In 1995, there were 20 rural hospitals in the B.C. Interior with functioning operating rooms. These were hospitals where general surgeons and Family Physicians with Enhanced Surgical Skills (FPESS) could perform surgeries, deal with trauma and provide caesarean sections (C-section), an essential supporting service for safe and sustainable maternity care.
In 2019, there are now only 10 rural hospitals that have functioning operating rooms, and some of those are dangerously close to closure themselves. This means that there are even fewer communities where locals can stay at home for basic surgeries and where mothers can be assured of specialized help if any difficulties occur during labour and delivery.
There is a recognized interdependency between sustainable anesthesia, maternity care and surgery.
“The ripple effect of the rural hospital operating room closures is that communities that have lost their surgical teams now also have significantly decreased capacity to deal with injuries from trauma. There are no anaesthetists and no surgical doctors in these hospitals anymore,” emphasized Dr. Vikki Haines, a Revelstoke FPESS. “Most of those places no longer deliver babies in their communities either because they don’t have anyone left that can provide emergency C-sections. This has even farther reaching recruitment implications. Without a specialized support team the, family physicians, ER doctors and midwives are often less willing to practice in small communities”
In 2017, alarm over this escalating crisis spurred the launch of the Rural Surgical and Obstetrics Network Initiative (RSON) — a province-wide collaborative effort of communities, Health Authorities and the Rural Coordination Centre of BC — to stabilize rural surgical programs.
Dr. Haines is the local Clinical Lead for the initiative and was part of the provincial stakeholder group that made their case for supporting RSON to a government advisory council. “Just one retirement, or one doctor moving away, can be the end of a vulnerable service,’ she said, ‘it’s not always easy to retain the right type of physicians in rural locations. It’s a fine balance to keep them busy since small populations don’t have enough surgical volume for full-time anaesthetists and surgeons. This is why rural physicians work hard to develop a broad skillset and function in teams to provide patients with access to care across the spectrum, from clinic visits to emergency care, surgery, delivery of babies, care of the elderly and at the end of life. This is a necessity to meet the range of community needs, as well as to ensure stable jobs a.k.a. stable health services without disruptions or gaps in care.”
The RSON proposal was successful, and in 2017, $27 million was granted to bolster rural surgery programs in Revelstoke, Fernie, Creston, Golden, Lillooet, Vanderhoof and Smithers over a 5 year period.
While Revelstoke currently has a strong OR team of four FPESS, three Family Practice Anesthetists (FPAs), and seven OR nurses, it hasn’t always been that way. For three years in the early 2000s Dr. Cam Molder was the only surgeon in town. He was on call 365 days a year until Dr. Dries Mostert was recruited in 2009. Dr. Haines joined the team in 2013, and Dr. Bret Batchelor in 2016. In 2017, there was a real scramble for new FPAs when 20-year veteran Dr. Alex Farrugia was briefly the only one.
“In the past, Revelstoke’s surgical program has been vulnerable,” explained Dr. Molder. “I give credit to all the newcomers who put a lot of energy into bringing funding to Interior Health and provincial jurisdictions to support this good cause.”
RSON’s goal is to sustain rural surgical and maternity services. For example, in Revelstoke, the new funding has increased the number of days the operating room is open. This means a greater volume of cases and shorter wait times for local patients, plus more capacity for out-of-town specialists from Vernon, Kamloops and Salmon Arm to visit, bringing with them new types of surgeries, expanding the Revelstoke team’s scope of experience, providing mentorship and regional networking.
Additional staff were also hired at QVH, boosting the efficiency of the weekly surgical service as well as improving local research capacity. A new Best Practices Quality Nurse has been hired to direct data collection and quality improvement projects related to surgical and maternity services.
Another exciting addition is new remote presence technology, allowing local doctors to liaise with specialists at bigger hospitals using specialized videoconferencing. “I like to call it The Robot,” joked Dr. Haines. “It’s a two-way screen unit on a boom, that can be used in our emergency and operating rooms to allow a specialist, such as a trauma surgeon in Vancouver, to ‘beam in’ from any computer or smart phone, see what’s happening with our patient in real time, and provide advice and assistance with management of serious cases. This sort of technology could be critical when the highways are closed or in the middle of the night in a snowstorm when we can’t get a helicopter to fly in for a pick up.” Dr. Batchelor’s leadership brought the only high-tech screen unit currently in B.C. to Revelstoke for it’s trial run this year, and he is now assisting the other communities participating in the RSON program to upgrade their tech connections as well.
A further benefit to increased capacity in Revelstoke is that patients from bigger centres can come here for simpler operations sooner as wait lists in major centres can be quite long. It means time could be freed up at bigger hospitals for more complex procedures, while smaller hospitals perform basic operations, reducing wait lists across the system.
“This project illustrates both a mindset change and a shift in culture about how we can more effectively use all of our resources in Interior Health,” noted Julie Lowes, Acute Health Services/Site Manager and RSON Interior Health Project Lead at QVH.
“Our overarching goal is to sustain the high-quality surgical program we’ve got, which in turn supports our obstetrical services and trauma response,” Lowes elaborated.
Dr. Jude Kornelson, a professor in the Department of Family Practice at the University of British Columbia and the co-director of the Centre for Rural Health Research, will be studying the outcomes of RSON. During visits to Revelstoke in February and September 2019 she and her team have been meeting local stakeholders, hosting community focus groups and doing surveys to hear from people about their surgery experiences and needs.
“We’re looking at what happens in this facility. All of the patient outcomes of people who have procedures here,” she explained. “We’re also looking at the procedural or surgical outcomes of everybody who lives in Revelstoke regardless of where they have their service, so we can do some comparisons.”
A health-care economist will be looking at the economic impact of the project, not just in terms of the cost of delivering healthcare, but also in terms of the cost to individuals by factoring in things like the cost of traveling out of town for surgical or maternity care.
This is important research because there have been very few studies of rural surgical sites at a systemic level, explained Dr. Kornelson. According to Dr. Haines, while the RSON initiative is being studied in BC, there is watchful interest from across Canada, the U.S. and even Australia as health policy-makers look for the best ways to deliver rural health care. A successful proof of concept would be ground-breaking, especially for these countries where small communities are separated by vast geography.
“There will be a research paper that we hope changes rural surgical services globally,” said Dr. Haines. “It’s exciting to be part of, exciting that seven or eight little BC towns could lead this charge, and very rewarding for us personally as we witness a great deal of hard work beginning to pay off for our own community, stabilizing and strengthening the team-based services provided here.”
Correction: An earlier version of this story attributed it to Katherine Brown. In fact, Alex Cooper was the author.