Nursing urgent care back to health

Londoners seeking urgent care this summer may find the doctors are out - replaced by specially trained nurses.

There aren't enough emergency doctors available to staff even the skeleton hours at the urgent care centre at St. Joseph's Health Care, officials said Wednesday.

"With the shortage, we looked at other models," said Dr. Gillian Kernaghan, chief executive of St. Joseph's.

That look came after a push by an outside expert brought in by regulators to find out what's gone wrong with emergency care in London.


Dr. Kevin Smith, the chief executive of St. Joseph's Health System in Hamilton, told The Free Press Wednesday he isn't aware of any similar-sized city with London's ER struggles and he's already found a handful of practices that may need changing.

Those changes include relying not only on emergency doctors, but also on nurse practitioners specially trained in areas that make them qualified to diagnose, order tests, prescribe drugs and perform procedures within the scope of that expertise.

Starting Friday, the urgent care centre will replace some doctors with nurse practitioners every Friday, Saturday and Sunday -- the three days of the week when patient volume is traditionally lowest.

Those three days are also when doctors get the least money, because in the urgent care centre they've been paid for each service they provide -- and fewer patients mean fewer bucks.

Rather than having three doctors those days, the centre will have one or two.

That shift may later expand to include busier days of the week, Kernaghan said.

Smith also pointed to another concern -- recruiting. While London hospitals have embarked on a number of recruiting campaigns for ER doctors, including at the start of the year, those efforts have been piecemeal and lacked resources and focus to compete with other cities, he said.

"It's been a bit ad hoc," Smith said.

Some cities have been much more aggressive, hiring recruiters, freeing up time for doctor leaders to make recruiting a priority.

London hospitals may need to adopt similar measures and budget for that, Smith said.

His message carries weight: only was asked to do the review by regional regulators, but he's a former head of the Ontario and has been a go-to person by Ontario's Ministry to fix problems.

His investigation of London began weeks ago and he's since spoken with the city's head of emergency services, Gary Joubert, and received a few e-mails and calls from emergency doctors.

Next week he will meet with all emergency staff, including doctors, to try for more insight into what isn't working and how to fix it.

He's already focused on several concerns beyond recruiting and the use of nurse practitioners:

    London hospitals should stop treating their urgent care centre as secondary to their two emergency rooms.

    The Ministry should explore whether it's created bad incentives by paying doctors in urgent care differently than doctors in emergency rooms: The latter are paid per session, regardless of the number of patients.

    must be more effective telling people to stay away from emergency or urgent care unless they truly need it.

    should make sure most emergency docs like their work, or recruiting will suffer.

His recommendations come as London hospitals scramble to reduce wait times in and staff an urgent care centre that may be closed on some summer weekends.

St. Joe's hired a private company to fill some emergency shifts starting Friday.

The urgent care centre, set up in 2005, at first opened from 8 a.m. to 10 p.m. daily to handle people who needed immediate care for conditions less severe than what would require a trip to an emergency room.

Those hours have since been cut back twice, most recently in January, with new hours: 8 a.m. to 4 p.m.

The halving of hours comes as struggle to keep pace or find hospital beds for those who need them. Patients have been stranded in for as long as three days waiting for a hospital bed, leaving paramedics with patients they take there rather than in the community.

The emergency crunch isn't the first for London: In 2005, hospitals hired the same private company to provide 700 hours of doctor shifts a month after emergency doctors warned there wasn't enough staff to keep fully functioning just weeks before Christmas.