Registed Nurses' Association of Ontario

ER Pressures

ER Pressures

Dear Minister Smitherman,
We understand that the Ministry of Health and Long Term Care (MOHLTC) and the Ontario Medical Association (OMA), later this week expect to announce a plan to ensure stable, reliable emergency department (ED) coverage. The Registered Nurses’ Association of Ontario (RNAO) and our expert group, the Nurse Practitioners’ Association of Ontario (NPAO), would like to take this opportunity to provide you with a nursing perspective on potential solutions.

We are asking that Nurse Practitioners (NPs) be fully integrated within solutions to ED crises. As you know, there are no longer regulatory barriers to increased utilization for NPs in EDs. Government, supported by OMA, OHA, RNAO and the CNO – made changes to Regulation 965 of the Public Hospitals Act in 2003. The specific intent of these changes was to ensure that NPs were able to work to their full potential and to admit and treat patients in EDs. Despite the fact that NPs are authorized to admit and treat patients in EDs, very few are employed in them. Minister, we believe that Government must provide hospitals with the necessary funding to employ more NPs and we are urging you to do so.

The distribution of the acuity of patient visits supports increased use of NPs as a solution to the crisis in EDs. Fifty-seven per cent of patients in Ontario visiting an ED have complaints that are not urgent including: cuts and bruises, rashes, urinary tract infections, mild abdominal pain, or chronic problems such as back pain. Minister, as we all know NPs have the knowledge, skills and ability to treat these patients. Moreover, research shows that care provided by NPs in EDs is at least equal to that provided by physicians and patients are satisfied with the care they receive.

The IBM-McMaster study on the Integration of Primary Health Care NPs identified that NP job satisfaction is high in EDs and that physicians working with NPs in EDs value their role in these settings. The report also identified that the barrier to NPs working in EDs rests with the financial disincentives for physicians under alternate payment programs. Such programs have been widely implemented in Ontario, evidence that these models work for both physicians and hospitals. Under the auspices of the Nursing Secretariat, a Working Group has been meeting to develop strategies to address this issue.

We also caution you against looking to a return to a fee-for-service payment model as a solution. This could have a negative impact on retention and recruitment of physicians, especially in rural and teaching hospitals where patient volumes are less predictable. Furthermore, a fee-for-service system that includes higher remuneration to entice more physicians to work in EDs could shift physicians away from the provision of primary care towards ED care. Any solution that reduces access to primary care will only increase the number of Ontarians that have to rely on emergency rooms for their primary care – exacerbating the problems in EDs.

A return to a fee-for-service model for emergency physician compensation would also be inconsistent with this government’s health transformation agenda. It would result in financial incentives for physicians that would undermine a collaborative approach to care delivery in EDs and present another barrier for NPs’ practice. Ontario needs ‘out of the box’ thinking and approaches to resolve current challenges in access to care in EDs. NPs, as part of inter-professional collaborative teams in EDs, are key to Ontario’s success story for patient care and patient satisfaction and the recruitment and retention of both NPs and physicians.

Minister, the time is now to provide hospitals with the necessary funding to employ NPs. We urge you to do what is right for Ontarians by fully integrating NPs into your solution for stable and adequate ED coverage. Ontarians across this magnificent province deserve no less. Increasing use of NPs is a viable and cost-effective option that will reduce physician workload, overcrowding, and long waits in hospital EDs. We look forward to seeing this valuable resource within your upcoming announcement.

With kindest regards,

Doris Grinspun, RN, MSN, PhD (cand), O.Ont.
Executive Director, Registered Nurses’ Association of Ontario

Willi Kirenko RN(EC), MN, PHC/AC NP
President, Nurse Practitioners’ Association of Ontario
cc. Premier Dalton McGuinty

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