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Characteristics of Remote and Isolated Health Care Facilities: An Environmental Scan

Service Line: Environmental ScanIssue: 73Publication Date: April 2018Report Length: 25 Pages

ENVIRONMENTAL SCAN

ENVIRONMENTAL SCAN Characteristics of Remote and Isolated Health Care Facilities: An Environmental Scan 2

Authors: Calvin Young, Aleksandra Grobelna

Cite As: Characteristics of remote and isolated health care facilities: an environmental scan. Ottawa: CADTH; 2018. (Environmental scan; no. 73).

Acknowledgments: The authors would like to acknowledge Dinsie Williams for assistance identifying survey respondents and resources, and reviewing the report; Teo Quay

for project scoping and reviewing the report; Lesley Dunfield for reviewing the report; Eftyhia Helis and Jeannette Smith for input on the clarity of the report; Shawn Gervais

for providing project management support; Michelle Mujoomdar for assistance identifying international survey respondents; and Alice Brown and Joan Reiter for input on

the project survey and assistance identifying survey respondents.

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ContextProviding all citizens in the geographically diverse country of Canada access to universal, equitable, and high-quality health care is a challenge that many health care decision-makers face.1 One strategy to provide vital health care services to Canadians living in remote areas has been the establishment of remote community health care facilities that offer both emergency and primary care. The aim of these facilities is to provide patients living in remote or isolated communities with timely access to quality health care until they are discharged or transferred to secondary or tertiary treatment facilities. The medical staff at remote community health care facilities may be limited to nurses and primary care physicians, and these facilities are equipped with essential medical equipment and supplies.2

Deciding on which equipment, level of services, and staffing are essential in the remote or isolated health care setting is challenging due to a number of considerations. While there is a need to have immediate access to a variety of potentially life-saving services in these remote facilities, it is not possible in many cases to provide services typically offered at facilities in urban settings (e.g., advanced laboratory diagnostics, oncologic services, specialized pediatric care), due to the limited availability of health care resources.2,3 In addition, consideration should be given to ensure equitable and consistent levels of access to care across the country in order to mitigate health disparities, especially among historically underserviced Indigenous populations.1,4 Several challenges must be overcome to provide equitable care in a remote setting, including identifying suitable staffing models, providing high-quality education and training to health care staff, retaining trained staff, and managing the financial burden associated with remote locations (e.g., transportation costs).5,6 In Indigenous communities, traditional perspectives on health and wellness must be respected.4,7 All of these factors must be considered to ensure that an adequate, safe, and effective level of basic care can be provided in the remote setting.

In light of these issues, the purpose of this Environmental Scan is to identify the medical equipment, level of services, and staffing that are deemed essential in remote community health care facilities throughout Canada and other countries that face similar challenges in servicing remote and isolated populations. The information presented in this report may be of use to health care decision-makers and practitioners looking to assess the equipment, level of services, and staffing at health care facilities in remote and isolated communities to better suit the needs of patients.

ObjectivesThis report summarizes information obtained through a literature search and survey of key informants in Canada and other countries. The key objectives of this Environmental Scan are as follows.

1. Identify the key components of essential medical equipment and supply lists used in remote and isolated health care facilities in Canada and other countries.

2. Describe the characteristics (e.g., level of services and staffing) of health care facilities in remote and isolated communities in Canada and other countries.


MethodsThe findings presented in this Environmental Scan are informed by a limited literature search and responses to the “Characteristics of Remote and Isolated Health Care Facilities Environmental Scan Survey” (Appendix 1), gathered between October 6 and December 15, 2017.

For the purposes of this Environmental Scan, health care facilities are defined as “remote and isolated” if they are located a minimum of four hours away from hospital services by ground transportation, with or without road access.8,9 Although this definition was utilized for both the literature search and the survey, there are numerous other definitions of “remote and isolated” that are described and cited by various Canadian and international organizations. These definitions are further mentioned in the discussion section of this report.10-14

A peer-reviewed literature search was conducted using the MEDLINE and the Cochrane Library bibliographic databases. The search was limited to English-language documents published between January 1, 2007, and June 8, 2017. Regular alerts updated the search until project completion; only citations retrieved before November 30, 2017, were incorporated into the analysis. Conference abstracts were excluded from the search results. No methodological filters were applied. Grey literature was identified by searching relevant sections of the Grey Matters checklist: https://www.cadth.ca/grey-matters

Literature identified through database searching was screened for relevance. In the first level of screening, titles and abstracts were reviewed and the full texts of potentially relevant articles were retrieved. The final selection of full-text articles was based on their relevance in answering two research questions.

1. What are the lists of essential medical equipment, or guidance regarding essential medical equipment, for remote and isolated health care facilities in Canada and other countries?

2. What are the characteristics (i.e., distance from hospital services, road access, services offered, and types of staff) of remote and isolated health care facilities that provide care for eligible patients in Canada and other countries?

In addition to the literature search, survey responses were collected from key informants involved in the management of remote and isolated health care facilities in Canada and other countries. Informants were identified by CADTH staff, through professional and clinical networks, or referred by other survey respondents. A 12-question survey was developed and revised following review (see Appendix 1 for the survey). The survey was distributed via email on October 6, 2017, to both Canadian and international contacts. Survey questions required responses that were dichotomous (e.g., yes/no), nominal (e.g., list of options), and free text. The original cut-off date for survey responses was October 20, 2017; however, the deadline was extended until December 15, 2017, in order to accommodate respondents who required additional time. Surveys were considered partially completed if one or more questions were not filled out by the respondent. In cases where a single informant provided multiple responses, only the most recent response was considered for analysis. If a respondent indicated their facility did not qualify under the definition of “remote and isolated,” their responses were excluded from analysis. All respondents gave explicit written permission to use the information provided for the purpose of this report. A list of participating organizations is presented in Appendix 2.


Stakeholder feedback was solicited by emailing survey respondents a draft version of the report and asking for their comments, as well as by taking opportunities to gather public stakeholder feedback.

FindingsLiterature SearchA total of 789 citations were identified in the database search. After screening titles and abstracts, 777 citations were excluded and 12 potentially relevant reports from the electronic search were retrieved for full-text review. Additionally, 19 potentially relevant publications were retrieved from the grey literature search. Of these 31 potentially relevant articles, 30 publications were excluded for various reasons. Literature was excluded after full-text review because the individual articles either:

• were not specific to remote and isolated health care facilities (13 publications),3,15-26

• were published outside of the search time frame (one publication),2 or• did not answer the research questions (16 publications).1,4-6,27-38

Several publications were identified that provided lists of essential equipment for specific medical procedures or settings.3,15-26 Examples of such procedures or settings included childbirth,23 cardiopulmonary resuscitation,15 health care facilities of varying sizes,3 and pediatric prehospital care.17 Although these services may be appropriate in the remote setting, the literature made no specific mention of remote and isolated health care facilities, and therefore could not be included. The remaining excluded articles largely consisted of qualitative studies investigating whether the health care needs of remotely located or Indigenous populations were being met in specific countries or regions, as opposed to providing insight into the medical equipment necessary to provide care.1,4-6,27-38 A list of excluded studies is provided in Appendix 4.

The one document included for the purposes of this report is a guideline from the grey literature that was produced by the Northern Territory Government (Department of Health) in Australia. The guideline makes recommendations for specific clinical equipment required to deliver primary health care services in remote health centres.39

SurveyDue to the nature of the survey’s distribution, which included referrals, word of mouth, and the project team’s targeted efforts, the exact number of individuals who received the survey may not be quantifiable. However, at least 101 informants received the survey directly from the project team. A total of 27 survey responses were retrieved, including 16 complete responses and 11 partial responses. Respondents represented the following provinces, territories, and countries: Alberta (one response), British Columbia (two responses), Manitoba (one response), Newfoundland and Labrador (two responses), Northwest Territories (one response), Nunavut (one response), Yukon (one response), Finland (one response), Ireland (one response), New Zealand (11 responses), Norway (one response), UK (Scotland: two responses), and Sweden (two responses). Appendix 2 includes additional information on the organizations represented by the survey respondents. Two responses were excluded as they were duplicates. In addition, a large number of these responses (18) were excluded from final analysis as their facilities did not qualify under the definition of “remote and isolated.” Because these responses may still be of interest, the results of all survey respondents who considered themselves as working at a remote and isolated facility — the seven responses included in final analysis and 18 responses that did not qualify under the definition of remote and isolated — are presented in Appendix 3 (Tables A3 to A5). However, only the seven responses from individuals that do qualify under the definition of “remote and isolated” will be further discussed.


Only feedback from respondents who gave consent for their survey information to be used for this report was included.

The findings of this report are presented as responses to research questions.

1. What are the lists of essential medical equipment, or guidance regarding essential medical equipment, for remote and isolated health care facilities in Canada and other countries?

No literature was identified that answered this question in a Canadian context. However, one publication was identified in the literature search that provided insight into this research question from an international perspective.39 This document, which was produced by the Department of Health of the Northern Territory Government of Australia, provides recommendations for specific clinical equipment required to deliver primary health care services in remote health centres. In addition to a list of essential medical equipment, the document also recommends specific products, information on the suppliers, and indicative costs. In total, 158 medical devices and supplies were included in this list.

Six survey respondents from Canadian jurisdictions (Alberta, British Columbia, Northwest Territories, Nunavut, and Yukon) and one survey respondent from an international jurisdiction (Finland) provided information on the use of essential medical equipment and supply lists at their remote health care facilities. A summary of their survey responses is presented in Table 1. Three of the six respondents (50%) indicated their organization used essential medical equipment lists to stock their facility. None of these respondents shared their medical equipment list for inclusion in this report.

2. What are the characteristics (i.e., distance from hospital services, road access, services offered, and types of staff) of remote and isolated health care facilities that provide care for eligible patients in Canada and other countries?

No literature was identified to answer this question from either a Canadian or international perspective. Seven survey respondents provided insight into the characteristics of their health care facilities. The six Canadian respondents and one international respondent provided either complete answers (five respondents) or partially complete answers (two respondents) to the survey questions aimed at assessing the level of services and staffing available at their remote facilities. Their responses are presented in Tables 2 and 3.

Table 1: Utilization of Essential Medical Equipment Lists in Remote and Isolated Health Care Facilities in Canada and Other CountriesJurisdiction Does Your Organization Use an Essential

Medical Equipment List to Stock Your Facility? (6 Total Responses)

Would You Be Willing to Share This List Publicly? (3 Total Responses)

Yes No Yes No

Canada (n = 5); n (%) 2 (40%) 3 (60%) 0 2 (100%)

International (n = 1); n (%) 1 (100%) 0 0 1 (100%)

n = number in a subgroup of the sample under study.Note: Jurisdictions represented in these results include Alberta, British Columbia, Northwest Territories, Nunavut, Yukon, and Finland. Another jurisdiction (Newfoundland and Labrador) did not provide a response to either of these survey questions.


Three of the seven survey respondents (42.9%) reported having road access to their facility. Road access was unavailable at four of the six Canadian facilities (66.7%). Information on the size of the population that each health care facility served was retrieved from five respondents. Population sizes were 100 to 999 (n = 1, 20%), 1,000 to 2,499 (n = 1, 20%), 2,500 to 4,999 (n = 2, 40%), and greater than 5,000 (n = 1, 20%). A majority of survey respondents (three out of five, 60%) indicated that more than 50% of their total population was Indigenous. These results are presented in Table 2.

Information on the services and staffing available at remote and isolated health care facilities was retrieved from four Canadian and one international respondent.

The most common services offered by remote facilities were urgent care, emergent care, chronic disease management, public health services, mental health services, and oral care. These six services were reported to be available at all five respondents’ facilities. The next most common services offered were telehealth (n = 4, 80% of facilities), point-of-care testing (n = 4, 80% of facilities), home care (n = 4, 80% of facilities), diagnostic imaging (n = 3, 60% of facilities), and electronic medical records (n = 3, 60% of facilities). One international facility (Finland) stated that it also offered physiotherapy and a child welfare and maternity clinic. Additionally, one facility in Canada provided patients with electrocardiography and lab services.

Regarding the availability of staff, physicians and registered nurses were available at all five of the responding facilities (100%), although physicians were only on-site permanently in three of the sites (60%). Physician specialists, licensed practical nurses, and nurse practitioners were reported as being available to some degree at three facilities (60%). Finally, registered medical imaging technologists were available at two facilities (40%). It is important to note that the availability of these health care practitioners varied between on-site, visiting, and remote access scenarios. If a respondent was involved in the management of multiple remote facilities, their answer reflected the services and staff available at all locations combined, rather than on a per facility basis. Full results from the respondents are presented in Table 3.

Table 2: Characteristics of Remote and Isolated Health Care Facilities in Canada and Other Countries

Jurisdiction Does Your Facility Have Road Access? (7 Total Responses)

What is the Size of the Population That Your Health Care Facility Serves? (5 Total Responses)

What Percentage of the Population Serviced by Your

Facility is Indigenous? (5 Total Responses)

Yes No 0 to 99 100 to 999

1,000 to 2,499

2,500 to 4,999

≥ 5,000 ≥ 90% 50% to 90%

≤ 50%

Canada (n = 6); n (%)

2 (33.3%)

4 (66.7%)

0 1 (25%)

0 2 (50%) 1 (25%)

1 (25%)

2 (50%)

1

(25%)

International (n = 1); n (%)

1 (100%)

0 0 0 1 (100%)

0 0 0 0 1 (100%)

n = number in a subgroup of the sample under study.Note: Jurisdictions represented in these results include Alberta, British Columbia, Newfoundland and Labrador, Northwest Territories, Nunavut, Yukon, and Finland.


Table 3: Services and Staffing Available in Remote and Isolated Health Care Facilities in Canada and Other Countries

Survey Question Response Canada (n = 4); n (%)


Does Your Facility Have the Capacity to Provide Care for All Eligible Patients Requiring Care in the Serviced Community? (5 Total Responses)

Yes 1 (25%) 1 (100%)

Noa 3 (75%) 0

What Types of Services Does Your Facility Provide? (5 Total Responses)

Urgent care 4 (100%) 1 (100%)

Emergent care 4 (100%) 1 (100%)

Chronic disease management 4 (100%) 1 (100%)

Diagnostic imaging:Ultrasound

X-ray Advanced imaging modalitiesb

2 (50%) 3 (75%) 1 (25%)

0 0 0

Electronic medical records 2 (50%) 1 (100%)

Telehealth 4 (100%) 0

Point-of-care testing 3 (75%) 1 (100%)

Public health services 4 (100%) 1 (100%)

Home care 3 (75%) 1 (100%)

Mental health services 4 (100%) 1 (100%)

Oral care 4 (100%) 1 (100%)

What Types of Health Care Practitioners Provide Care at Your Facility? (5 Total Responses)

Physician: On-SiteVisiting

Remote access

2 (50%) 2 (50%)

0

1 (100%)00

Physician specialist: On-SiteVisiting

Remote access

1 (25%)2 (50%)

0

000

Licensed practical nurse: On-SiteVisiting

Remote access

3 (75%)00

000

Registered nurse: On-SiteVisiting

Remote access

4 (100%)00

1 (100%)00

Nurse practitioner: On-SiteVisiting

Remote access

2 (50%)1 (25%)

0

000

Registered medical imaging technologist:On-site Visiting

Remote access

2 (50%)00

000

n = number in a subgroup of the sample under study.Note: Jurisdictions represented in these results include British Columbia, Northwest Territories, Nunavut, Yukon, and Finland. Two jurisdictions (Alberta and Newfound-land and Labrador) did not provide responses to any of these survey questions.a There were several reasons for survey respondents answering no, including insufficient infrastructure or supplies (e.g., equipment, exam space), lack of clinical expertise to address specific patient needs, a lack of sufficient human or physical resources resulting in wait times, and the provision of a certain level of care at their facility followed by referral to a tertiary centre for higher levels of care.b Advanced imaging modalities include computed tomography, magnetic resonance imaging, and single-photon emission computed tomography.


In order to provide further insight into the services and staffing available in responding facilities, the data from Table 3 has been stratified by the size of the facilities’ servicing populations and presented in Table 4. One observation that can be made from these results is the importance of several services — including urgent care, emergent care, chronic disease management, public health services, mental health services, oral care — and staff, including physicians and registered nurses. These services and staff were available at all responding facilities, regardless of the size of the servicing population. The only facility that reported the availability of advanced imaging modalities had a servicing population between 100 and 999. These results should be interpreted with consideration of the small number of responding facilities (n = 5), often limited to one facility per servicing population range.

LimitationsThe findings of this Environmental Scan are not intended to provide a comprehensive review of the topic, but rather to present an overview of the essential medical equipment, level of services, and staff used in remote community health care facilities in Canada and other countries. The findings are not based on a systematic review of the topic; rather, they are based on a limited literature search and survey replies from responding jurisdictions. The amount of evidence identified in the literature that addressed the research questions was limited, with one publication included for discussion in this report. Despite reaching out to at least 101 individuals and organizations, seven responses (6.9%, seven out of 101) were included in the final analysis. Potential respondents were not identified for several Canadian and international jurisdictions of interest. Nearly all respondents were only able to speak on behalf of a single site or organization, rather than on behalf their jurisdiction’s health care system as a whole. In addition, their responses may have been influenced by their unique experiences and perspectives.

One factor that may have limited the number of responses included for analysis was the definition used for “remote and isolated.” The definition, described in the methods section of this report, required facilities to be located a minimum of four hours away from hospital services by ground transportation (with or without road access). This definition was used with Canadian geography in mind. Other countries that are not as vast, such as Ireland and New Zealand, and some Canadian jurisdictions with remote health care settings that do not exactly meet the criteria used, may not have facilities that qualify under the definition despite facing similar challenges in providing high-quality and equitable health care to remote and Indigenous populations. To acknowledge this limitation, information received from survey responses that did not meet the specific definition used for a remote area has been included in Appendix 3.

DiscussionThere appears to be some variability in the utilization of essential equipment lists and the characteristics of remote and isolated health care facilities in Canada and other countries. The use of essential medical equipment lists, which in theory should assist in ensuring a basic level of care is accessible in remote settings, was not universal among survey respondents, indicating that it may not be standard practice in the Canadian health care system. In addition, fewer than half of survey respondents (three out of seven, 42.9%) reported having road access to their facility, an important factor that may aid in the timely transfer of patients to larger treatment facilities. There was a considerable amount of variation in the size and characteristics of the populations serviced by these remote facilities, which can be expected when the diversity of Canada and other countries is considered. One key observation that emerges from the survey results is the high proportion of Indigenous populations that are provided care by these remote facilities. Three out of five responding facilities (60%) indicated that more than 50% of their servicing populations are Indigenous, and they emphasized the importance of acknowledging and respecting traditional perspectives on health and wellness.


Table 4: Services and Staffing Available in Remote and Isolated Health Care Facilities by Size of Servicing Population

Servicing Population; n (%)

0 to 99 (n = 0)

100 to 999 (n = 1)

1,000 to 2,499 (n = 1)

2,500 to 4,999 (n = 2)

≥ 5,000 (n = 1)

Services Offered

(5 Total Responses)

Urgent care NA 1 (100%) 1 (100%) 2 (100%) 1 (100%)

Emergent care NA 1 (100%) 1 (100%) 2 (100%) 1 (100%)

Chronic disease management NA 1 (100%) 1 (100%) 2 (100%) 1 (100%)


X-ray Advanced imaging modalitiesa

NA NA NA

1 (100%) 1 (100%) 1 (100%)

0 0 0

1 (50%) 1 (50%)

0

1 (100%) 0 0

Electronic medical records NA 1 (100%) 1 (100%) 1 (50%) 0

Telehealth NA 1 (100%) 0 2 (100%) 1 (100%)

Point-of-care testing NA 1 (100%) 1 (100%) 1 (50%) 1 (100%)

Public health services NA 1 (100%) 1 (100%) 2 (100%) 1 (100%)

Home care NA 1 (100%) 1 (100%) 2 (100%) 0

Mental health services NA 1 (100%) 1 (100%) 2 (100%) 1 (100%)

Oral care NA 1 (100%) 1 (100%) 2 (100%) 1 (100%)

Staffing Available

(5 Total Responses)

Physician: On-siteVisiting

Remote access

NANANA

1 (100%)00

1 (100%)00

1 (50%)1 (50%)

0

01 (100%)

0

Physician specialist: On-siteVisiting

Remote access

NANANA

1 (100%)00

000

02 (100%)

0

000

Licensed practical nurse: On-siteVisiting

Remote access

NANANA

1 (100%)00

000

2 (100%)00

000

Registered nurse: On-siteVisiting

Remote access

NANANA

1 (100%)00

1 (100%)00

2 (100%)00

1 (100%)00

Nurse practitioner: On-siteVisiting

Remote access

NANANA

1 (100%)00

000

1 (50%)1 (50%)

0

000

Registered medical imaging technologist: On-site

Visiting Remote access

NANANA

1 (100%)00

000

1 (50%)00

000

n = number in a subgroup of the sample under study.Note: The results presented here are the same as those displayed in Table 3, stratified by the size of the servicing population for each health care facility. Jurisdictions represented in these results include British Columbia, Northwest Territories, Nunavut, Yukon, and Finland. Two jurisdictions (Alberta and Newfoundland and Labrador) did not provide responses to any of these survey questions.a Advanced imaging modalities include computed tomography, magnetic resonance imaging, and single-photon emission computed tomography.


The survey results provided some insight into the services and staffing available at remote facilities represented by the respondents. All five survey respondents (100%) indicated that both physicians and registered nurses were available at their facilities, stressing the reliance on these health professionals for the delivery of primary care. The majority of responding facilities (three out of four, 75%) indicated they did not have the capacity to provide care for all eligible patients requiring care in the serviced community, for various reasons. Furthermore, not all facilities were able to provide access to physician specialists, nurse practitioners, or registered medical imaging technologists — professionals who are important for the delivery of care in other care settings. The survey results highlight the importance of transportation of patients, should specialized services be required.

In addition to the conclusions drawn from the survey, there appears to be a lack of published literature outlining the essential equipment, level of services, and staffing in the remote health care setting. The project team’s limited literature search yielded a single publication that provided some insight into the medical equipment and supplies deemed essential in the remote care setting. Although the identified publication may be of use to health care decision-makers and practitioners, increased availability of public documentation on this issue would likely allow for better-informed decisions.

As noted in the limitations, the response rate and noted variability in the criteria used to define remote health care settings posed further challenges in bringing forward relevant perspectives. Although the analysis in this report was restricted to the definition described in the “Methods” section, it is worth mentioning several alternative definitions of “remote and isolated” that were identified in the literature. This is not an exhaustive list of definitions in use, but illustrates the variation in what is considered “remote.”

A definition put forward by The Organisation for Economic Co-operation and Development (OECD) suggests that a community is considered remote if “at least 50% of its population needs to drive 60 minutes or more to reach a populated centre with more than 50,000 inhabitants.”10 The OECD notes that the use of this definition requires an accessibility analysis.10 Another definition, which has been used by Natural Resources Canada, suggests that a community is considered remote if it is permanent or long-term (five years or more) and is not currently connected to the North American electrical grid or to the piped natural gas network.11 Although this definition may be of importance for some organizations, it does not appear to have been developed considering the perspective of the Canadian health care system. The Registered Nurses’ Association of Ontario and the Rural and Northern Health Care Panel have described communities as remote if they either do not have year-round road access or rely on third parties for transportation to a larger centre (e.g., by train, airplane, ferry).12,13 However, this definition would exclude remote communities that are very isolated from larger treatment facilities but do have road access. The Canadian Institute for Health Information has defined “rural and remote” as small towns with a population less than 10,000, a definition that may be overly inclusive as there are some communities with a population less than 10,000 located in geographic proximity to large treatment facilities.14 Finally, the Canadian Association of Emergency Physicians uses various categories to define what might be considered remote health care settings, including “rural isolated” and “rural remote.”2

Overall, this variation in the criteria used to define “remote and isolated” demonstrates that there is limited consensus in the literature, adding complexity to the survey team’s attempt to reach a definition that applies to health care facilities located in Canada and


other countries. In addition, several sources have described the challenges encountered in defining the remote health care setting in Canada and beyond.12,40 While the definition of “remote and isolated” used in this report may be restrictive and exclude some potentially useful information as well as valid representation of communities considered remote in their local context, it was chosen as it is an objective definition that allows survey respondents to classify their facility as remote or non-remote.

Further work that uses more inclusive criteria for defining remote settings to acknowledge the variation across contexts may provide additional insight into the facility’s characteristics and needs related to essential medical equipment. Alternative approaches to information gathering that emphasize capturing the experiences of individuals working in remote health care settings could help further understanding in this area. Probing experiences that relate to essential medical equipment could help elicit responses about current environments without reliance on formal equipment lists or inventories. As well, opportunities for broader engagement and enhanced communication and collaboration among relevant stakeholders in remote health care and understanding the role of these approaches in improving information sharing may provide guidance for future research.

This report provides a brief overview of some of the issues related to the stocking and staffing of remote and isolated health care facilities in Canada and internationally.


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6. Increasing access to health workers in remote and rural areas through improved retention [Internet]. Geneva (Switzerland): World Health Organization; 2010. [cited 2017 Dec 7]. (Global policy recommendations). Available from: http://apps.who.int/iris/bitstream/10665/44369/1/9789241564014_eng.pdf

7. United Nations declaration on the rights of Indigenous Peoples [Internet]. New York (NY): United Nations; 2008 Aug. [cited 2018 Jan 25]. Available from: http://www.un.org/esa/socdev/unpfii/documents/DRIPS_en.pdf

8. Rural and Norhern Health Care framework/plan: stage 1 report [Internet]. Toronto (ON): Ontario Ministry of Health and Long-Term Care; 2010. [cited 2018 Jan 25]. Available from: http://www.ontla.on.ca/library/repository/mon/24012/306704.pdf

9. Considerations for definitions of “remote” and “isolated” in the context of pandemic (H1N1) 2009 [Internet]. Ottawa (ON): Public Health Agency of Canada; 2018. [cited 2018 Jan 25]. Available from: http://archive.li/tLlIo#selection-803.0-809.0

10. Directorate for public governance and territorial development [Internet]. Paris: OECD; 2011 Jun. [cited 2018 Feb 23]. Available from: https://www.oecd.org/cfe/regional-policy/OECD_regional_typology_Nov2012.pdf

11. Status of remote/off-grid communities n Canada [Internet]. Ottawa: Natural Resources Canada; 2011 Aug. [cited 2018 Feb 23]. Available from: https://www.nrcan.gc.ca/sites/www.nrcan.gc.ca/files/canmetenergy/files/pubs/2013-118_en.pdf

12. Coming together, moving forward: building the next chapter of Ontario’s rural, remote & northern nursing workforce. Report [Internet]. Toronto: Registered Nurses’ Association of Ontario; 2018. [cited 2018 Feb 23]. Available from: http://rnao.ca/sites/rnao-ca/files/RR_May8.pdf

13. Rural and northern health care report. Executive summary [Internet]. Toronto (ON): Ministry of Health and Long-term Care; 2010. [cited 2018 Feb 23]. Available from: http://www.health.gov.on.ca/en/public/programs/ruralnorthern/docs/exec_summary_rural_northern_EN.pdf

14. Hospital births in Canada: a focus on women living in rural and remote areas [Internet]. Ottawa: CIHI; 2013. [cited 2018 Feb 23]. Available from: https://secure.cihi.ca/free_products/Hospital%20Births%20in%20Canada.pdf

15. Quality standards for cardiopulmonary resuscitation practice and training. Primary care - minimum equipment and drug lists for cardiopulmonary resuscitation [Internet]. London (UK): Resuscitation Council (UK); 2013 Nov. [cited 2017 Dec 7]. Available from: https://www.resus.org.uk/quality-standards/primary-care-equipment-and-drug-lists/

16. What is the IAPB standard list? [Internet]. London (UK): The International Agency for the Prevention of Blindness (IAPB); 2017. [cited 2017 Dec 7]. Available from: https://iapb.standardlist.org/about/

17. Cheng A, Hartfield D. Minimum equipment guidelines for paediatric prehospital care. Paediatr Child Health. 2011 Mar;16(3):173-6. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3077309

18. Global atlas of medical devices [Internet]. Geneva (Switzerland): World Health Organization; 2017. [cited 2017 Dec 7]. (WHO medical devices technical series). Available from: http://www.who.int/medical_devices/publications/global_atlas_meddev2017/en/

19. WHO list of priority medical devices [Internet]. Geneva (Switzerland): World Health Organization; 2017. [cited 2017 Dec 7]. Available from: http://www.who.int/medical_devices/priority/en/

20. Equipment for medical responders at special events. In: EMS1.com [Internet]. 2016 Sep 6 [cited 2017 Dec 7]. Available from: https://www.ems1.com/ems-products/Ambulance-Disposable-Supplies/articles/123918048-Equipment-for-medical-responders-at-special-events/

21. Recommended emergency medical services equipment list [Internet]. Lincoln (NE): Nebraska Department of Health and Human Services; 2014 Feb 20. [cited 2017 Dec 7]. Available from: http://dhhs.ne.gov/publichealth/Documents/equipmentlist.pdf

22. NurseTheory.com [Internet]. Standard nursing gear and equipment list; 2017 [cited 2017 Dec 7]. Available from: http://www.nursetheory.com/standard-nursing-gear-and-equipment-list/

23. Interagency list of medical devices for essential interventions for reproductive, maternal, newborn and child health [Internet]. Geneva (Switzerland): World Health Organization; 2016. [cited 2017 Dec 7]. Available from: http://apps.who.int/medicinedocs/documents/s22018en/s22018en.pdf


24. Out-of-hospital premises inspection program (OHPIP). Program standards [Internet]. Toronto (ON): College of Physicians and Surgeons of Ontario; 2013 Sep; revised 2016 Dec. [cited 2017 Dec 7]. Available from: http://www.cpso.on.ca/CPSO/media/documents/CPSO%20Members/OHPIP/OHPIP-standards.pdf

25. WHO list of priority medical devices for cancer management [Internet]. Geneva (Switzerland): World Health Organization; 2017. [cited 2017 Dec 7]. (WHO medical device technical series). Available from: http://www.who.int/medical_devices/publications/priority_med_dev_cancer_management/en/

26. CFR - Code of federal regulations title 21 [Internet]. Silver Spring (MD): U.S. Food and Drug Administration; 2017 Aug 14. [cited 2017 Dec 7]. Available from: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=880&showFR=1

27. Gwynne K, Lincoln M. Developing the rural health workforce to improve Australian Aboriginal and Torres Strait Islander health outcomes: a systematic review. Aust Health Rev. 2016 May 23.

28. Shahid S, Teng TH, Bessarab D, Aoun S, Baxi S, Thompson SC. Factors contributing to delayed diagnosis of cancer among Aboriginal people in Australia: a qualitative study. BMJ Open [Internet]. 2016 Jun 3;6(6):e010909. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893856/pdf/bmjopen-2015-010909.pdf

29. Newham J, Schierhout G, Bailie R, Ward PR. ‘There’s only one enabler; come up, help us’: staff perspectives of barriers and enablers to continuous quality improvement in Aboriginal primary health-care settings in South Australia. Aust J Prim Health. 2016;22(3):244-54.

30. Laufik N. The physician assistant role in Aboriginal healthcare in Australia. JAAPA. 2014 Jan;27(1):32-5.

31. Baeza JI, Lewis JM. Indigenous health organizations in Australia: connections and capacity. Int J Health Serv. 2010;40(4):719-42.

32. Fortney JC, Kaufman CE, Pollio DE, Beals J, Edlund C, Novins DK, et al. Geographical access and the substitution of traditional healing for biomedical services in 2 American Indian tribes. Med Care [Internet]. 2012 Oct [cited 2017 Jun 14];50(10):877-84. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3446690/pdf/nihms399977.pdf

33. Whop LJ, Garvey G, Lokuge K, Mallitt KA, Valery PC. Cancer support services--are they appropriate and accessible for Indigenous cancer patients in Queensland, Australia? Rural Remote Health. 2012;12.

34. Bar-Zeev SJ, Barclay L, Farrington C, Kildea S. From hospital to home: the quality and safety of a postnatal discharge system used for remote dwelling Aboriginal mothers and infants in the top end of Australia. Midwifery. 2012 Jun;28(3):366-73.

35. Castleden H, Crooks VA, Hanlon N, Schuurman N. Providers’ perceptions of Aboriginal palliative care in British Columbia’s rural interior. Health Soc Care Community. 2010 Sep;18(5):483-91.

36. Kruger E, Jacobs A, Tennant M. Sustaining oral health services in remote and indigenous communities: a review of 10 years experience in Western Australia. Int Dent J. 2010 Apr;60(2):129-34.

37. McGrath P, Holewa H, Kail-Buckley S. “They should come out here ...”: research findings on lack of local palliative care services for Australian aboriginal people. Am J Hosp Palliat Care. 2007 Apr;24(2):105-13.

38. Thi Thuy Nga N, Thi My Anh B, Nguyen Ngoc N, Minh Diem D, Duy Kien V, Bich Phuong T, et al. Capacity of commune health stations in Chi Linh district, Hai Duong province, for prevention and control of noncommunicable diseases. Asia Pac J Public Health. 2017 Jul;29(5_suppl):94S-101S.

39. Standard clinical equipment PHC remote guideline [Internet]. Darwin (Australia): Northern Territory Government of Australia. Department of Health; 2017 Jul 31. [cited 2017 Nov 17]. Available from: http://remotehealthatlas.nt.gov.au/standard_clinical_equipment.pdf

40. Wakerman J. Defining remote health. Aust J Rural Health. 2004 Oct;12(5):210-4.


Appendix 1: Survey QuestionsA. General InformationPlease include some information about your role as it pertains to remote or isolated health care provision.1. What is the name of your organization(s)?

2. In which jurisdiction is your organization located? £ Alberta

£ British Columbia

£ Manitoba

£ New Brunswick

£ Newfoundland and Labrador

£ Nova Scotia

£ Northwest Territories

£ Nunavut

£ Ontario

£ Prince Edward Island

£ Quebec

£ Saskatchewan

£ Yukon

£ FederalHealth Canada

£ International

Please specify country. Click here to enter text.

3. What is your profession? £ Director or manager of remote care facility

£ Government decision-maker overseeing remote care provision

£ Health care administrator, manager, or director within health authority overseeing remote care provision

£ Physician overseeing remote care provision

£ Registered nurse or nurse practitioner overseeing remote care provision

£ Other: please specify. Click here to enter text.

£ Do not wish to say


B. Content Questions4. Is your health care facility located in a remote and/or isolated location (based on the definition of being

located a minimum of four hours away from hospital services by ground transportation, with or without road access)?

£ Yes

Please list distance from nearest hospital services (list in kilometres)

£ No

5. Does your facility have road access? £ Yes

£ No

6. Does your organization (government, regional health authority, community medical centre) stock your facility using a standardized list of medical equipment considered essential for providing emergency and basic primary health care services in remote or isolated locations (e.g., crash cart list, treatment room list, assessment room list, other)?

£ Yes

£ No

7. If your organization does have a medical equipment list(s), would you be willing to share it (them)? £ Yes, and if so:

£ publicly

£ in confidence with a Canadian health care jurisdiction

£ No

8. What is the size of the population that your health care facility serves? £ 0 to 99

£ 100 to 999

£ 1,000 to 2,499

£ 2,500 to 4,999

£ 5,000 or greater


9. Does your facility have the capacity to provide care for all eligible patients requiring care in the serviced community?

£ Yes

£ No (select all that apply):

£ due to insufficient infrastructure or supplies (e.g., equipment, exam space)

£ due to lack of clinical expertise to address specific patient needs

£ due to lack of sufficient human or physical resources resulting in wait times

£ other: Click here to enter text.

10. What percentage of the population serviced by your facility is Indigenous (i.e., First Nations, Inuit, Métis, other)?

£ More than 90% of the population is Indigenous

£ 50% to 90% of the population is Indigenous

£ Less than 50% of the population is Indigenous

11. What types of services does your facility provide? (Please check all that apply.) £ Urgent care (emergency ambulatory services)

£ Emergent care (emergency resuscitation and stabilization with coordination for medical evacuation)

£ Chronic disease management

£ Diagnostic imaging:

£ Ultrasound

£ X-ray

£ Advanced imaging modalities (e.g., CT, MRI, SPECT)

£ Electronic medical records

£ Telehealth

£ Point-of-care testing

£ Public health services

£ Home care

£ Mental health services

£ Oral care

£ Other: please list. Click here to enter text.


12. What types of health care practitioners provide care at your facility? Select the relevant type(s) of access for each practitioner (select all that apply).

£ Physician:

£ on-site * visiting * remote access * not available

£ Physician specialist:


£ Licensed practical nurse:


£ Registered nurse:


£ Nurse practitioner:


£ Registered medical imaging technologist:


£ Other: please list. Click here to enter text.


(option to add multiple other entries)


Appendix 2: Information on Survey RespondentsTable 5: Canadian Organizations That Provided Responses to the SurveyProvince/Territory Organization Represented by Survey Respondents

British Columbia First Nations Health Authoritya,b

Alberta Alberta Health Servicesa,b

Manitoba Northern Regional Health Authorityb

Newfoundland and Labrador Eastern HealthWestern Healtha,b

Nunavut Government of Nunavut, Department of Healtha,b

Northwest Territories Government of Northwest Territories, Health and Social Servicesa,b

Yukon Government of Yukon, Department of Health and Social Servicesa,b

Note: There were a total of eight Canadian respondents, including four health care administrators, managers, or directors at the health authority level, one government decision-maker, and three others. The facilities of two Canadian respondents were not in remote locations, according to the definition used in this report, and were therefore not included in the analysis.a Respondent was included in the final analysis.b Respondent was included in the Appendix 3 results.

Table 6: International Organizations That Provided Responses to the SurveyCountry Organization Represented by Survey Respondents

Ireland Health Information and Quality Authority

Finland Lapland Hospital Districta,b

Norway Norwegian Institute of Public Health

United Kingdom (Scotland) Healthcare Improvement Scotlandb

NHS Highlandb

Sweden The Dental and Pharmaceutical Benefits Agency (TLV)b

Region Norrbottenb

New Zealand Ministry of Health (three respondents)Rural Canterbury Primary Health Organisationb

Pinnacle Midlands Health Networkb

Nga Mataapuna Orangab

Awarua Whanau Servicesb

Te Hauora O Turanganui A Kiwab

Ngati Hine Health Trustb

Central Otago Health Servicesb

Note: There were a total of 17 international respondents, including four health care administrators, managers, or directors at the health authority level, one government decision-maker, three directors or managers of remote care facilities, two physicians overseeing remote care provision, and seven others. The facilities of 16 international respondents were not in remote locations, according to the definition used in this report, and were therefore not included in the analysis.a Respondent was included in the final analysis.b Respondent was included in the Appendix 3 results.


Appendix 3: Survey Results from Respondents Who Do Not Qualify Under the Inclusion Criteria Used to Define Remote Health Care FacilityAlthough this Environmental Scan was specifically focused on health care facilities located a minimum of four hours away from hospital services by ground transportation, with or without road access, there were 11 responses from individuals who considered their health facility to be remote or isolated despite not qualifying under this definition. Responses from these respondents, as well as those from respondents who were included in the analysis, are summarized in the following tables (there are 18 total responses, including 15 complete responses and three partial responses). A full synthesis of these responses was not conducted as this was outside of the scope of this report.

Table 7: Utilization of Essential Medical Equipment Lists in Remote and Isolated Health Care Facilities in Canada and Other CountriesJurisdiction Does Your Organization Use an Essential

Medical Equipment List to Stock Your Facility? (17 Total Responses)

Would You Be Willing to Share This List Publicly? (16 Total Responses)

Yes No Yes No

Canada (n = 6); n (%) 4 (66.7%) 2 (33.3%) 0 5 (100%)

International (n = 11); n (%) 7 (63.6%) 4 (36.4%) 2 (18.2%) 9 (81.8%)

n = number in a subgroup of the sample under study.Note: Jurisdictions represented in these results include Alberta, British Columbia, Manitoba, Northwest Territories, Nunavut, Yukon, Finland, New Zealand (which provided seven responses), UK (Scotland), and Sweden (which provided two responses).

Table 8: Characteristics of Remote and Isolated Health Care Facilities in Canada and Other Countries

Jurisdiction Does Your Facility Have Road Access?

(18 Total Responses)

What is the Size of the Population That Your Health Care Facility Serves? (16 Total Responses)

What Percentage of the Population Serviced by Your

Facility is Indigenous? (16 Total Responses)

Yes No 0 to 99 100 to 999

1,000 to 2,499

2,500 to 4,999

≥ 5,000 ≥ 90% 50% to 90%

≤ 50%

Canada (n = 7); n (%)

3 (42.9%)

4 (57.1%)

0 1 (20%)

0 2 (40%)

2 (40%)

1 (20%)

3 (60%)

1 (20%)


11 (100%)

0 0 2 (18.2%)

3 (27.3%)

1 (9.1%)

5 (45.5%)

2 (18.2%)

3 (27.3%)

6 (54.5%)

n = number in a subgroup of the sample under study.Note: Jurisdictions represented in these results include Alberta, British Columbia, Manitoba, Newfoundland and Labrador, Northwest Territories, Nunavut, Yukon, Finland, New Zealand (which provided seven responses), UK (Scotland), and Sweden (which provided two responses).


Table 9: Services and Staffing Available in Remote and Isolated Health Care Facilities in Canada and Other Countries

Survey Question Response Canada (n = 5); n (%)


Does Your Facility Have the Capacity to Provide Care for All Eligible Patients Requiring Care in the Serviced Community? (16 Total Responses)

Yes 1 (20%) 7 (63.6%)

Noa 4 (80%) 4 (36.4%)

What Types of Services Does Your Facility Provide? (16 Total Responses)

Urgent care 4 (80%) 6 (54.5%)

Emergent care 4 (80%) 5 (45.5%)

Chronic disease management 5 (100%) 10 (90.9%)


X-ray Advanced imaging modalitiesb

2 (40%)3 (60%)1 (20%)

2 (18.2%)3 (27.3%)2 (18.2%)

Electronic medical records 2 (40%) 8 (72.7%)

Telehealth 5 (100%) 4 (36.4%)

Point-of-care testing 4 (80%) 5 (45.5%)

Public health services 4 (80%) 9 (81.8%)

Home care 3 (60%) 9 (81.8%)

Mental health services 4 (80%) 9 (81.8%)

Oral care 4 (80%) 4 (36.4%)

What Types of Health Care Practitioners Provide Care at Your Facility? (15 Total Responses)

Physician: On-siteVisiting

Remote access

3 (60%)2 (40%)

0

7 (70%)1 (10%)

0

Physician specialist: On-site Visiting

Remote access

2 (40%)2 (40%)

0

04 (40%)

0

Licensed practical nurse: On-site Visiting

Remote access

4 (80%)00

3 (30%)2 (20%)

0

Registered nurse: On-site Visiting

Remote access

5 (100%)00

7 (70%)2 (20%)

0

Nurse practitioner: On-site Visiting

Remote access

3 (60%)1 (20%)

0

5 (50%)00

Registered medical imaging technologist:On-site Visiting

Remote access

2 (40%)00

1 (10%)0

1 (10%)

n = number in a subgroup of the sample under study.Note: Jurisdictions represented in these results include British Columbia, Manitoba, Northwest Territories, Nunavut, Yukon, Finland, New Zealand (which provided seven responses), UK (Scotland), and Sweden (which provided two responses).a There were several reasons for survey respondents answering no, including insufficient infrastructure or supplies (e.g., equipment, exam space), lack of clinical expertise to address specific patient needs, a lack of sufficient human or physical resources resulting in wait times, and the provision of a certain level of care at their facility followed by referral to a tertiary centre for higher levels of care.b Advanced imaging modalities include computed tomography, magnetic resonance imaging, and single-photon emission computed tomography.


Table 10: Services and Staffing Available in Remote and Isolated Health Care Facilities by Size of Servicing Population

Servicing Population; n (%)

0 to 99 (n = 0)

100 to 999(n = 3)

1,000 to 2,499(n = 3)

2,500 to 4,999(n = 3)

≥ 5,000(n = 7)

Services Offered(16 Total Responses)

Urgent care NA 2 (66.7%) 2 (66.7%) 3 (100%) 3 (42.9%)

Emergent care NA 2 (66.7%) 1 (33.3%) 3 (100%) 3 (42.9%)

Chronic disease management NA 3 (100%) 3 (100%) 3 (100%) 6 (85.7%)


X-ray Advanced imaging modalitiesa

NA NA NA

1 (33.3%)1 (33.3%)1 (33.3%)

01 (33.3%)

0

1 (33.3%)1 (33.3%)

0

2 (28.6%)3 (42.9%)2 (28.6%)

Electronic medical records NA 2 (66.7%) 3 (100%) 2 (66.7%) 3 (42.9%)

Telehealth NA 2 (66.7%) 0 3 (100%) 4 (57.1%)

Point-of-care testing NA 2 (66.7%) 2 (66.7%) 1 (33.3%) 4 (57.1%)

Public health services NA 3 (100%) 2 (66.7%) 3 (100%) 5 (71.4%)

Home care NA 2 (66.7%) 3 (100%) 3 (100%) 4 (57.1%)

Mental health services NA 2 (66.7%) 3 (100%) 3 (100%) 5 (71.4%)

Oral care NA 1 (33.3%) 1 (33.3%) 2 (66.7%) 4 (57.1%)

Staffing Available(15 Total Responses)

Physician:On-site Visiting

Remote access

NANANA

1 (33.3%)1 (33.3%)

0

3 (100%)00

2 (66.7%)1 (33.3%)

0

4 (66.7%)1 (16.7%)

0

Physician specialist:On-site Visiting

Remote access

NANANA

1 (33.3%)1 (33.3%)

0

02 (66.7%)

0

02 (66.7%)

0

1 (16.7%)1 (16.7%)

0

Licensed practical nurse:On-site Visiting

Remote access

NANANA

2 (66.7%)1 (33.3%)

0

1 (33.3%)00

2 (66.7%)00

2 (33.3%)1 (16.7%)

0

Registered nurse:On-site Visiting

Remote access

NANANA

2 (66.7%)1 (33.3%)

0

3 (100%)00

3 (100%)00

4 (66.7%)1 (16.7%)

0

Nurse practitioner:On-site Visiting

Remote access

NANANA

2 (66.7%)00

2 (66.7%)00

1 (33.3%)1 (33.3%)

0

3 (50%)00

Registered medical imaging technologist:

On-site Visiting

Remote access

NANANA

1 (33.3%)00

00

1 (33.3%)

1 (33.3%)00

1 (16.7%)0

1 (16.7%)

n = number in a subgroup of the sample under study.Note: The results presented here are the same as those displayed in Table A5, stratified by the size of the servicing population for each health care facility. Jurisdictions represented in these results include British Columbia, Manitoba, Northwest Territories, Nunavut, Yukon, Finland, New Zealand (which provided seven responses), UK (Scotland), and Sweden (which provided two responses).a Advanced imaging modalities include computed tomography, magnetic resonance imaging, and single-photon emission computed tomography.


Appendix 4: Excluded Studies of Potential InterestSeveral publications were identified from the literature search regarding the health care needs of Indigenous people or essential equipment lists for specific medical procedures or settings. Although these publications could not formally be included in the report as they did not meet inclusion criteria, their contents may be of interest to the readers of this report. A list of these publications, categorized by their topics (and reason for exclusion), is provided as follows.

Recommendations and Equipment Lists for the Remote Setting in Canada (Published Prior to 2007)1. Recommendations and discussion. Equipment. In: Recommendations for the management of rural, remote and isolated

emergency health care facilities in Canada. Ottawa (ON): Canadian Association of Emergency Physicians (CAEP); 1997 Mar 1. Available from: http://caep.ca/resources/position-statements-and-guidelines/management-rural-remote-and-isolated-emergency-health-c

Equipment Lists or Guidance for Specific Procedures or Settings (Not Specific to the Remote Setting) 2. CFR - Code of federal regulations title 21. Silver Spring (MD): U.S. Food and Drug Administration; 2017 Aug 14. Available from:

https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=880&showFR=1

3. Global atlas of medical devices. Geneva (Switzerland): World Health Organization; 2017. (WHO medical devices technical series). Available from: http://www.who.int/medical_devices/publications/global_atlas_meddev2017/en/

4. NurseTheory.com. Standard nursing gear and equipment list; 2017. Available from: http://www.nursetheory.com/standard-nursing-gear-and-equipment-list/

5. What is the IAPB standard list?. London (UK): The International Agency for the Prevention of Blindness (IAPB); 2017. Available from: https://iapb.standardlist.org/about/

6. WHO list of priority medical devices. Geneva (Switzerland): World Health Organization; 2017. Available from: http://www.who.int/medical_devices/priority/en/

7. WHO list of priority medical devices for cancer management. Geneva (Switzerland): World Health Organization; 2017. (WHO medical device technical series). Available from: http://www.who.int/medical_devices/publications/priority_med_dev_cancer_management/en/

8. WHO. Medical devices by health care facility. Geneva (Switzerland): World Health Organization; 2017. Available from: http://www.who.int/medical_devices/innovation/health_care_facility/en/index1.html

9. Equipment for medical responders at special events. In: EMS1.com. 2016 Sep 6. Available from: https://www.ems1.com/ems-products/Ambulance-Disposable-Supplies/articles/123918048-Equipment-for-medical-responders-at-special-events/

10. Interagency list of medical devices for essential interventions for reproductive, maternal, newborn and child health. Geneva (Switzerland): World Health Organization; 2016. Available from: http://apps.who.int/medicinedocs/documents/s22018en/s22018en.pdf

11. Out-of-hospital premises inspection program (OHPIP). Program standards. Toronto (ON): College of Physicians and Surgeons of Ontario; 2013 Sep; revised 2016 Dec. Available from: http://www.cpso.on.ca/CPSO/media/documents/CPSO%20Members/OHPIP/OHPIP-standards.pdf

12. Recommended emergency medical services equipment list. Lincoln (NE): Nebraska Department of Health and Human Services; 2014 Feb 20. Available from: http://dhhs.ne.gov/publichealth/Documents/equipmentlist.pdf


13. Quality standards for cardiopulmonary resuscitation practice and training. Primary care - minimum equipment and drug lists for cardiopulmonary resuscitation. London (UK): Resuscitation Council (UK); 2013 Nov. Available from: https://www.resus.org.uk/quality-standards/primary-care-equipment-and-drug-lists/

14. Cheng A, Hartfield D. Minimum equipment guidelines for paediatric prehospital care. Paediatr Child Health. 2011 Mar;16(3):173-6.

15. Increasing access to health workers in remote and rural areas through improved retention. Geneva (Switzerland): World Health Organization; 2010. (Global policy recommendations). Available from: http://apps.who.int/iris/bitstream/10665/44369/1/9789241564014_eng.pdf

Studies on Remote or Indigenous Populations Note that these studies do not answer the research questions.

16. Thi Thuy Nga N, Thi My Anh B, Nguyen Ngoc N, Minh Diem D, Duy Kien V, Bich Phuong T, et al. Capacity of commune health stations in Chi Linh district, Hai Duong province, for prevention and control of noncommunicable diseases. Asia Pac J Public Health. 2017 Jul;29(5):Suppl:94S-101S.

17. Acute care in remote settings: challenges and potential solutions. London (UK): Nuffield Trust; 2016 Jul. Available from: http://www.aomrc.org.uk/wp-content/uploads/2016/08/Acute_care_remote-settings_100816-2.pdf

18. Clarke J. Difficulty accessing health care services in Canada. Ottawa (ON): Statistics Canada; 2016 Dec 8. (Health at a glance). Available from: http://www.statcan.gc.ca/pub/82-624-x/2016001/article/14683-eng.pdf

19. Gwynne K, Lincoln M. Developing the rural health workforce to improve Australian Aboriginal and Torres Strait Islander health outcomes: a systematic review. Aust Health Rev. 2016 May 23.

20. Newham J, Schierhout G, Bailie R, Ward PR. ‘There’s only one enabler; come up, help us’: staff perspectives of barriers and enablers to continuous quality improvement in Aboriginal primary health-care settings in South Australia. Aust J Prim Health. 2016;22(3):244-54.

21. Shahid S, Teng TH, Bessarab D, Aoun S, Baxi S, Thompson SC. Factors contributing to delayed diagnosis of cancer among Aboriginal people in Australia: a qualitative study. BMJ Open. 2016 Jun 3;6(6):e010909.

22. Laufik N. The physician assistant role in Aboriginal healthcare in Australia. JAAPA. 2014 Jan;27(1):32-5.

23. Bar-Zeev SJ, Barclay L, Farrington C, Kildea S. From hospital to home: the quality and safety of a postnatal discharge system used for remote dwelling Aboriginal mothers and infants in the top end of Australia. Midwifery. 2012 Jun;28(3):366-73.

24. Fortney JC, Kaufman CE, Pollio DE, Beals J, Edlund C, Novins DK, et al. Geographical access and the substitution of traditional healing for biomedical services in 2 American Indian tribes. Med Care. 2012 Oct;50(10):877-84.

25. Whop LJ, Garvey G, Lokuge K, Mallitt KA, Valery PC. Cancer support services--are they appropriate and accessible for Indigenous cancer patients in Queensland, Australia? Rural Remote Health. 2012;12.

26. Access to health services as a social determinant of First Nations, Inuit and Métis health. Prince George (BC): National Collaborating Centre for Aboriginal Health; 2011. Available from: https://www.ccnsa-nccah.ca/docs/determinants/FS-AccessHealthServicesSDOH-EN.pdf

27. Baeza JI, Lewis JM. Indigenous health organizations in Australia: connections and capacity. Int J Health Serv. 2010;40(4):719-42.

28. Castleden H, Crooks VA, Hanlon N, Schuurman N. Providers’ perceptions of Aboriginal palliative care in British Columbia’s rural interior. Health Soc Care Community. 2010 Sep;18(5):483-91.


29. Kruger E, Jacobs A, Tennant M. Sustaining oral health services in remote and indigenous communities: a review of 10 years experience in Western Australia. Int Dent J. 2010 Apr;60(2):129-34.

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