emergency physician in Powell River, B.C., and co-lead of two virtual emergency-support programs. He says many visitors to small-town ERs at night can be treated by a nurse with the support of a remote doctor.Alia Youssef/The Globe and Mail
Michael Tiller, the mayor of the Newfoundland town of New-Wes-Valley, is thankful the doors of his community’s only emergency room have largely stayed open through the national health care staffing crisis of the past few years.
He just wishes there was a doctor behind those doors more often.
Much of the time, the physicians overseeing the ER are behind a screen, beamed in from someplace in Canada less isolated than Mr. Tiller’s town of 1,200 people, an hour-and-a-half’s drive northeast of Gander.
New-Wes-Valley’s small hospital, the Dr. Y.K. Jeon Kittiwake Health Centre, operated a virtual ER for the equivalent of 313 days between July, 2021, and April of this year – more than any other hospital in Newfoundland and Labrador, according to data The Globe and Mail gathered for its “Secret Canada: Your Health” project.
The project, which brings to light important health care data not tracked nationally or made public, discovered that just more than a third of emergency departments in Canada had experienced at least one temporary shutdown in the past five years because of a lack of doctors and nurses.
Canadian ERs closed their doors for at least 1.14 million hours since 2019, records show
It also found that in a growing number of places, ER closures were being staved off by virtual models in which a nurse or advanced-care paramedic provides hands-on care under the supervision of a far-away doctor.
British Columbia’s virtual emergency service has prevented 8,700 hours of potential closures in 16 small communities since 2021. Alberta recently launched a virtual ER pilot project at five northern hospitals. New Brunswick is experimenting with virtual care in hopes of speeding up service in a few ERs where in-person physicians are also working.
In Newfoundland, the province most dependent on virtual ERs, more than a dozen hospitals have used virtual care to prevent about 40,000 hours of ER closures, most as part of a contract with the Canadian arm of New York-based for-profit company Teladoc Health.
The province signed a two-year, $22-million virtual-care contract with Teladoc Health Canada in 2023, part of which is dedicated to remotely staffing small-town ERs outfitted with Teladoc equipment.
“It’s a catch-22,” Mr. Tiller, a former paramedic, said of virtual emergency care. “You do not want, in any circumstances, your ER closed. But by putting these stop gaps in place, is it a detriment to your ultimate goal of getting a doctor?”
Mr. Tiller’s mixed feelings reflect the breadth of the debate over virtual ERs.
Some regard them as a godsend for small, physician-starved communities that would otherwise face chronic ER closures. Others are dead set against the virtual option, arguing that it is unsafe to advertise an emergency department as open when there is no doctor on site or on call to handle time-sensitive crises such as car accidents and heart attacks.
“We don’t want to see virtual care as a stand-alone solution, especially within the field of emergency medicine,” said Aimee Kernick, a B.C. emergency physician.
Dr. Kernick is the president of the Canadian Association of Emergency Physicians, a group concerned enough by the rise of virtual ERs that it published a statement last summer saying that if there isn’t a physician trained in emergency care on site, the facility shouldn’t be labelled an emergency department.
The group wrote a more detailed draft position statement this year recommending that if virtual ERs are to become a permanent feature of the health system in rural Canada, they be “purposefully integrated into a hybrid patient care system,” with clear communication to the public.
Late last month, groups representing doctors and nurses in the Northwest Territories criticized officials at Yellowknife’s Stanton Territorial Hospital, the only high-level trauma facility in the territory, for considering “an untested ‘virtual ER’ model” if the hospital can’t find enough doctors to fill every shift this summer.
Krystal Pidborochynski, a spokeswoman for the Northwest Territories Health and Social Services Authority, said in an e-mail that a virtual ER “would never be viewed as a replacement for in-person care, but rather a contingency approach that could be used in the event of a severe shortage scenario.”
In some Canadian communities much smaller than Yellowknife, virtual care is already a regular backstop for staffing shortages. Some health leaders consider the innovative model essential to keeping small ERs open around the clock and to preventing precious local doctors from leaving because of the punishing hours.
Ioana Lupu, chief of staff of the 22-bed hospital in Fort Nelson, B.C., turns to a publicly funded and operated service called Virtual Emergency Room Rural assistance, or VERRa, to cover night shifts when her emergency department is short of doctors.
The B.C.-based doctors who work for VERRa are assigned virtual shifts at small hospitals whose ERs are at risk of closing temporarily. They communicate with in-person nurses equipped with iPads on stands.
Until recently, Dr. Lupu was one of only two physicians in Fort Nelson, a town of 2,600 near the boundary with Yukon. “One can easily get burned out from not sleeping enough,” she said.
Hospitals in rural and northern Ontario await ER staffing certainty: ‘If we close, people die’
B.C.’s VERRa model requires that a physician such as Dr. Lupu be in the community in case a patient with life-threatening injuries needs immediate care, said Brydon Blacklaws, an emergency physician in Powell River and co-lead of two virtual emergency-support programs, including VERRa.
However, many people who visit small ERs at night have ailments that can be dealt with by an in-person nurse and remote doctor, which allows the local doctor to get a full night’s sleep more often. Dr. Blacklaws sees virtual ERs as a recruitment and retention play for on-the-ground staff.
“We’ve had lots of new [medical] residents and new grads who go rural say that they never would have stayed if it wasn’t for this type of virtual support,” he said.
In Newfoundland, by contrast, the government allows ERs to stay open virtually even when there is not a doctor in town, so long as an in-person nurse, paramedic or respiratory therapist is trained in airway-management techniques to restore and maintain patients’ breathing.
“Every evaluation that we have had done on our program shows that we are at the same level of patient safety and quality as in-person,” said Joby McKenzie, managing director of Teladoc Health Canada. “As it relates to patient safety and quality, when the doors are closed, what does patient safety and quality look like then?”
Teladoc also operates in two emergency departments in B.C., and is running an $866,000, one-year pilot project inside a handful of rural emergency departments in New Brunswick.
The goal of the New Brunswick plan was to reduce ER waiting times by having remote doctors handle less-acute cases while in-person physicians treated sicker patients. But the program met with enough pushback that part of the pilot was recently cancelled at one hospital and will be finished at another.
“Virtual care is always the last-ditch effort,” said Desmond Whalen, senior medical director of the eastern rural zone for Newfoundland and Labrador Health Services. “The really, really last-ditch effort is to close the door, but we will do everything in our power to put a person in the town before we say, ‘We’ve got no other means, we have to go virtual.’”
With a report from Yang Sun
