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Inside the February 2008 print edition of Canadian Healthcare Technology:


High-performance CT
Philips, Toshiba and GE have all pushed the envelope when it comes to Computed Tomography. At the recent RSNA meeting in Chicago, the vendors announced leading-edge CT systems. We provide coverage of this and other DI developments.

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Project improves patient flow for UHN’s ED
Since implementing an Emergency Department Transformation Project, the University Health Network’s ED has seen a 20 percent reduction in length of stay for patients going home and an overall 6 percent reduction in length of stay.

READ THE STORY ONLINE


Hospitals of the future
A hospital building boom is under way across Canada and the United States, as medical centres build new facilities and refurbish old ones. They’re all re-thinking traditional hospital designs in a bid to improve patient care.

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Technology assessors
A group consisting of brainy doctors and technologists are objectively evaluating new systems in Montreal. They’re determining whether the technologies deliver what they’re supposed to, in a cost effective manner.

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Sole sourcing your IT?
The way you source your equipment, by open tender or sole sourcing, can have serious legal repercussions. Our legal columnist takes a look at issues that should be considered.


PLUS news stories, analysis, and features and more.

 

Breakthrough technologies shown to attendees at key conference

By Jerry Zeidenberg

CHICAGO – Funny how physicians are often pictured as conservatives who cling to old tools and methods of working. It’s hard to make this argument when you see radiologists flocking to the annual RSNA convention, anxious to kick the tires – so to speak – and acquire the newest medical innovations.

The meeting surely didn’t disappoint them, as the show floor was rife with technology developers showing off their latest marvels – many of which were truly new and potentially ground-breaking.

Computed Tomography: Perhaps the biggest buzz was generated by new developments in CT scanning. Just a year or two earlier, machines capable of scanning 64 slices at a time were seen as incredibly advanced. This year, Philips announced its iCT – which grabs 256 slices in one rotation – while Toshiba startled the meeting even further with a device that acquires 320 slices at a time.

At a press conference, Toshiba vice president of marketing, John Zimmer, explained that the company had also been developing a 256-slice scanner, but during the testing phase various radiologists asked if the coverage could be boosted just a bit further.

What the physicians really wanted was a scanner that could image the entire heart with a single rotation of the circular gantry. That feedback prompted Toshiba to push the envelope and produce a 320-slice machine with a 16-cm coverage area.

“That’s what differentiates us from the others,” commented Behram Engineer, vice president of Toshiba Canada’s medical group. “The slice is the thinnest in the market – at 0.5 centimetres – and the coverage is the widest.”

It wasn’t done just for bragging rights in the slice war, notes Engineer. With the 16-cm coverage area, you can image the heart or brain faster, resulting in lower X-ray dosage. “We’ve cut the dose by up to 80 percent,” commented Engineer.

The low dose is particularly useful for children, whose growing bodies are especially vulnerable to radiation. “Every pediatric hospital will want an advanced CT scanner,” said Engineer. “It would be immoral not to have one, because of the dosage issues.”

What’s more, the new AquilionONE CT captures so much information, you may reduce or eliminate the need for other types of scans. For example, cardiac patients may not need an angiography exam, which carries with it the possibility of disrupting plaque and causing an embolism. Instead, they could have non-invasive CT angiography performed.

And Engineer suggests this new generation of CTs could also replace many nuclear med applications, meaning that patients wouldn’t require radioactive tracers – a particularly poignant observation, given the recent shutdown of the nuclear reactor at Chalk River, Ont., and the resulting shortage of medical isotopes.

Just as significantly, by producing such detailed information in a single exam, the new CTs can speed up treatment for patients. That’s especially important for heart and stroke victims, as treatment in the first three hours – the golden window – can be critical to their recovery.

Engineer pointed out that Toronto has become the first site in the world to install an AquilionONE. The University Health Network has a machine up and running at its Munk Cardiac Centre, and its Toronto Western wing, a site renowned for neuro treatment and research, will be getting one this Spring.

Of course, Philips’ 256-slice iCT scanner is no slouch, either, when it comes to lowering X-ray doses and gathering more detailed information. The company is projecting shipments of 20 – 25 scanners in the four months following the RSNA – a good indication of demand for the high-powered systems.

It’s not just about the scanner, of course. At a press conference, Jim Fulton, general manager of CT for Philips, noted that software advances must go hand-in-glove with the scanner improvements, as a single CT exam of this kind can generate 5,000 images. You need software that not only reconstructs the slices into 3D images, but does it quickly, in a form that assists the radiologist.

To that end, Philips has produced CT software that automates reconstructions and analyses for cardiac exams and brain perfusion studies, advanced vessel studies, lung and liver analyses, and virtual colonoscopies.

Again, it all boils down to making faster, more accurate decisions, with improved safety for patients. “We can screen for coronary artery disease in a shorter time, with a lower dose, than ever before,” commented Steve Rusckowski, CEO of Philips Medical Systems. “That’s what’s important about the iCT, not that it has more slices.”

For its part, GE Healthcare announced a new set of CT technologies dubbed ‘High Definition’ that it will add to future products. “We’re on the threshold of re-inventing CT,” asserted Gene Saragnese, vice president for global CT at GE Healthcare.

The company is seeking to increase imaging speed, resolution and coverage area without resorting to adding additional detectors and slices.

At the core of this ‘rethink’ of CT is a brand new detector material. It’s based on the garnet gemstone, because of the gem’s unique optical properties. According to the company, X-ray processing is much faster and the images more accurate – with fewer artifacts – by using the garnet-based material.

Interventional Radiology: Exciting developments in IR were on display at the RSNA convention. Of note was the robotic, fluoroscopic C-arm, complete with motorized table, all devised by Siemens. The giant arm is designed like its human counterpart, with joints at the ‘wrist’, ‘elbow’ and ‘shoulder’, with each joint providing three degrees of freedom.

Already, there are three clinical sites installed – at the University of Virginia, St. Luke’s Hospital in Houston (part of the Baylor health system) and at the Grosshadern hospital in Munich, Germany.

Called the Artis ‘zeego’, the system resembles the robotic arms seen in the automotive industry, but is designed to solve problems besetting Interventional Radiologists in the IR suite. Namely, using existing systems, it’s difficult to see the whole area of interest.

“There have always been limitations in IR, in getting complete coverage,” said Dr. James Williams, a leading developer of the project. “Either you have to move the patient, or you have to add a huge detector, and then you can’t angulate as well.”

He added that in IR procedures, “You need to see both the entry point and the target, but in the past, sometimes you couldn’t get these in the same image. “With this solution, you can see both,” he asserted, noting the 45 cm coverage of the detector provides, for example, full liver coverage and full lumbar spine imaging.

By providing better control of the C-arm, radiologists can access what they need to observe and obtain close access to the patient – without moving the patient.

The table is also motorized and coordinates its movements with the C-arm. Dr. Williams said the cost of the Artis zeego system is approximately US$1.5 million – a price tag, he said, about 10 percent lower than a biplane system.

Meanwhile, over at the Philips pavilion, a team demonstrated a software breakthrough on a C-arm. The company has developed software that converts fluoro images into real-time 3D, giving radiologists a much better picture of their instruments inside the patient.

“We’re creating CT-like images from fluoro by using CT algorithms,” commented John Desch, vice president of marketing and strategy for Philips in North America. He noted that Philips is a worldwide leader when it comes to interventional radiology, with annual sales of about $1 billion worth of IR solutions.

Molecular imaging: GE Healthcare has targeted molecular imaging as a growth market, and is supplying customers with entire solutions, including the supporting infrastructure. And the results are reaching Canada.

At the RSNA, the company noted that it recently won orders to build and equip two cyclotrons, in Halifax, N.S., and London, Ont. The cyclotrons are being constructed to provide radioactive tracers for use in local Positron Emission Tomography (PET) scanners, which are widely considered to be the imaging ‘gold standard’ for identifying cancers in the body and determining whether tumours are advancing or shrinking during therapy.

PET scanners are also proving useful in the identification of various cardiovascular and neurological disorders.

In Halifax and London, GE Healthcare is leading the complete implementation of the cyclotron and chemistry systems, including FASTlab technology, an automated synthesis system for streamlining the production of radiotracers such as FDG. The two sites will be operational in 2009.

Peter Robertson, general manager of GE Healthcare Canada, based in Mississauga, Ont., said the combined cyclotrons, FASTlab systems and related equipment at the sites each represent investments of between $5 million to $10 million.

“We’re providing them with an end-to-end offering, including training on how to use the systems,” said Robertson.

3D imaging: TeraRecon, of San Mateo, Calif., pioneered the ‘thin computing’ model in medical imaging, in which three-dimensional processing is done on a central server rather than the radiologist’s workstation. This means a radiologist can work from any location and still perform sophisticated reconstructions, as a remote computer is actually handling the heavy-duty lifting.

Without much fanfare, TeraRecon (www.terarecon.com) has won over an impressive array of Canadian radiology departments. According to Serge Letourneau, eastern Canada sales manager for TeraRecon, there are 18 installations of the system in Canada, including Sunnybrook Health Sciences Centre in Toronto, as well as sites in Sherbrooke, Que., St. John’s, Newfoundland, the Atlantic Health Sciences Centre in New Brunswick, the QE II in Halifax, and the CHUM and MUHC in Montreal.

More are on the way, Letourneau noted.

It’s impressive to see the range of procedures that TeraRecon has available – all as thin computing applications that can be run from any computer by accessing central servers.

As well, TeraRecon introduced a new super-server capable of rendering 500,000 CT images – an important product, according to the company, in light of the new 256-slice and 320-slice CT scanners announced at the show. Others are sure to follow, and the need for high-charged servers, ready and able to handle large image sets, will be required for fast, 3D reconstructions.

Computer-aided Detection (CAD): Recently, in the United States, demand for breast MR exams has surged. The modality has been recognized as an effective way to detect breast cancer and to check on it after chemotherapy or surgery. In March 2007, the American Cancer Society recommended that women with a 20 to 25 percent or greater lifetime risk of breast cancer undergo an annual MRI, in addition to conventional mammograms.

Because it’s such an accurate tool, especially for high-risk women with dense breast tissue, the use of MRI for breast exams has made its way into Canada, too.

The problem with breast MR, however, is that it can generate hundreds of images in a single study. It takes intensive reading by a trained radiologist to go through the images, searching for tell-tale signs of lesions.

One of the ways to handle the challenge is through the use of Computer-aided Detection software.

“Breast MR generates 1,200 to 1,800 images for every case,” commented Dr. Ian Gardiner, a radiologist specializing in breast imaging. “What if you miss the images with the problem?”

To improve the odds of catching every lesion, Dr. Gardiner has been using Confirma’s CADstream software for breast MRI at his clinic – the Canada Diagnostic Centre, in Vancouver, B.C. Confirma is based in Bellevue, Wash., near Seattle.

Dr. Gardiner says that he and two colleagues have been the first radiologists in Canada using CAD for breast MRI in Canada, and strongly recommends that others start using it, too.

He stresses that CAD software isn’t making the diagnosis. Rather, it’s a tool for improving the whole procedure – from diagnosis, to reporting, to surgical planning. “A lot of people are trying to get away from the term CAD, because it’s a misnomer,” says Dr. Gardiner. “It’s evaluation and planning software.”

Indeed, on the diagnosis side, the software appears extremely helpful –even to the on-looking layperson. That’s because the software highlights suspicious lesions in colour. “You’re much less likely to overlook a red blob than a grey mass,” commented Dr. Gardiner.

The Confirma software can do this by taking cues from the MRI and contrast agents, which are used to spot the areas of greatest blood flow – using the principle that cancers are faster growing than normal tissue and thus require more blood flow.

Automating areas of concern in this way has resulted in faster readings. Dr. Gardiner says that his reading time has been reduced to 15 to 20 minutes for even the most difficult cases, down from 90 minutes. That’s enabling him to read more cases each day – a gain for his clinic and for the Canadian healthcare system, which is plagued by shortages of radiologists and long waiting lists for diagnostic exams.

On an optimistic note, Dr. Gardiner believes that with early detection, deaths from breast cancer could be eliminated. “Early detection is the key,” he says. “There are too many women today in hospices.”

The best tool for early detection, he adds, is MR. “It can accurately assess the true extent of the disease, something that’s underestimated by mammography and ultrasound.” More information about Confirma is available at www.confirma.com

Ease of use:
You might invent the world’s greatest gizmo, but if people find it difficult to use, they’ll likely fling it aside and do things the old way.

That’s been a typical story with computerized technologies – especially for software solutions, which have been plagued by busy interfaces and complex operating procedures.

The result? Computerized systems are often implemented that few people actually use. In project management circles, that’s called project failure.

Enter Carestream Health, the former Kodak health group that was recently purchased by Toronto-based Onex Corp.

Carestream has put time and effort into creating refreshingly simple and easy-to-use interfaces for a variety of solutions. “In a crowded marketplace, software is becoming a key differentiator for us,” commented Diana Nole, president of digital capture solutions for the Rochester, N.Y.-based company.

Carestream has also been working at automating numerous processes for radiologists and technologists – that is, letting the computerized solutions do more of the low-level work, leaving more time for the professionals to do higher-value procedures.

A case in point: the latest iteration of Carestream’s voice-enabled RIS (whose worldwide development team is based in Summerside, Prince Edward Island) automates the time-consuming task of entering demographics and other patient-related data when dictating reports.

According to the company, the RIS has the ability to pre-populate radiology reports with patient and exam information captured during order entry, so radiologists do not need to spend valuable time dictating patient and exam information that is already available. This includes: patient name, date, type of exam, referring physician, symptoms, and other data.

At RSNA 2007, Carestream also demonstrated its work on image fusion – fusing in perfect registration, for example, CT and MR images on the same workstation. “We can do this with images from different modalities and vendors, and the software merges them automatically,” commented Ulf Andersson, worldwide general manager of enterprise solutions. The benefit, of course, is that varying modalities will capture different types of information; a fused image can provide more information to the radiologist in a single reading.

Another automated solution: Carestream demonstrated as a work-in-progress a ‘dashboard’ that automatically determines which technologists are taking the best images on the various modalities in a hospital. Using a variety of measurements – such as rejects, underexposed, overexposed, patient movement and image blur, etc., the dashboard will automatically compile statistics about the effectiveness of the departmental workforce.

“It tells you how they’re doing, and where they need to improve,” commented Nole. As a result, hospitals gain quick feedback about who needs additional training. In turn, they can reduce the need for re-takes and also improve the quality of images sent to radiologists.

Significantly, the analytical system is an objective way of measuring image quality in a radiology department. “Many departments have techs doing their own quality control – but that isn’t the best situation,” commented Eileen Heizyk, worldwide marketing manager for digital capture solution. She noted that people will often give themselves high ratings, when they could really benefit by brushing up their skill sets.

PACS: Industry-giant McKesson showed how it’s integrating images from different departments into its solutions. In particular, at RSNA 2007 it announced the integration of bronchoscopy and gastrointestinal imaging with its PACS. (A year earlier, it demonstrated the inclusion of ENT images in this way.) “By using the PACS for storage, you’re not adding another silo to the hospital,” commented George Kovacs, director of product marketing. “The CIO is happy, because you’ve extended PACS to departments that weren’t able to benefit before from this kind of system. And the radiologists are happy, too, as they can see images from other departments.”

To better link various departments, and their generalists and specialists, McKesson is incorporating technologies such as unified communications into its solutions. You can build intelligence into such systems, says Kovacs. For example, “The system will know who the on-call radiologist is,” and will automatically route images to him or her.

As a work-in-progress, McKesson showed how giant touchscreens, which radiologists can use without a keyboard or a mouse, will be incorporated into hospitals. All of the necessary tools are at hand – such as PACS and the rest of the HIS – using high-res images and videoconferencing. A demonstration showed how a physician can quickly manipulate the various tools, all by tapping various points on the jumbo screen, without a keyboard or mouse. There’s quick connectivity to colleagues, including those who might be at home.

Philips, for its part, demonstrated similar technologies as part of its ‘Reading Room 20/20’ concept, also a work-in-progress. A whole pavilion was dedicated to demonstrating this concept, which included a giant, futuristic desk whose surface included multiple screens on the expansive, white surface. On a wall, a super-sized screen allowed for videoconferences with colleagues – who appeared as large as life.

Meanwhile, Agfa demonstrated new features in its upcoming IMPAX 6.4 release. One of the more interesting components: an ‘active target’ feature for CT and MR navigation, in which the radiologist can target a location on one plane, and also view the corresponding anatomy in other planes. For example, you can pinpoint a spot in the kidney whilst peering at a coronal view, and the software will automatically link to and display the same location in the axial and sagittal views. If no corresponding location is available in a co-planar series, the series will darken and inform the user by means of overlaid text.

The company also showed its virtual colonoscopy software, which offers ‘one-click’ reconstructions and simple structured report creation, which can include images. “You don’t have to wait for techs to do the reconstructions,” commented Dave Wilson, marketing director.

As a work-in-progress, the company demonstrated an application called ‘registration fusion’, in which exams from different modalities such as CT, MR and PET can be overlaid on each other, with differences in anatomy highlighted for the user. The software enables comparison of functioning tissue to anatomical structures, for easier identification of pathology.

Agfa also showed its ‘radiologist dashboard’, which pipes patient data from other departments onto the radiologist’s workstation. The information can include vital signs, pathology and lab data, pharmacy and medications, and others, all in real-time. “We want to give radiologists the tools and information they need without requiring them to move anywhere else, or to rely one anyone else,” commented Jason Knox, product manager. That access to information can be particularly important when the radiologist needs answers and his or her colleagues aren’t available.

Data for the radiologist dashboard may be obtained from any number of disparate sources within the hospital. Agfa has been refining this kind of multifarious integration through its alliance with MEDSEEK; together, the companies have been building large-scale physician portals for hospital corporations in Canada, tying together dozens of applications so that doctors can gain quick access to the information they need.

On the workflow front, Agfa has addressed the increasingly important critical test results management issue by integrating an automatic alerting application from Vocada into its PACS system. If a critical test result is found in an exam, the user can prioritize the alert, select the caregivers to notify, and generate an audio clip outlining their concern and care plan. Vocada will send a notification to the caregiver’s mobile device instructing them to contact the system to securely retrieve the message.

If there is no response within a defined timeframe, the issue can be escalated up a chain of command. “If an alert goes without a response, it can be programmed to go failover to the department chief, and after him, to the chief of medicine, for example,” commented Knox. Once the message is received, the alert creator is notified in order to close the loop. Importantly, there’s also an audit trail, so that managers can analyze patterns and see who isn’t responding to alerts over the long term.

“Radiologists can spend too much time trying to contact the referring physicians and often don’t know if the message was received,” said Knox. “This solution offers them a time-sensitive, secure way to manage these critical scenarios.”

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Project improves patient flow for UHN’s ED

By Patti Enright

TORONTO – Since implementing an Emergency Department Transformation Project, the University Health Network’s ED has seen a 20 percent reduction in length of stay for patients going home and an overall 6 percent reduction in length of stay. For patients being transferred to Alternate Level of Care (ALC) facilities, UHN has seen a 22 percent decrease in length of stay. As well, the number of discharges now happening before 11 am to ALC facilities has increased 73 percent.

The project began in March 2006, when the University Health Network (consisting of Princess Margaret, Toronto General and Toronto Western Hospitals) systematically set out to significantly improve patient flow from the Emergency Department (ED) to General Internal Medicine (GIM), as well as to the organization’s post-acute care partners. It was all in an effort to reduce wait times and improve access to UHN’s EDs.

More than 200 clinicians and multiple community partners collaborated with a project management team from Shared Information Management Services, the information management and technology department for UHN and 12 other healthcare organizations in the Greater Toronto Area.

The result was the creation of a framework that ensures care is well coordinated and standardized from admission to discharge across the three hospital sites.

The ED-GIM Transformation Project consisted of two parts:

• Designing, developing and implementing process improvements to enhance patient flow;

• Knowledge transfer between and to other hospitals.

A team comprised of various clinical leaders from both Toronto General and Toronto Western Hospitals, as well as SIMS project management experts, industrial engineers, academics and data analysts, were charged with designing, developing, implementing and evaluating an array of improvement initiatives divided amongst six themes:

• Care Coordination

• Care Model

• Workflow

• Work Environment

• Team Renewal

• Communication of Information

Results that were achieved include:


Coordination with community care

• Problem: GIM staff were not fully aware of the most appropriate or available community services. This caused delays in potential patient discharges, and referrals without adequate planning.

• Solution: Working in collaboration with Bridgepoint Health, a major provider of complex continuing care, the group implemented an on-site Bridgepoint Health Assessment Team at UHN. The team attended patient care rounds on UHN’s GIM floor, identifying patients who may be appropriate for Bridgepoint rehabilitation services or continuing care.

• Results: An integrated discharge planning process enabling earlier discharges through patient prioritization and planning, ultimately expediting patient flow. To date, there has been a 160 percent increase in patients being transferred from UHN to Bridgepoint.


Allied health team alignment

• Problem: Physicians working in the ED and GIM units were aligned by team, whereas Allied Health (AH) staff were located geographically by floor. As the AH staff would regularly rotate floors, this arrangement required them to interact with multiple physicians. Communication between the two groups was difficult, due to the lack of a consistent team structure.

• Solution: Align AH staff with the physician-based teams.

• Results: Enhanced communication increased patient and staff satisfaction. There was an 18 percent decrease in ALC patient days (i.e., patients no longer requiring acute care) and a 68 percent decrease in time between AH referral to patient discharge, due to the gained efficiencies in the new team alignment structure.


Workflow: ED Acute – Staff Assignments

• Problem: There were no standards defining which nurses were assigned to various patients.

• Solution: Nurses were assigned to rooms close to one another. There is a redesigned patient chart to incorporate visual controls, so that action is prompted in an appropriate timeframe. Finally, there is an established process for bed cleaning to improve the turnaround time.

• Results: 57 percent decrease in time to prepare for the next patient, 59 percent decrease in time required for initial RN review of a patient chart (i.e., from 27 minutes to 11 minutes) and 63 percent reduction in RN travel time.


ED work environment

• Problem: Prior to the project, up to 21 percent of a nurse’s time (about one full day every two weeks) was spent searching for equipment and supplies, coping with equipment breakdown and using supply carts that were not stocked consistently.

• Solution: Using an approach from the car company Toyota that emphasizes working together to improve the environment, staff sorted, de-cluttered and organized their environment so that less time is spent searching for and/or repairing equipment.

• Results: 72 percent decrease in time searching for equipment/supplies in the Toronto General Hospital’s ED and 44 percent reduction in Toronto Western Hospital’s ED.


Communication of information: Electronic IP whiteboard

• Problem: Relevant information was not being shared with appropriate staff due to the large number of different data sources. In addition, some information was lost or not documented, causing communication gaps among staff.

• Solution: Working with SIMS technical specialists, the group implemented a centralized electronic whiteboard, allowing interdisciplinary information to be inputted and displayed on a large monitor near the ED’s nursing station.

• Results: The electronic inpatient whiteboard serves as a centralized communication tool, capturing and displaying information such as a patient’s estimated discharge date in real-time. ED staff report improved interdisciplinary communication, continuity of care, improved discharge planning and reduced time searching for patient information.

For more information on the project, visit the toolkit at www.patientflowtoolkit.ca.

Patti Enright is a Communications Specialist with Shared Information Management Services (SIMS), of which the UHN is a member.

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When expanding, hospitals are putting thought into ‘smart’ designs

By Neil Versel

It has been widely documented that patient handoffs and transfers are chronic sources of medical errors, but reducing these weak spots in a large hospital likely requires a comprehensive redesign of workflow. The construction of a new facility or major renovation of existing space provides just the opportunity some innovative institutions have been looking for.

While it might be hard to picture a 150-year-old institution as an innovator, leave it to venerable Brigham and Women’s Hospital in Boston to rethink the idea of a centre of excellence.

The Harvard teaching hospital needed more inpatient beds for cardiac care, as well as an overhaul of its surgical and imaging areas, so it decided to create a cardiovascular centre in order to maintain competitiveness in a cutthroat marketplace.

A “major philosophical and cultural question” was whether this was to be a free-standing heart hospital or a true part of the BWH campus, according to executive vice president and chief operations officer Kate Walsh. “This serves as a core component of the Brigham and Women’s Hospital integrated campus,” Walsh says. “It is not a heart hospital next door.”

The space also had to be acuity-adaptable to reduce handoffs, and had to support innovation and translational research. Thus, cardiovascular imaging was located in this new building, scheduled to open in the spring, and each new inpatient room can convert to intensive care if necessary.

“This is a big change for our staff,” Walsh explained at the 2007 Healthcare Facilities Symposium, a meeting of architects, engineers and healthcare executives held in Chicago.

It was a big change for everyone, actually.

Construction of Shapiro Cardiovascular Center gave the hospital the chance to improve the traffic flow inside the facility, grouping like services together and, significantly reducing the number of potential handoff points. “We build spaces all the time but we don’t always consider patient flow through those spaces,” Walsh says.

For the architects, it was a challenge to develop a 120,000-square-foot space before the service line was fully developed, on a campus that has evolved over a century and a half. “We worked very diligently to keep the zones pure,” says André Aoun, a principal of Cannon Design, the architecture firm that designed Shapiro.

For Walsh, part of the plan was about “way finding,” such as how to get a patient from the emergency department to the cardiac catheterization lab. Under an early plan, this path went through the waiting room for radiation oncology, already a highly stressful area for patients. The final design has three distinct connections across Francis Street from the main hospital: a sky bridge for the public, an underground route for patients and a lower passage for service operations.

The new building will have the hospital’s self-developed electronic medical records, even though cardiology isn’t fully up on the system. Hospital leadership did not want to move paper charts over from the old facility, but they did include space for paper just in case I.T. was not ready.

During the design phase, BWH held a technology summit. Walsh says staff wanted help integrating technology they already had, rather than scramble to learn new systems during and after the move. “We are testing new things like wireless [connectivity] and flat screens in the old space first to encourage integration,” she says. “I.T. needs to be involved sooner rather than later.”

All of this planning and integration is so that BWH can further its goal of multidisciplinary, patient and family-centred care. As Walsh puts it, what happens when a family member isn’t just a visitor, but is in the room during a code?

Other forward-looking institutions are heading in a similar direction.

At Grey Nuns Community Hospital in Edmonton, family-centred care is the mantra for the consolidation of women’s health programs. “A key principle is that women need to be cared for in the context of their families,” says Gail Cameron, patient care manager for postpartum care, the intermediate care nursery and pediatrics at regional health authority Capital Health.

In renovating the third floor to handle an explosion of births and to put all women’s programs on a single floor, the hospital is adding five new labour and delivery rooms (LDRs) to the existing seven, and re-allocating other space. The project also seeks to improve safety by reducing patient handoffs and movement – and by mitigating other risks.

There’s a direct, secure, non-public link from labour and delivery to the neonatal intensive care unit (NICU). The LDR area includes a combination of single rooms and pods, plus quiet areas to minimize noise transfer between rooms. Family lounges are situated to provide security, acoustic control and infection control, as well as comfort, according to Robin Snell, vice president of lead designer Parkin Architects.

The majority of mechanical services run through the corridor of quiet zones, and there is a single penetration of electrical and HVAC lines into each zone to reduce infection risk. A goal of this redesign is to incorporate only technology that does not separate the baby from the family, unless absolutely necessary, such as in the neonatal ICU. “There are no newborn nurseries in this new design,” says Cameron.

The NICU will have day-night light patterns to promote regular sleep, and noise will be minimized to help detect problems as they occur.

In non-critical postpartum areas, there are plans for 24-hour access to food for mother and newborn. Their families will have menu service in café-style waiting rooms, including Second Cup coffee. There will be a cyber café as well, for educational as well as entertainment purposes.

Overhead paging is being eliminated from the nursery. Instead, staff will carry pagers or cell phones. For further quiet, the hospital has installed a two-stage fire alarm, with the first stage visual, all in the name of patient comfort.

Even though the new space won’t be fully ready until winter 2009, the hospital already has set up a social committee to help integrate new hires, a change team to serve as liaison between staff and management, and an equipment team to select medical devices, monitors and communication systems, including I.T.

When it comes to comfort, flexibility and adaptability, few recent projects can compare to the Richard M. Ross Heart Hospital at the Ohio State University Medical Center, which opened in Columbus in late 2004. “We’re a very technologically friendly building,” administrative director Richard B. Davis says matter-of-factly.

The entire medical campus now is unified, and a fleet of 42 robots roams the hallways, passing out meals and fresh linens, restocking supplies, removing trash and generally doing the work of 200 full-time staffers.

Within Ross, rooms are standardized on all inpatient floors and adaptable to varying levels of acuity. Nursing stations are decentralized. Curved hallways in D-shaped inpatient wards minimize the steps that nurses have to take, and the corridors are uncluttered.

Ross has what Davis calls a “high-tech floor,” which can support equipment as heavy as 14 tonnes, and provides easy access from outside to a wide, main hallway for delivery of future technology. Installation of a Stereotaxis catheter took just 2½ months, beating the vendor’s previous best by 6 weeks, according to Davis. Typical installation time is six months.

A single cardiologist can cover five stress tests simultaneously and still monitor catheterization across the hall.

Nursing documentation and electronic medication administration are done at the bedside with a Clinicomp EMR, though OSU is entertaining bids for a new inpatient system. “What we wanted to do is untether the nurse from a centralized nursing station,” Brown says. There is a nursing support area behind the scenes for charting when the patient might need a little more privacy to recover.

Davis says patient satisfaction is 84.2 percent in Ross, compared to 76.8 percent across the University Health System. “We didn’t distinguish ourselves when we were just two floors in the main building,” he says. Faculty and staff satisfaction also is higher, and nursing turnover was a minuscule 2 percent in 2006 and 4 percent for the first nine months of 2007.

It’s hard to argue with numbers like that.

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Technology assessment unit helps hospitals make informed decisions

By Andy Shaw

To paraphrase Gilbert and Sullivan, James Brophy is the very model of a modern healthcare technology assessor. Dr. Brophy, a practicing cardiologist with both an engineering degree and a PhD in epidemiology behind him, is the director of a joint effort by two of Canada’s largest university hospitals in Montreal to rigorously evaluate any healthcare technology that’s being considered for use.

Since 2001, as the founding head of a shared Health Technology Assessment Unit (TAU), the bilingual Brophy has been easily crossing cultural and linguistic differences between the mostly-English McGill University Health Centre (MUHC) and the mostly-French speaking Centre Hospitalier de l’Université de Montréal (CHUM).

As such, Dr. Brophy and his team conduct evaluations and make recommendations based on painstaking research to their respective decision-makers about what healthcare technology to buy and what not to buy – be it a piece of hardware, a process, or even a drug.

“What we do is separate the wheat from the chaff,” says the no-nonsense Dr. Brophy. “Some technology that appears can seem very exciting, but often it is based just on hype. Some of it, on the other hand is really good stuff. And that’s what you want to make sure you are spending your dollars on.”

Early on in his tech assessor existence, Dr. Brophy concluded that the OACIS electronic medical record (EMR) system was very good stuff. The open, interoperable nature of OACIS with its fully configurable clinical data repository at its core, made it ideally adaptable to the quite different cultures of MUHC and CHUM. A joint OACIS project team continues to adapt and extend the reach of the EMR at both hospitals.

With nearly 30 assessments of various technologies behind them, Dr. Brophy and and his TAU team now includes two full time researchers and several part-timers who collectively have medical, engineering, and economic expertise. Together they field requests from both CHUM and MUHC departments and these days are putting newer, mostly clinical technologies under the microscope.

“There are two elements in our process,” explains Dr. Brophy. “One is to review the literature on all the evidence that is out there and ask: What is that evidence telling us about that particular technology’s safety, and about its effectiveness versus its cost? That’s the evaluation element. The second element goes beyond the evaluation and makes a recommendation as to what the two hospitals should be doing, or not doing, with this technology.”

Brophy is quick to point out, however, that he and TAU are not treated as oracles.

“We know that not everyone is going to share our opinion, so we make our recommendations to a special executive committee that represents both hospitals,” says Dr. Brophy. “On that committee sit reps from administration, from nursing, from the doctors, from the pharmacists, from other allied health workers, and it also includes a patient representative. There are seven people from MUHC and seven from CHUM.”

The committee then debates the recommendation, and can alter it before passing it on to the director general of each hospital.

“Sometimes we will present reasons we see for adopting and not adopting the technology, so there can be an informed debate,” says Dr. Brophy. “There may be good clinical reasons for adopting it, but administrative or cost reasons for not.”

In almost all of their work, Dr. Brophy’s unit involves an interested clinician right from outset.

“The epidemiologist or cardiologist or whoever the clinician may be, is going to be aware of the nuances of their speciality that the technology may affect. And if we end up recommending adoption of the technology, it’s going to make buying in by the executive committee much easier, since the clinician has been involved from the start,” he says.

Currently, the TAU is examining the worth of technologies connected with:

• Patient wait times at MUHC and CHUM

• Neuromodulation to control urinary and fecal incontinence

Followed likely by:

• Non-invasive cardiac valve replacement

• Natriuretic peptide testing for excessive sodium in breathless emergency patients.

Typical of TAU assessments (submitted in English and French) are the following:

The use of image-free computer-assisted systems in total knee replacement surgeries (March 2007) – Recommendation: “There is no convincing evidence that demonstrates improved clinical outcomes with the computer assisted navigation systems in total knee replacement surgery. However, expert opinion believes that this technology is likely to decrease malalignment in some patients. For this reason it is recommended that funding for a limited number of cases (Max. 40) annually should be approved for use in patients at the highest risk of malalignment. This will also allow the MUHC and the CHUM to fulfill their role as educational institutions.”

Spinal Monitoring: Use of Intraoperative Neurophysiological Monitoring During Spinal Surgery (July 2005) – Conclusion: “There is good evidence to support the conclusion that intraoperative spinal monitoring during surgical procedures that involve risk of spinal cord injury is an effective procedure that is capable of substantially diminishing this risk.

“In the absence of any precise estimates it is reasonable, for the purpose of this decision, to assume that an expenditure of approximately $46,000 per year (or $460 per patient) might prevent one patient suffering serious permanent spinal cord injury and less serious complications or sequelae in approximately 2 other patients. Even if the cost of maintaining such patients is excluded, this is a highly acceptable cost to benefit ratio.”

Dr. Brophy offers several cautions about such conclusions and recommendations found in his reports.

“First, we could be viewed as a barrier to technology uptake, but we are not. Indeed, I think if you broke down all our assessments, so far you’d find that for about one-third of them we said, no we don’t think this (technology) gives you good bang for your buck, another third we said, yes we’ll get considerable health benefits out of it at an acceptable cost and it should therefore be adopted. And about a third we said, maybe for targeted kinds of patients this would be a useful addition,” says Dr. Brophy. “Also it’s important to note that we are not a decision-making body. We’re simply here to improve decision-making and help ensure we are getting value for our money.”

Note: All of the TAU’s reports are available online at http://www.mcgill.ca/tau/publications/

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