Chapter 2: What Have Emergency Departments Become and What Should They Be?

1. EDs should prioritize emergent and urgent care based on the definitions outlined in this chapter as per Table 1.
2. To do so, they should review their ED usage and identify non-emergent populations that have the greatest impact on their bottleneck resources, then negotiate or develop more appropriate alternative care options and pathways for these patients. Top priority populations will include admitted patients waiting for inpatient beds, frail elderly patients (especially those requiring housing, placement, or complex chronic disease management), and patients with chronic mental health and addiction concerns.

Chapter 3: ED Categorization, Quality, and Standards

1. Provincial health ministries should establish Emergency Care Clinical Networks (ECCNs) to coordinate clinical service and HR planning, operational guidance, and quality improvement-patient safety initiatives.
   1. A National Emergency Clinical Care Council (NECCC) should be created; endorsed by CAEP, supported by the federal government (secretariate, administration, travel, integration with CIHR etc.), and given a mandate by the Council of Provincial Deputy Ministers of Health to support the EM:POWER recommendations at the provincial level through national collaborations, benchmarking, and sharing of successes, innovations, and lessons learned.
   2. Provincial Ministries of Health and/or Health Authorities should fund and enable these provincial ECCNs and integrate them with the broader healthcare system governance structure.
   3. Emergency physicians, ideally in a co-lead dyad, should provide leadership to these ECCNs and be given a seat at the appropriate decision-making tables.
2. ECCNs should oversee categorization, standardization (facilities, equipment, required competencies) and integration of EDs and other emergency care access points.
   1. A Plain-language 4 level categorization taxonomy should be used to help guide clinical services planning. Level 1 ED = comprehensive services associated with large tertiary care hospital, Level 2 ED = advanced services associated with other large urban or regional hospitals, Level 3 ED = full services associated with community general hospital, Level 4 ED = basic services associated with small rural hospital.
   2. These levels should be determined/assigned by population weighted distance calculations, annual volumes, and be modified by the function the ED is expected to fulfill in the system. Once assigned, the MoH/HA must adequately fund and support each ED site to meet this required function. EDs must meet the standards consistent with their level of designation.
   3. Network-integrated Urgent Care Centres and Network-integrated peer-to-peer Virtual Care (P2PVC) in this context means that these access points to the Emergency Care system must be designed, integrated, and held to the same quality improvement patient safety standards as EDs (One Network, many Access points).
   4. CAEP/NECCC should create a national template and example standards for provinces to adopt in the domains of physical space, safety, equipment, DI/lab availability, medication availability, staffing numbers/ competencies/ professionalism, and transitions of care pathways.

Chapter 4: Competencies, Certification and Teamwork

1. ECCNs should ensure that to work in an ED, attaining and maintaining individual and team emergency care competencies is required. The resources and opportunities necessary to meet this expectation should be funded and/or supported by the MoH/HA.
2. The CAEP 2020 vision statement should be updated, nuanced, and re-endorsed to reflect distinctions between Level 1-4 EDs in Canadian urban and rural centres.[1] All emergency physicians entering practice in Level 1 and Level 2 EDs should be certified in emergency medicine. Coverage in Level 4 EDs can be provided by comprehensively-trained family physicians with the necessary EM competencies. Level 3 EDs should work towards coverage by certified emergency physicians over the next decade. Given the shortage of emergency physicians in Canada, concerted efforts to increase EM residency training positions and prepare practice-eligible certification candidates will be crucial in attaining this goal.
3. CAEP and emergency care leaders in nursing and paramedicine should advocate for the funding/support necessary for nurses and paramedics to attain and maintain emergency care competencies. They should also encourage all providers to work to their full scope of practice, and enable expanded scopes where needed (e.g., geriatric critical care, etc.).
4. ECCNs should establish and support team-based care, creating complementary roles and responsibilities in the service of patient needs.
   1. Team science should be used in the design and evaluation of team performance in the ED.
   2. Mid-level providers such as NPs, PAs, Doctors of Pharmacy (Pharm Ds) etc. should attain/maintain emergency care competencies, and be added to the ED staff when and where they complement the team approach to improving patient care.
   3. Inter-disciplinary simulation should be used extensively in the training and maintenance of competence of ED teams. Simulation resources and programs should be funded and supported by ministries of health and health authorities.
   4. Emergency physicians should provide a leadership role in a team approach to care in an ED.
   5. A Community of Practice (muti-disciplinary, shared goal, common interests) approach to improving emergency care across silos, sectors, and systems should be intentionally developed and supported.

Chapter 5: System Integration

1. ECCNs should endorse the 10 principles of healthcare system integration [4] and develop and implement projects that follow those principles.
2. Emergency care systems should experiment with, evaluate, and adapt/adopt (or eliminate based on the evaluation) integrated Urgent Care Centre access points and peer-to-peer virtual care support among EDs.
3. Emergency care systems should work with EMS agencies to implement and evaluate pre-hospital coordination centres and expanded scope EMS concepts.
4. Emergency Departments must have 24/7/365 access to single call, no-refusal support by specialists, and operational clarity and consistency around transfers and admitting services.

Chapter 6: Emergency Physician Resource Planning

1. ED directors at the site level should understand the logic and variables of the Savage Model so that they can keep the current data points necessary for the model to be accurate.
2. Provincial ED leaders should understand the logic and variables of the Savage Model so they can influence ministerial and university policy makers around potential leverage points. This will reduce the current and projected FTE gap in ED coverage in Canada.
3. Health ministry and authority leaders must understand the link between clinical services planning and HHR planning (including impacts provider burnout) in emergency care systems.
4. Health ministry and authority leaders must be prepared to adequately fund and support a system that meets the current, future, and surge needs of its population.

Chapter 7: Access Block and Accountability Failure

1. Ministries of Health should initiate the introduction of accountability frameworks like those described here, which incorporate accountability zones, expectations, and performance targets.
2. Ministries of Health should drive system accountability planning, assure population-capacity-alignment, and establish a legislative and labour environment (including financing) that allow hospital CEOs, boards, and regional authorities to be effective.
3. Facility and program leaders should acknowledge the concept of accountability zones and develop real-time policies to clarify care accountability in unclear or disputed cases (see Accountability Zones).
4. Facility and program leaders should implement accountability performance measures specifying timely patient access and flow targets for all programs (Table 4).
5. Program leaders should develop effective queue management strategies and surge contingency plans that do not involve blocking access and deferring care to other programs.
6. To improve patient access to care and achieve program accountability, program leaders should drive the implementation of many or most of the accountability strategies described in this document.
7. Facilities should implement demand-driven overcapacity protocols that will be activated when pull systems are failing and access block is compromising care delivery. Overcapacity protocols should also bridge the hospital-to-community transition.
8. Regional, facility and program leaders should implement accountability measurement and reporting systems. They should monitor care gaps and use defined performance measures to determine whether gaps are best addressed through new capacity, enhanced efficiency, or reallocation of existing resources. Where the root cause is capacity, they must advocate for new resources. Where it is inefficiency or misallocation, they must demand change. [8]

Chapter 8: Disaster Preparedness

1. At all levels of the healthcare system there must be a clear and consistent understanding of what defines a disaster: when the demand placed on the system has outstripped its ability to deliver care.
2. All healthcare facilities (including hospitals, long-term care homes,) and agencies, (including public health, prehospital, patient transport, and community healthcare) must have a minimal degree of competency in disaster, and have their competency tested periodically.
3. All healthcare facilities must have a plan for surge capacity. Because a system that is near or above 100% occupancy cannot, by definition, cope with surges, the plan must include a constant level of actual bed redundancy. This redundancy must consist of real beds—staffed, but unoccupied—as opposed to theoretical bed expansion above the existing census.
4. Outside of healthcare facilities and agencies, the primary care system needs to be supported and educated for its role in disaster preparedness.
5. Facility competency must include (but need not be limited to):
   1. Risk assessment.
   2. Identification of local populations at risk.
   3. Incident command.
   4. Triage
   5. Mass casualty events/mass gatherings.
   6. Hazardous materials including basic knowledge and procedures related to biological, chemical, radiological, and nuclear events.
   7. Cyber readiness.
6. Preparedness planning needs to be high concept and must include an all-hazards approach.
7. Preparedness planning must be integrated at all levels of the health system.
8. At the institutional level, the ideal model for Emergency Management is a dyad model, comprising of an upper-level administrator with formal training and experience in Emergency Management, and a dedicated Physician in the Medical Director role.
9. In addition to the above, institutions and agencies must prepare plans that:
   1. Are uniform in format and structure, allowing for mutual aid between local facilities and agencies as well as across and between regions and provinces/territories.
   2. Are coordinated with Federal/Provincial/Territorial initiatives and support.
   3. Have a defined command and control structure based on IMS principles and supported by an emergency operation centre.
   4. Are simple and easy to review rapidly.
   5. Include role description checklists (“job action sheets”) that allow for a quick understanding of the immediate tasks for staff while activating the next level in response.
   6. Are based on best practices.
   7. Are tested and exercised annually with a formal review every three years.
   8. Follow a standardized format and include key components to allow uniform and interoperable plans that cross Provincial borders. Facilitating this process will require support and guidance from the Federal government within the parameters of the Canada Health Act
   9. Allow for mutual aid between organizations and across jurisdictions/licensures. This will require a process of national licensure for healthcare providers.
10. Education and training in disaster preparedness should have dedicated annual funding to both achieve and maintain competency.
11. Competency should be validated though structured cyclical auditing that, where applicable, should be integrated as a critical factor into the existing evaluation processes of the organization.
12. Disaster response must be a Required Organizational Practice (ROP) without which healthcare facilities cannot be accredited. Specifically, accredited healthcare facilities and agencies must make disaster preparedness an accreditation requirement which is assessed using specific, measurable, and scientifically-driven standards.
13. Facility training must include periodic exercises that involve all components of the disaster response and that are objectively assessed for purposes of quality improvement.
14. Any educational program must promote coordination of services and alignment of disaster plans between the various healthcare providers and health system components within a community, such as first responders, primary caregivers, fire, police and relevant government and local agencies involved in health emergencies to ensure ongoing healthcare to all citizens.
15. All planning must take into consideration vulnerable segments of the population, such as children, the elderly, and patients with special needs.
16. In each jurisdiction all relevant professional colleges must support the development and delivery of standardized professional education in disaster preparedness to any trainees, and to practicing professionals who could be called-upon to respond to a healthcare disaster.
17. All training and education on Disaster Preparedness across Canada, whether delivered by federal, provincial or territorial authorities, should share:
    1. Common resources for risk assessment, readiness assessment, planning and reporting.
    2. Common guidelines upon which they can base their planning, with the resultant uniformity in disaster preparedness.
    3. Common structure and education models for maintenance of disaster preparedness competence for all responders and care providers.
    4. Clarification of the division of authority between healthcare facilities, regional authorities, the Ministries of Health, the Public Health Agency of Canada, and other Federal and Provincial/Territorial agencies.
    5. Common reporting, command and communications methodology between healthcare facilities, regional authorities, the Ministries of Health, the Public Health Agency of Canada, and other Federal and Provincial/Territorial agencies.
18. To ensure interoperability between regions and all levels of healthcare, the Federal government—in cooperation with the Provinces & Territories—must provide uniform planning tools and resources to achieve the previous point. Ideally, a federal health emergency response plan should include:
    1. A core set of concepts, principles, terminology, and technologies covering the incident command system.
    2. A multi-agency coordination system.
    3. A unified command protocol.
    4. A training strategy.
    5. Identification and management of resources.
    6. A process for defining qualifications and certification.
    7. Tactics that support the collection, tracking, and reporting of incident information and incident resources. [19]
19. While the training at the Federal and Provincial/Territorial level should help organizations break down their inter-organizational silos, all training should also emphasize the breaking down of planning and communication silos within healthcare facilities.
20. Create a common national database for unidentified patients, ideally with trackable location identifiers, which would be available to all healthcare centres to ensure effective identification and reunification of patients and families.

Chapter 9: Coevolving in the Research and Quality Ecosystem

1. Increase funding, training, infrastructure, and planning to support and expand the emergency medicine research workforce.
2. Develop a pan-Canadian EM research network with highly connected nodes. Each node should have the resources necessary to coordinate researchers across the EM spectrum and facilitate inter-specialty, interdisciplinary and interprovincial collaborations. This network should incorporate all relevant stakeholders, so we can become an integrated community of practice and learning health system with a focus on achieving the Quintuple Aim.
3. Facilitate data-sharing across jurisdictions. Develop a simplified and harmonized national approach to funding, data-sharing, privacy and legal agreements, ethics approval and research consent. Eliminate the need for redundant data, ethics, and privacy processes for multicentre and multi-jurisdictional research.
4. Link clinical care, quality improvement, knowledge transfer and knowledge translation using models to move research rapidly to the bedside.
5. Emergency medicine research efforts and funding should focus on the most urgent and impactful patient and population healthcare needs.

Chapter 10: The Future of Digital Health in Emergency Medicine 

1. EM leaders in Canada must work together with all stakeholders to build a DH record system which allows access for both patients and direct healthcare providers.
2. To achieve this, health information systems should be integrated at regional, as well as F/P/T levels.
3. Emergency physicians must embrace leadership and stewardship roles in DH, to ensure that the most effective initiatives are supported and that precious public resources are not diverted to frivolous ventures or privatization of DH.
4. EM specialists should assume key roles in the regulation of DH applications in healthcare by way of legislation and government policies.
5. Departments of EM and EM professional societies should collaborate in national and global translational (practically-oriented) research to best apply digital heath’s strengths to EM’s needs.
6. EM training and professional development should be reviewed to ensure core competencies related to the use of DH are taught.
7. Digital health should be a focus of quality improvement initiatives at hospital EDs and academic ED departments.
8. Appropriate consideration should be given to the varying levels of digital literacy, access, and education in Canada’s populations to help prevent barriers to the equitable and fair implementation of digital ED health. [39,40]

Chapter 12: Emergency Medicine’s Future Role in Health Policy and Advocacy

1. CAEP should actively engage with federal/provincial/territorial ministries, health policy experts and medical organizations to promote the EM:POWER report and its recommendations.
2. Provincial ministries of health should fund and enable Emergency Care Clinical Networks (ECCN) and integrate them with the broader healthcare system governance structure.
3. The Provincial/Territorial Council of Deputy Ministers of Health should establish and utilize a National Emergency Care Council, comprised of provincial leadership from across Canada, to help address key challenges (e.g., crowding, closures and HHR), and assist in the development of accountability networks and disaster preparedness. (See also Chapter 3, recommendation 1a.)
4. CAEP should continue alliances with organizations who share their goals and objectives such as CMA (Canadian Medical Association), NENA (The National Emergency Nurses Association), IFEM (The International Federation for Emergency Medicine), and the Coalition for Gun Control.
5. EM:POWER’s framework recommendations should be presented to provincial and regional ECCNs as a basis for system redesign at a more granular level, based on local population health needs and resources.
6. EM training programs should include public affairs as part of a Health Systems Science curriculum, to educate residents and nurture the next generation of public affairs leaders.

Chapter 13: Emergency Medicine in the Era of Climate Change

1. Adapt to emerging conditions, now and in the near future.
2. Emergency physician leaders should be familiar with patient population-health, and ED operational impacts of current climate change events, such as wildfires, prolonged heat events, floods and population displacement.
3. Canada has a National Adaptation Strategy for climate change, which hosts a Disaster Risk Reduction table. Much of this is relevant to emergency physicians and should be integrated into EM training (see Education below). Emergency medicine disaster experts should be integral parts of this conversation and sit at the table.
4. Mitigate the trajectory of change.
5. ED directors must be aware of the temperature and precipitation projections for their region, plan for the consequent operational impacts, and work with climate-savvy architects and engineers to design infrastructure for a changing environment.
6. Emergency medicine leaders must collaborate with governments and other healthcare stakeholders to ensure the necessary supply of pharmaceuticals and other products and mitigate their impact on the environment.
7. Educate ourselves, our patients and our elected leaders
8. Because emergency physicians are familiar with treating patients impacted by extreme heat, wildfires, and floods, they should increase their role in public education related to climate change and climate emergencies, and
9. CAEP should harness its internal expertise in education, research, and public affairs—along with allies from other disciplines—to help illustrate and mitigate the health impacts of climate change.
10. Emergency physicians should contribute to making planetary health a societal priority.

Chapter 14: Building on Values: Justice, Equity, Diversity, and Inclusion (JEDI) in Emergency Medicine

1. Emergency care programs (ECPs) should promote diversity within leadership and among healthcare staff, to better understand and care for the communities they serve.
2. ECPs should foster patient and community engagement from marginalized groups in clinical service planning and delivery.
3. All ECP staff must undergo formal training to better understand the different cultures and populations they serve.
4. ECPs should expand the collection and utilization of sociodemographic data to better evaluate and address JEDI within their programs. There should be public reporting of key operational outcomes that impact marginalized and oppressed populations.
5. Academic departments of emergency medicine should contribute to the understanding and amelioration of inequities in emergency care delivery by supporting JEDI-focused research and multidisciplinary special interest groups (SIGs).
6. JEDI must be a paramount consideration as digital health is incorporated into Canada’s healthcare system.

Chapter 15: Lessons from Other Healthcare Systems

Canada has a relatively poor-performing healthcare system, and we can learn from others. Our review of international practices suggests that high-performing systems are more centralized, integrated, and collaboratively managed than Canada. There are no magic bullets, but several potential innovations are highlighted in the list below:

1. Develop a national workforce strategy with strong federal input using a standardized approach to data, measurement, integration, and prediction.
2. Eliminate interprovincial mobility barriers.
3. Increase physician capacity, primarily through medical school expansion, targeting the OECD average of 3.6 per 1000 population with appropriate distribution matching population needs.
4. Introduce market-based incentives to attract physicians to practice in areas of most need (e.g. generalist-specialist mix, marginalized populations, and rurality).
5. Encourage health professionals, including medical trainees, to work to full scope.
6. Increase peer-to-peer support by telemedicine for rural physicians.
7. Shift away from global hospital budgets toward activity-based funding, but tailor it to the Canadian system with appropriate guardrails.
8. Under an accountability framework, develop system-wide flow targets aimed at improving access to long-term care, acute care, emergency care, diagnostic imaging, specialty access and primary care. Incorporate incentives that discourage gaming, and progress toward these targets in a graded fashion. We strongly recommend 85% hospital occupancy. Consider short-stay units that are not holding areas.
9. Make long-term care the priority target for new spending but ensure this investment is linked to an accountability framework and performance measurement.
10. Evolve toward an aging-at-home model. Consider increasing patient and family co-payments adjusted to ability to pay and having home care patients considered part of a hospital’s case-mix for funding allocation.
11. Add LTC transition spaces and community overcapacity beds that would serve as rapid intake buffer capacity to improve access to care and hospital outflow. Consider policies to incentivize rapid re-integration of hospitalized ALC patients back into the community.
12. Introduce virtual support and community paramedics to augment home (and facility) care and reduce transfers to hospital.
13. Implement overcapacity protocols that bridge the hospital-community outflow interface.
14. Acknowledge the reality that provider compensation in the public system must be competitive with the private system.
15. Consider privatization only in areas where evidence resulting from comprehensive comparisons with other healthcare systems suggests an improvement of patient and population outcomes. At a minimum, there should be no equity threats. If implemented, closely monitor the system for—and regulate response to—unintended consequences.
16. Collaborate with international partners to develop more comprehensive international recommendations for health system improvement.

Learn from and collaborate with other countries to be an effective Learning Health System.

[1] A Plain-language 4 level categorization taxonomy should be used to help guide clinical services planning. Level 1 ED = comprehensive services associated with large tertiary care hospital, Level 2 ED = advanced services associated with other large urban or regional hospitals, Level 3 ED = full services associated with community general hospital, Level 4 ED = basic services associated with small rural hospital