NORTH EAST LOCAL HEALTH INTEGRATION NETWORK. Urgent & Emergent Access to Service Teleconference Ophtalmology May 11, 2011

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Colin Chambers
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1 Participants: Dr. Isser Dubinsky, Hay Group/ NE LHIN Monique Rocheleau, NE LHIN Dr. Tim Zmijowskyj, NE LHIN Drs. Stephen Kosar, HRSRH Kevin Lee, HRSRH Drs. Jason Giroux, SAH George Golesic, SAH Daniel Sharp, SAH Dr. Alejandro Oliver, TADH, Mr. Richard Rodrigue, Regional Manager, OMA Agenda Item Discussion Action Welcome & Introductions Current State Drs. Dubinsky and Zmijowskyj, Ms. Rocheleau and the attending ophthalmologists introduced themselves. Currently there are two Ophthalmologists in Timmins, one of whom is very senior, who provide coverage for 90% of the nights and weekends. There is a need for at least one more ophthalmologist in the community. However, limited hospital resources may be an obstacle to further recruitment. Sudbury has five full-time ophthalmologists, some of whom have a subspecialty orientation to their practice. There is one locum surgeon with a subspecialty interest in ocular plastics, who provides one week per month of service. The Sudbury group endeavours to ensure seamless on-call coverage. However, it is acknowledged that in some circumstances (e.g. a national conference attended by all of the local ophthalmologists) gaps in the call schedule occur. There are also a significant number of uncovered weekend days. Sudbury perceives a need to augment its staff. Their ideal target would be eight Page 1

2 full-time equivalents, which would be achieved by adding a full-time specialist in ocular plastics and two more generalists, or perhaps one generalist and one retinal surgeon. There are no impending retirements. Sault Ste. Marie currently has five ophthalmologists, four of whom have comprehensive practices, and one of whom practices only medical ophthalmology. Seamless coverage is provided. The community is seeking to recruit a further one to two surgeons over the next two years. Although no representatives of North Bay participated in the teleconference, there are three practitioners in that city, all of whom do provide on-call services. Two of the three are a husband-and-wife team, and only one of this couple does surgical procedures. The third practitioner, the senior member of the group, performs surgery and provides limited on-call coverage. Consequently, seamless coverage is not provided. Although the senior practitioner provides a valuable service, if this individual should retire, the community will need to recruit at least two additional ophthalmologists. It was suggested that further recruitment might be difficult because of issues getting operating room time for additional recruits. Coverage In the past, when Sudbury did not have 24/7 coverage, practitioners in Sault Ste. Marie provided coverage. However, it was acknowledged by all participants that cross coverage is difficult secondary to the distances involved in transferring patients in the north. Establishing a LHIN wide schedule would be further complicated by the potential for an unequal distribution of cross coverage, owing to the limited number of surgeons in Timmins and North Bay and their ability to provide cross coverage for those in SSM and Sudbury. For example, it was suggested that if emergent care were necessary in Timmins, it would be easier to go to Toronto than to travel to another centre in the north. At the current time, there is informal recognition of the fact that each of the centres has a defined "coverage area". For instance, it is felt that Elliot Lake is the informal boundary between Sault Ste. Marie and Sudbury, with patients from that community being referred equally to SSM or Sudbury. SSM covers the area west of Elliot Lake and Sudbury takes responsibility for the communities east of Elliot Lake including Manitoulin Island. Page 2

3 North Bay provides coverage for Sturgeon Falls. Transfers It was felt that of all referrals, the number of true "emergencies" is small, and comprises approximately 5% of all referrals. The group acknowledged that many referrals could be deferred. It is difficult for the ophthalmologists to determine the degree of urgency when they cannot physically assess the patients, and when many of the referring physicians are not expert in determining the degree of urgency of the consultation. To ensure access for genuinely urgent or emergent conditions, emergency physicians and family physicians in the LHIN would benefit from additional training. For example, the Timmins ophthalmologists have taken an active role in providing educational sessions to Timmins emergency physicians regarding the diagnosis of particular conditions (e.g. vitreous haemorrhage, etc.). In Timmins, the emergency physicians have learned to perform ultrasound of the eye, and consequently, referrals are generally excellent. However, referrals received from centres outside of Timmins may be of lesser quality. In Sault Ste. Marie, requests for consultation are physician specific, and again the quality of referrals is seen as higher when generated within the community of Sault Ste. Marie than in some of the outlying communities. Participants from Sudbury echoed a similar sentiment. In discussing opportunities to decrease the number of referrals, it was felt that this would be difficult because patients being referred do need access to a slit lamp and anterior chamber evaluation. Further educating the physicians providing emergency department coverage and family physicians was thought to be a difficult prospect, particularly as there are so many locum emergency physicians and family physicians in the LHIN. In Sudbury, they are endeavouring to do telehealth screening for patients with diabetic retinopathy but it is proving to be technically challenging and such Page 3

4 screening cannot currently be relied on for all urgent problems. It was also felt that providing coverage for other centres might be complicated, should ophthalmologists be asked to see other surgeons postoperative complications. Infrastructure No planning for a single or a series of cataract centres has occurred within the NE LHIN. While it is acknowledged that such centres might provide an alternative venue for the conduct of cataract and other minor surgery, concern was expressed that the establishment of such a centre might "steal" ophthalmologists away from general hospitals and the provision of comprehensive eye care. In Sudbury, operating room access was felt to be a significant issue, particularly as it would pertain to accommodating new recruits to any of the area hospitals. In part, this relates to physicians who may be reluctant to give up their current allotment of operating room time, in part because of a lack of sufficient up-to-date equipment such as specialized lasers, and in part, because of the fact that procedures are, in general, conducted in the main operating room, rather than ambulatory surgical centres. The Sudbury hospital emergency department has a dedicated eye room equipped with advanced diagnostic instruments. However, due to space constraints, the equipment is crowded into a small area in order to provide more space for general emergency department care. As a consequence, the room and equipment are often unavailable. This may become an even greater concern when the Eye Clinic is moved to the Memorial campus. Sault Ste. Marie currently has sufficient operating room time and other infrastructure for their program. Seamless Call Because Timmins only has one surgeon, access to operating room resources is not felt to be difficult and there is felt to be good equipment on site. A methodology to ensure the provision of seamless call was discussed. From the perspective of Sault Ste. Marie, this is not an issue as coverage is currently seamless. Page 4

5 The Sudbury ophthalmologists feel that coverage is virtually complete and are hesitant to develop a model in which the availability of on-call surgeons in Sudbury would be advertised throughout the LHIN, as it might increase the number of referrals. It was also felt that some referrals might then require secondary transfer to major centres such as London or Toronto, particularly for trauma cases. Apparently, the Sudbury emergency physicians have become quite adept at deferring referrals for a period of one to two days until an ophthalmologist is available to see the patient. In Timmins, the emergency physicians are also felt to exhibit good judgment and are capable of deciding which patients can wait for a day to be seen locally. It was pointed out that many urgent referrals are transferred directly to ophthalmologists offices, where they receive appropriate care. There is no formal communication mechanism in the LHIN, delineating which hospitals do, or do not have an eye surgeon on call. In order to do so it would be necessary to have accurate and up-to-date information. This may not always be available as pertains to the call schedule. It was also agreed that providing telephone advice to referring physicians regarding which patients could have their referral deferred would be a possibility. It was suggested, as one alternative, that Timmins and North Bay could engage in a cross coverage arrangement, in order to ensure seamless access to care, not only in those centres, but also for patients in outlying centres that traditionally refer to those communities. In order to determine whether this model will work, it will be necessary for the surgeon in Timmins to engage in discussion with his colleagues in North Bay. It was also pointed out that those optometrists with appropriate training have recently had their scope of practice extended, and they are now licensed to provide an enhanced menu of treatments, and to prescribe certain medications. As there are a larger number of optometrists than ophthalmologists in the LHIN and many Page 5

6 communities without an ophthalmologist have an optometrist in the community, this may portend an additional opportunity to ensure access to out of hours care for patients with urgent and emergent problems. It was suggested that the emergency departments in those communities should communicate with the local optometrists to determine their willingness to see referrals, both in and out of office time. In fact, the Timmins emergency physicians apparently already use the local optometrists to assist on occasion. If such a model is to be pursued, it will be important to publicize in the emergency physician community. Date & Time of next meeting / Adjournment To be determined. Page 6

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