Campbellford Memorial Hospital’s ER orientation shift program helps bring physicians to rural community

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Not all cars are the same. When most people purchase a new car, they will usually take a “test drive” to understand the bells and whistles that make it unique. A decision to purchase (or not) soon follows. Similarly, not all hospitals, and in particular, their Emergency Departments (ER) are alike. Yet, in many hospitals today, new physicians are expected work in an ER with little orientation to prepare them for that first time they get “behind the wheel”, working a shift in this new environment. In July, 2008, Campbellford Memorial Hospital (CMH) adopted an Emergency Room Orientation Shift Program to help new physicians “test drive” the hospital’s ER and experience medical practice in a rural community. The program is supporting the hospital’s physician recruitment efforts and its patient safety focus with positive success.

Historically, finding physicians willing to work in the ER at CMH was a challenge. Located in east Northumberland County (about 1.5 hours east of Toronto), the hospital serves approximately 30,000 Northumberland, Peterborough and Hastings County residents, as well as a large seasonal population of cottagers and tourists enjoying the beautiful Kawartha Lakes Region and the Trent River System. CMH’s 24 hour Emergency Department has approximately 22,000 visits each year. Some new physicians may be unprepared to work in a busy ER or harbour anxiety that could interfere with their job performance.

Laurie Smith is the physician liaison and emergency room scheduling professional at CMH and leads the Trent Hills Physician Recruitment and Retention Committee. In 2010, the Rural Ontario Medical Program (ROMP) honoured Laurie as its Education Coordinator of the Year. To address ER coverage challenges, Dr. Norm Bartlett, Chief of Emergency Services at CMH and Smith took a closer look at its current practices to create a way to build on the resident teaching experiences Dr. Bartlett already provides to new residents in the hospital’s ER. Their goal was to determine how they could use these opportunities more effectively to support physician recruitment.

This collaboration is paying off for the hospital, its patients and new physicians with the creation of a paid “Orientation Shift” for recent graduates or other physicians new to the ER to assist them in being comfortable working in ER at CMH.

Explains Smith: “The concept is simple: pay recent graduates or those new to CMH ER to spend up to eight hours with Dr. Bartlett during one of his weekday shifts. This allows new physicians to tour the hospital site, assess what equipment is available – including a new CT scan – meet the staff, ask questions, see the flow of the department and learn local referring patterns before taking on a solo shift in what can be a very busy emergency.”

Participants may split the eight hours into two or three more convenient blocks or come for most of a day shift. “All we ask is that they book a minimum of three ER shifts with us in the three months following their orientation,” explains Smith.

“We have a high turnover of new doctors to our hospital to cover empty ER shifts,” says Dr. Bartlett, adding: “Having new faces around is a good thing, but new physicians are typically not aware of the current processes at our hospital or the resources in the region. The orientation shifts have helped doctors get their feet on the ground and have their questions answered in real time as they are seeing patients. It has been well received by doctors and by nursing.”

Participants also get to sample life in a rural hospital: “In a rural ER like ours, you have more limited medical resources and staff. Typically, you are the only physician working in the ER during your shift. You are required to do a lot more things on your own with a greater reliance on nursing staff than you might experience in a larger, urban hospital. You also have to rely on local resources for problem solving. New physicians typically have expectations and needs that should be managed in this setting.”

Smith was aggressive in targeting the pool of PGY3 EM graduates coming out of the Queen’s University program in Kingston. “Queen’s is our closest medical school neighbour and it made sense to foster this relationship with them, not only to help staff our ER, but also to give ER candidates some solid rural ER experience,” she says.

To date, CMH ER has had 14 physicians participate in this initiative since its introduction. “This program is now a valuable resource for our hospital, ensuring the hospital has the ER coverage it needs and helping us build a growing pool of physicians that we can draw upon for these needs,” says Smith, adding: “A spin-off of the original idea is “shift-sharing” where two new graduates work together so they are better equipped to cope with the real jitters of being “it” in a rural ER. Participants have been more than willing to split the shift remuneration in exchange for the comfort and safety this opportunity provides.”

“Several doctors have returned after they’ve met their three ER shift commitment and continued to work at the hospital,” notes Smith.

Dr. Al Bell, a graduate of Queen’s University’s Enhanced Skills Program, Emergency Medicine, has had an opportunity to participate in CMH’s ER Orientation Program and characterizes the experience this way:

“One of the most daunting things after completing residency is the realization that the most difficult part of our career is often not the medicine, but rather the understanding of what resources are available wherever we choose to practice and how these can be most readily accessed. In essence, patient presentations are largely unchanged regardless of location, but each hospital has its own nuances related to computer systems, investigation availability, consults, transfers, and innumerous other issues. Some hospitals may give you a 10-15 minute overview specific to their facility prior to the first shift, but anyone who has undertaken in this realizes it is clearly insufficient. That is why the paid 8-hour orientation shift at CMH is such a great idea, especially for new graduates. It certainly increased my comfort, and it is just another reason why CMH is such a great place for patients and staff.”

Another important area covered off as part of the Orientation is patient handover administration and transfer issues, an area that is increasingly recognized as high risk for patient care. Handover is the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis. The primary aim of handover is to ensure effective continuity of patient care. Handoffs were once seen as simply the last thing a physician did before leaving the hospital. Dr. Bartlett is among a growing number of physicians that realizes it is a skill that needs to be taught, practiced, and improved upon.

“Patient safety is a significant priority at CMH. Proper patient handover is a key part of the discussion with new residents and physicians working in our ER. That’s what makes this program a win-win – we benefit with greater ER coverage drawing upon a larger pool of physicians who know and understand our hospital and the community it serves. Program participants get a chance to build their confidence and get hands on experience complemented with expanded instruction on how to do daily tasks in the hospital’s ER. Most importantly, our patients receive quality care in a safe environment.”