Radiologists search for ways to put patient, not image, at the centre of care
CHICAGO – At the most recent Radiological Society of North America conference, held in November, the talk was of putting ‘Patients First’. In fact, that was the theme of the conference, but it could be a difficult change of mindset when physicians are used to being put on pedestals in hospitals and worshiped as demi-gods.
For radiologists, it means moving out of the reading rooms and getting back in touch with patients – of humanizing the relationship with the sick. Not only are patients asking for respect and better care, but in the United States, Medicare reimbursement rates will be tied to patient satisfaction starting this year.
In Canada, patient satisfaction – or dissatisfaction – is a quick measure of the overall quality and efficiency of hospitals and clinics. When large numbers of patients are griping, it’s a pretty clear indication that things are not working as they should.
To address issues of quality and patient satisfaction, forward-looking radiology departments and companies are busy developing solutions. A major step forward is the rise of image-enabled Personal Health Records, which essentially offer patients quick access to their own diagnostic images and reports.
The idea is to make it easier for patients to share pictures and reports with their many care-givers. Too often, patients are asked to retrieve their images on CDs at hospitals, a task that eats up hours of their time, not to mention the money needed for the hospital parking lot. Even after obtaining the CDs, the disks can be lost and new ones are soon needed for the next hospital visit.
For its part, Carestream Health, based in Rochester, N.Y., announced MyVue, a cloud-based solution for radiology departments that enables patients to access exam images, anytime, anywhere.
The company recently offered MyVue to 3,000 patients at Houston Medical Imaging, a chain of three out-patient imaging centres in Houston, Tex., and 1,500 of them signed up. Patients were able to download images and reports and forward them to their physicians, saving them a lot of time and trouble.
“They found it easy to use,” said Bob Hamilton, general manager of Carestream Health Canada. “Out of the 1,500 patients, there were only 47 calls to the IT department,” most of which were for password resets and not because of difficulties with the portal. Hamilton noted the actual cost of making CDs for patients at hospitals and hospitals can run to $60,000 to $70,000 a year, when you factor in staff time for duplicating the disks, the equipment and the couriers that are sometimes used to send them.
That money can be saved by allowing patients to access their own images. Hamilton said the solution would make a good deal of sense for Canadian hospitals, which also spend time and money on making CDs for patients.
What’s more, if physicians can’t readily access previous exams, they often order new ones; it’s estimated that up to 30 percent of radiological exams are medically unnecessary. If patients can quickly obtain previous exam images for their doctors, repeat exams would likely be reduced, and the savings to the system could be significant.
To this end, the RSNA itself launched its own Image Share network in 2011, which enables patients to access their diagnostic images at five participating hospitals. This year, the RSNA announced it has received $5.3 million over two years to expand the system. The money comes from the National Institute of Biomedical Imaging and Bioengineering and there is an optional $5.5 million for an additional two years.
According to the RSNA, there is interest from 20 more hospitals to join the network. The idea behind the project is to make it much easier for patients to share their medical images with caregivers. This should reduce the number of redundant exams that are ordered by physicians, which will in turn reduce health costs and X-ray exposure to patients.
The Image Share network currently includes five sites: Mayo Clinic in Rochester, Minn., the Mount Sinai Medical Center in New York, the University of California – San Francisco, University of Chicago Medical Center, and University of Maryland Medical Center in Baltimore. The network has been used by more than 2,000 patients since it began operation in 2011.
Expect to see more PHR solutions of this type as patients push for more control of their records, and radiologists and hospital managers see image-sharing with patients as something that actually improves their workflow. In Canada, the solution may also obtain the blessing of provincial governments, who foot the bills for unnecessary exams.
What were other highlights of RSNA 2012? Here are some of them:
Ultrasound: Siemens Healthcare showed its wireless ultrasound system, called the Acuson Freestyle. There is no cable joining the transducer and the workstation – which is a world-first, according to Siemens. “It’s a monumental task to get rid of the cable,” commented Joe Urbano, a Siemens ultrasound developer and a member of the team that devised the Freestyle. “The front end has been shrunken and encapsulated in the probe.”
It took six-and-a-half years to produce the innovation, which involves breakthroughs in acoustics, batteries, radio design, miniaturization and image processing. One of the biggest challenges was in producing a wireless probe with enough computer processing power, but which requires relatively little energy and doesn’t drain the battery. “It uses less than four watts,” said Urbano.
The system is being aimed at interventional and operating room procedures, where ultrasound is extremely useful but cables dangling from the transducer heads are cumbersome and a source of potential infection. Immediate applications are for line placements, drainage procedures, cysts and nerve blocks.
Urbano noted the system is currently being tested at more than 20 beta sites. It will be offered commercially in the near future, and additional types of transducer heads will be developed. “This will be a whole platform,” he commented. Currently, three wireless transducers are available, with applications for general imaging, vascular and musculoskeletal and nerve imaging.
For its part, GE Healthcare had its own ultrasound news to announce at the RSNA meeting. The company in November 2012 acquired U-Systems Inc., of Sunnyvale, Calif., which has produced a flat-panel, 3D ultrasound technology capable of detecting cancers – quickly and without physical discomfort – in women with dense breasts. The system, called the somo• v Automated Breast Ultrasound (ABUS) has been approved in the U.S. as an adjunct to mammography, and is also available in Canada.
According to a study in the New England Journal of Medicine, women with dense tissue in 75 percent or more of the breast have a risk of breast cancer four to six times as great as women with little or no dense tissue. Since dense breast tissue decreases mammography’s effectiveness in detection, the somo• v ABUS has proven to be a tremendous advancement in the visualization of cancer-hiding tissue in dense breasts.
Recent studies showed the somo• v ABUS found 30 percent more cancers in women who have had a normal mammogram, normal physical examination and dense breasts.
The somo• v ABUS can conduct the exam in 10 minutes for both breasts, compared with the 45 minutes required using traditional ultrasound. What’s more, the system is automated, meaning it is operator independent and doesn’t require a highly skilled technologist.
While MRI is still the gold standard for breast cancer detection, MRI is much more expensive than ultrasound and requires much more time for an exam. In Canada, the somo• v ABUS is available for about $250,000.
X-ray dose: In recent years, the need to reduce the X-ray doses given to patients has been top-of-mind for radiologists and technologists. The industry continues to innovate to bring radiation doses to a minimum, while maximizing the effectiveness of their equipment.
For its part, Toshiba Medical announced a clever way of doing this in its fluoroscopy system.
Called Spot Fluoro, a work-in-progress, the system allows the operator to collimate (focus down) on an area of interest, such as where a stent or coil is being placed. This area takes up a small portion of the display screen. Meanwhile, the operator can still see a large area of the patient’s anatomy, as the system has captured a ‘freeze-frame’ and displays it simultaneously. The live radiation, however, is only being focused on the small area of interest.
“You’re saving the patient from receiving a lot of radiation,” commented John Morra, who works as a senior clinical consultant for Toshiba Medical of Canada.
He explained that in any procedure where you fluoro for a long time, the patient will get a lot of radiation. Toshiba has produced a second innovation that helps monitor the dose – letting the radiologist or technologist know that it’s time to stop or to move the beam. It’s a work-in-progress called the Visual Tracking System, and it presents a striking visual chart on a screen, using colour bars in real-time, to alert the operator that radiation limits are being reached.
“When it hits the red, you should adjust the C-arm and image in a different position,” said Morra. “It’s especially important in pediatrics, where the patients are very sensitive to radiation.”
Several companies have recently emerged with applications that chart the radiation patients are receiving over a period of time. Radimetrics, of Toronto, made waves in recent years with its breakthrough software in this area. Using the system, you can monitor the amount of radiation a patient is accumulating, from a variety of modalities and even in different hospitals. You can also check to see if various machines are emitting too much radiation, or if radiologists and technologists are ordering too many exams or use protocols that involve too much radiation. There’s feedback in all of this, too, as you can reduce the exams given to patients who seem to be receiving too much radiation. You can also inform radiologists and technologists that their orders and protocols could be improved.
To the surprise of many, it was announced during the RSNA meeting that Bayer had purchased Radimetrics for an undisclosed amount, and was making a bigger push into the diagnostic imaging marketplace.
Meanwhile, Agfa announced that it has produced a similar product, a system that monitors the radiation dose produced by equipment and accumulated by patients through multiple exams. The system also makes use of algorithms that account for the age of patients, the organs being imaged, and other factors, to determine whether dosing thresholds are being exceeded.
The Agfa solution, which was devised in Canada and will be sold worldwide, is currently being tested by the Queen Elizabeth Hospital, part of Capital Health in Halifax. Having such a system provides care-givers with analytical tools.
“The idea is to have an enterprise-wide record of patient exposures,” said Andy Hind, vice president at Agfa Canada. “It allows you to ask whether a patient should have another scan, and to compare radiation exposure at different hospitals. You start asking, why is CT exposure at one hospital higher than at another?”
Additionally, by comparing doses and the effectiveness of exam results, “You can develop standards,” said Hind. “You can determine, for example, what the dose should be for a head and neck scan.” In this way, protocols can be standardized across an organization, to optimize the dose so that results are maximized and X-ray exposure to the patient is minimized.
Computed Tomography: At the same time, technology developers continue to drive down the dose emitted by their equipment while further improving their imaging abilities. A case in point is Toshiba, which announced its most advanced CT system – the Aquilion ONE Vision Edition. According to the company, it offers the largest bore [opening] and the thinnest slices on the market.
The new machine boasts a gantry rotation of 0.275 seconds and 320 detector rows that cover 16 centimetres in a single rotation. Each image slice is only 500 microns. Due to the wide bore and fast rotation, the Aquilion ONE Vision Edition can accommodate the heaviest of patients and those with high heart rates.
The system also sports Toshiba’s third-generation dose reconstruction software, AIDR 3D, which is said to incorporate improved imaging while reducing the X-ray exposure to patients. “We’re now dealing with microSieverts of radiation, not milliSieverts,” commented David McDougall, CT product manager, Toshiba of Canada. “We’re getting close to the radiation level of a chest X-ray.”
As well, the fast imaging is ideal for cardiac exams, as it can capture the entire heart in one beat, thereby reducing the blurring that occurs from the motion of the heart.
The new Aquilion ViSION is scheduled for installation at the University Health Network in Toronto in early 2013, in association with a research agreement. The Aquilion ONE, which is also a 16 cm 4D Volume CT, is installed at 19 sites across Canada.
One of these installs, noted McDougall, is in Corner Brook, Newfoundland and Labrador, where it enables physicians to conduct top-flight exams without sending patients to larger centres, such as St. John’s or Halifax.
Toshiba Medical Systems also offers the Aquilion Prime, a scanner with an 80 detector row that’s capable of producing 160 slices per rotation – an effective technology for community hospitals. The first installation in Canada, said McDougall, went into Cowansville, Que., in February 2012; and during the RSNA conference in November, an Aquilion Prime went live at the Collingwood General and Marine Hospital, in Collingwood, Ont., while another was being installed in Dunnville, Ont., at the Haldimand War Memorial Hospital.
“Collingwood went from an old four-slice machine to the new 160-slice, Aquilion Prime,” said McDougall. “They wanted a scanner capable of a range of exams, including trauma, bariatric work and pediatrics.” It’s an impressive jump in capabilities, and it’s made possible by changes in pricing and shifts in medical practice.
MRI: GE Healthcare raised the eyebrows of many with a new MRI technology called Silent Scan. It addresses a major problem in most MRI exams – the horrendous noise. In fact, MRI scans are typically as loud as a jetliner or rock concert, and it’s difficult for many patients to remain still for four to five minutes while in the closed, noisy MRI tunnel. “An anxious patient can be alarmed, forcing you to conduct the exam all over again,” commented Baldev Ahluwalia, premium segment manager, global MR business at GE.
In contrast, the Silent Scan technology, which is currently awaiting approval by the FDA in the United States, counteracts the noise and creates a near-silent environment. And the technology adds only 20 seconds to the duration of an exam, said Ahluwalia.
GE Healthcare said that traditional forms of noise mitigation in MR systems have focused on muffling the sound made by the scanners. This new approach treats the sound at its source, using high-fidelity gradients, ultra-fast radio frequency technology and an improved 3D reconstruction technique called Silenz.
For its part, Philips was touting its No. 1 MRI rating in a recent KLAS report. In particular, Philips was showcasing its SmartPath to dstream technology, a digital solution that boosts the signal-to-noise ratio by up to 40 percent.
As well, the company is claiming that recent workflow improvements are resulting in up to 30 percent increases in patient throughput – something that should be of interest to imaging centres that have wait lists for MRI.
A Philips spokesperson cited automation of processing and improved coil handling as two of the reasons for the throughput improvement.
On the cutting-edge of MRI research, Philips has been working with Yale University and Case Western Reserve University to determine which drugs would be most effectively used to treat breast cancers, based on the texture of the tumour. It has been found that sub-types of breast cancer can be identified through MRI images, and these sub-types respond best to certain medications. In this way, more effective therapies can be developed for women in the fight against breast cancer.
Molecular imaging: Siemens announced a breakthrough in the diagnosis of Alzheimer’s disease, with a solution that allows clinicians to determine the presence or absence of the disease in a living patient. It’s said to be the first time this can be done in a definitive way – other tools and assessments are all inconclusive when it comes to diagnosing Alzheimer’s in a living and breathing patient. Only an histological exam in a post-mortem could positively spot the presence of Alzheimer’s disease.
Now, however, Siemens has put together a three part solution that can even recognize early onset Alzheimer’s.
The system makes use of the company’s mCT PET scanner, for which it developed a special radiotracer. (It did this in alliance with the pharmaceutical giant Eli Lilly. That’s why Eli Lilly had a presence at the RSNA last year.)
Siemens vice president for molecular imaging, Alexander Zimmerman, noted that it’s one of the first radiotracers made to detect a specific disease. Because of the magnitude of Alzheimer’s, Siemens has established nine sites across the United States to produce the tracer, which has a half-life of 112 minutes. It’s planning on establishing an additional 16 manufacturing sites.
The F18 radiotracer is able to attach itself to the amyloid plaques that disrupt signals between neurons in the grey matter of the brain. It’s the presence of the plaques, detected by the high-sensitivity PET scanner, which enables clinicians to determine whether a patient has Alzheimer’s.
But Zimmerman points out that a third component of the solution has been devised to effectively make the assessment – it’s software that assesses six zones of the brain and determines whether plaques are in the grey or white matter. Buildups in the white matter are normal, but amyloid plaques among the grey cells are a serious problem. The software, devised in conjunction with clinical experts, can help physicians make a definitive diagnosis.
Zimmerman said this is an important step, as “one out of five people diagnosed with Alzheimer’s do not actually have it.” The 80 percent with other forms of dementia can be treated, he asserted, while those with Alzheimer’s cannot.
This can lead to a change of medications for those without Alzheimer’s, said Zimmerman. For those with the disease, there is the chance to get one’s affair in order. That could involve spending more quality time with loved ones, seeing the world, and setting up the resources to deal with later stages of dementia.
It could also include enrolling in clinical trials of new medications. While many see a diagnosis of Alzheimer’s as a death sentence, there has been an explosion of research of late and new treatments are on the horizon. Additionally, the United States launched a $156 million National Alzheimer’s Plan last year to tackle the disease, which is also energizing the field. Effective treatments may yet appear.
Direct radiography and PACS: In the area of direct radiology, Canadian innovator Imaging Dynamics Corp., has been going through various management changes in recent years but is still keeping its hat in the ring. In particular, the Calgary-based company has been lauded for the quality of its software, called Magellan. It recently won a $30 million order from China for CCD technology and flat panels, and IDC has also been working with international health groups on the eradication of TB worldwide.
Interestingly, the company is now selling a mobile X-ray unit using hardware that is manufactured in Italy; IDC has added elements of its own Magellan software.
Other companies announced DR panels, including Rayence of South Korea, which is selling new and innovative panels through Canadian distributor Nuon, of Edmonton.
Nuon, headed by Mark Little, is also leading the charge to expand the of PACS and enterprise imaging solutions from Visage Imaging, of San Diego, into Canada. Visage Imaging is a subsidiary of Pro Medicus, of Australia; the company already has several installations in Canada, and the plan is to capture additional sites by showing Canadian users its combination of attractive price and advanced features – including fast access to all types of studies using thin-client technology. The solution, Visage 7, is said to offer access to radiological studies and information in multiple locations, without replicating the data.
Hamilton hospitals to monitor DI quality
Radiology and nuclear medicine specialists in Hamilton, Ontario will participate in a pilot project, starting in February, to check the quality of their reporting in real time, one of the first such pro-active, cross-institutional quality assurance initiatives in Canada.
Hamilton Health Sciences (HHS) and St. Joseph’s Healthcare Hamilton (SJHH), which have an integrated diagnostic services department, are running the project with software from Real Time Medical, a Toronto-based developer of solutions for the management of diagnostic imaging workflow.
The Real Time system can route a radiologist’s report to another radiologist for a quality check – before it is transmitted to the referring physician. The peer review is done anonymously – neither the radiologist nor the reviewer knows the other’s identity.
The system is primarily designed to help radiologists and nuclear medicine physicians identify and correct any areas of potential improvement, while at the same time giving the patients the added safety of doing so in real time. A small but significant predetermined percentage of each radiologist reports are selected for review. When discrepancies are discovered, immediate action can be taken, and the correct results are then sent to the referring physician. As well, the system provides a real time educational opportunity in allowing the radiologist or nuclear medicine physician to identify areas of improvement and acquire additional knowledge.
HHS and SJHH are affiliated with McMaster University’s Faculty of Health Sciences. Together, they employ the hospital sector’s 60 radiologists and nuclear medicine physicians, although the pilot project will involve a smaller number of radiologists and nuclear medicine physicians initially.
“Our ultimate goal is to establish a city-wide Diagnostic Services physician quality assurance program that will contribute to and improve the quality of Hamilton’s medical and molecular imaging services,” says David Wormald, integrated assistant vice president, diagnostic services and medical diagnostic unit at HHS and SJHH.
While there is no consensus in the radiology literature, some studies suggest a typical “clinically significant discrepancy rate” of 3 percent to 5 percent, based on retrospective quality assurance checks, and while the Hamilton organizations lack data on their own error rate, Wormald says he has no reason to think it’s out of line with professional norms.
“That’s why setting up this project will allow us to have a better understanding around using a quality-based feedback system that would allow us to actually start to track and monitor” discrepancies, says Wormald.
When the pilot is completed at the beginning of May 2013, the results will be assessed with a view to a permanent program in Hamilton. Moreover, says Wormald, “It would help us inform a potential solution that could be used not only across our LHIN (Local Health Integration Network) but potentially as a provincial solution.”
“We’ve had some early discussions with key stakeholders in government, and they’re very interested in our pilot and potential outcomes. We’ll be looking to present that to them,” he says.
If the outcomes are promising, HHS and SJHH may, by next autumn, issue a Request for Information (RFI) to canvas the marketplace for potential vendors and obtain a reading on price. Real Time Medical has provided its DiaShare software for the pilot.
Real Time Medical would have to tender alongside other suppliers in a Request for Proposal (RFP) process if a permanent quality assurance program is established. Wormald notes of the Real Time solution that “the product they’re offering is unique in the marketplace.”
Whereas other software may identify discrepancies retrospectively, DiaShare does so in real time. “The peer review system allows us to get prospective and timely feedback, so that if there is a discrepancy, it would be identified before the report is actually issued and could be corrected,” says Wormald.
Besides providing real-time quality assurance, DiaShare can “load balance” among radiologists. If there are, say, 100 exams waiting to be read, the system would allocate them among the available radiologists. It can send certain imaging exams to the radiologist best qualified to read them – e.g., infant X-rays to a pediatric radiologist.
If a radiologist is busy or behind schedule, their exams can be re-directed to a radiologist who is more available. That allows the reporting to be done quicker, which means that treatment of the patient can start sooner.
Ian Maynard, co-founder and CEO of Real Time Medical, notes that, historically, “the systems in place weren’t designed to address workflow issues, only data storage and display. A radiologist could be tied up in a complex case, and their in-box would fill up. Now, depending on the urgency of the other cases, the backlog could automatically be reassigned to another radiologist.”
He points out that the load balancing capability is itself a major contribution to quality reporting in radiology. “It’s often workload and fatigue that contribute to potential errors.” Several provinces have taken steps to address radiology discrepancy rates in recent years. “It’s a common issue anywhere radiology is practiced,” says Maynard.
In October 2009, New Brunswick’s Ministry of Health hired Real Time Medical to review all the reports of one radiologist since 2006. “We deployed 26 radiologists to review two years’ worth of examinations in three months,” recalls Maynard. The investigation, which involved 30,000 imaging examinations, found the radiologist’s discrepancy rate was about 16%.
In 2010, Real Time Medical was hired by health authorities in Newfoundland and Labrador to do a quality assurance review of four radiologists and about 5,200 cases.
In August 2012, B.C.’s Ministry of Health ordered an investigation of thousands of medical scans, including CT scans and ultrasounds, performed in B.C. hospitals after errors by three radiologists at separate facilities were discovered. The ministry announced on December 11th that it had selected Atlanta-based McKesson Corp.’s QICS software for a peer-review quality assurance system for the province’s radiologists. Real Time Medical was the second of two shortlisted vendors in the RFP process.
The Vancouver Island Health Authority (VIHA) will roll out McKesson’s software in the first phase of the program, which will involve 200 radiologists. Later, at full scale, the program will be the single largest cross-institutional initiative of its kind in North America.
“Conducting peer review of radiologist reports is challenging, particularly across distinct infrastructures, hospital systems and PACS [that] we have throughout our province,” says Dr. John Mathieson, the Authority’s medical director, medical imaging, in a news release. “[For] the first time we’ll have the ability to run a comprehensive, province-wide quality improvement process, and be able to make some valuable changes that will result in better reporting of imaging studies.”
Tele-trauma network provides expertise to many remote hospitals
By Sheldon Gordon
TORONTO – A first-of-its-kind tele-trauma project is enabling a small group of emergency experts to assist remote hospitals when patients come through their doors with serious trauma, including gunshot and knife wounds. The specialists may soon be equipped with iPads or other tablets that allow the viewing of patient images and videos wherever the physicians happen to be, and to provide advice and coaching at a distance.
Currently, the Toronto Trauma Telemedicine (3T) network enables emergency department specialists at St. Michael’s Hospital and Sunnybrook Health Sciences Centre in Toronto to connect via video-conference to five non-trauma hospitals in Ontario, providing remote support to physicians dealing with severe cases and expediting transport to a trauma centre.
The project was originally launched at St. Michael’s in 2010. Several trauma specialists initially were on call weekdays from 8 a.m. to 5 p.m. The Toronto Trauma Telemedicine coverage was expanded to 24/7 in October 2011 when Sunnybrook joined. There are now 10 trauma specialists participating.
“Any time we talk about this with another hospital that doesn’t do a lot of trauma, they say, ‘What a great idea, We’d like to have that support available to us when we deal with our trauma patients,’” says Dr. Christopher Hicks, trauma team leader at St. Michael’s and project lead for the 3T network.
The project started with three non-trauma hospitals participating, and an additional two hospitals were subsequently added. The referring hospitals are Peterborough Regional Health Centre, South Muskoka Memorial Hospital, Huntsville District Memorial Hospital, Humber River Regional Hospital (at two sites) and The Scarborough Hospital. Three more non-trauma hospitals are being prepped for early addition to the system, says Hicks.
The system was developed with input from the Ontario Telemedicine Network (OTN), and relies on desktop computers for the consulting MDs. The referring hospitals are equipped with “interns” – mobile terminals that can be moved to the patient’s bedside and have cameras that can be zoomed in and out remotely to show the patient’s injuries.
The trauma telemedicine idea is modeled on Ontario’s 10-year-old Tele-Stroke Program, which maintains a neurologist on call to provide advice on the treatment of all stroke patients in the province who have initially been brought to a hospital that lacks the expertise to administer clot-busting drugs. Like a
stroke, trauma is a very time-dependent condition, and early intervention is critical in the process to optimize outcomes.
“But trauma is still pretty rare and episodic at a lot of the sites,” says Hicks. The pilot project’s intake has been, on average, one or two cases a week over the past year, he says. That patient load may rise in 2013 if the three additional non-trauma hospitals come onboard.
There haven’t been enough cases yet to permit an evaluation of outcomes. A study, however, is being done to examine whether the project improves transport times between non-trauma and trauma centres. (Transfer from a northern Ontario hospital to a trauma centre has been subject to long wait times, taking from six to 11 hours.)
“If the network were used in the care of all trauma patients,” says Hicks, “it would have a potential role for keeping more of them where they are” – at the non-trauma facilities – instead of being transferred. As it is, the project was designed to accept mostly critically ill patients who require transport.
“We wanted to get patients with multi-system injuries,” says Hicks. “Our numbers are skewed toward penetrating traumas, e.g., stab wounds and gunshot wounds, because that’s the sort of injury that a lot of non-trauma hospitals are just not that familiar with.” (In contrast, the majority of trauma patients in Ontario have suffered blunt trauma, mainly from vehicular accidents.)
“There have been a few cases where I’ve really seen the value of having a video image over just a phone conversation” with the referring physician, says Hicks. “When you’re just talking on the phone, you’re a bit at the mercy of what the person tells you and what you remember to ask. When you’re looking remotely at the patient, you get a lot more information, judging how severe their injuries really are.”
Whereas with the old system of transport, the receiving hospital would call for the trauma patient to be transferred later in the process, “we’re encouraging the hospital to call us right at the beginning of the patient-care encounter,” says Hicks. “That allows us to intervene early and help make decisions on transport early. It helps unclog their [ER] departments, too.”
In one case, a patient received at a non-trauma hospital had a stab wound to the chest. Hicks, using the high-speed video link, could see that the wound extended to his diaphragm and belly. “I suspected that he might have an injury to his liver and intervened to say that the patient should be taken to a trauma centre for a CT scan. We were able to speed up his time from mucking around at the referring site to getting him over here quickly.”
The 3T network hopes to introduce mobile devices for its consulting MDs early next year.
These will free the doctors from having to be tethered to work stations at the trauma centre (or sticking close to their home computers when on call.) We have already piloted a mobile version of the project with simulations using a computer-controlled mannequin of a patient,” says Hicks. “We’ve piloted on the iPad, and the images are fantastic.”
If the 3T network were extended to all of Ontario, all non-trauma hospitals would be equipped with telemedicine capability. A single trauma doctor would be on call for the province, providing real-time clinical support and assisting in transport decisions and management of regional trauma resources. But that province-wide coverage may happen only gradually, says Hicks.
“You have to have enough [patient] volume that it makes sense to ask a trauma specialist to sit home all night at their desktop computer when they’re not all that likely to get a call, more often than not. This is where the mobile devices come in. The technology is there. It’s a matter of getting OTN and the Ministry of Health to be comfortable with the notion of using video conferencing for patient care. ”
HSC creates time-saving electronic solution for post-partum unit
WINNIPEG – A homegrown system for automating the collection of critical patient information at the Health Sciences Centre has dramatically reduced the paperwork for nurses, freed up time for additional patient care at the bedside, and has provided patient safety benefits.
Heath Sciences Centre (HSC) is a large 750 bed tertiary teaching hospital which serves patients from Manitoba, Northwestern Ontario and Nunavut. It is currently implementing a Lean initiative to reduce costs, improve efficiency and increase patient safety.
Susan Harrison, manager of the Family Centred Mother and Baby Unit, a busy post partum unit, and Shauna Mason, clinical resource nurse, enrolled in the lean training being offered by HSC in November 2010 and immediately identified patient information gathering as the first lean project they would tackle.
At that point, the reporting system consisted of nursing staff collecting critical patient information on note paper. When they returned to the nursing station, they would hand copy data from their notes to a large whiteboard as a reference for other caregivers.
At change of shift, incoming nurses would copy patient data for their patient assignment on their own notepaper for their reference. At end of shift, they would again update the whiteboard. Additionally, selected information for all admitted patients was then transcribed to a summary report for use by the manager of the unit, the clinical resource nurse or charge nurse who needed it readily available while making rounds on the unit.
Obviously, there was a lot of manual data collection and transcribing, which is a less than ideal use of nursing resources. The more critical issue was the very real potential for transcription errors and/or omissions that could adversely affect patient safety.
Using their lean training, Harrison and Mason created a report which documented the problems and potential solutions.
The proposed solution was to purchase or develop a standalone database program into which staff would enter data. While potentially an improvement over the existing process, a lot of effort would still be required to enter patient names, their bed locations, and maintain the patient list when discharges occurred. There had to be a better way.
Harrison approached HSC’s Health Information Services department for help, where she learned that a similar project was already in progress. This other project had established a real time feed from the hospital Admissions, Discharge, Transfer (ADT) system, which would automatically populate the patient name and demographic information into a database. All that was required was to modify the existing program to collect the data elements that the Family Centred Mother and Baby Unit required.
Brett Wasny, from the decision support department of HSC and Michael Zhang from the Winnipeg Regional Health Authority (WRHA), were assigned to work with Harrison and Mason to turn this project from an idea to a reality.
Harrison and Mason worked with their staff to confirm and clarify the essential information that was needed for shift to shift reporting, as well as what was required for managers and charge nurses. This was sent to the design team, who built a prototype using MS Access to facilitate rapid development of the database application. Once the specifications were documented, they were handed over to Zhang and his computer science students from the University of Winnipeg to program a web based solution.
The staff met regularly to discuss the project and provided valuable feedback as the work progressed. Involving front line staff in a meaningful way during the design and development phases created buy-in and enthusiasm for the project, which was critical to maintaining momentum while the inevitable bugs were worked out.
The HSC Foundation provided a $5,000 grant, which allowed the team to pay the students a modest stipend for their work on creating this application. From the first meeting to go live took about 15 months.
The limited budget meant we were at the mercy of the availability our computer science students (who were doing the bulk of the programming). They took time from their studies and other commitments to work effectively for free, which we obviously appreciated, although a couple of them had the temerity to leave the project part way through to get real paying jobs!
Now, nurses can log into the system, quickly update information and generate patient list reports to use during their shifts. Less time recording data manually means more time at the bedside providing care. The manager/CRN are happy too, since they can print off summary reports for their reference when rounding with physicians and other health professionals.
This program has expanded to include interdisciplinary team members such a support staff (modified work sheets for their needs), to the social workers and nurses in the Breast Feeding Service seeing this patient population. Roughly 85 staff members are benefitting from the new system.
The breadth of the information captured electronically is impressive. In addition to basic demographic information like name, age, hometown, and attending physician and current bed location, nurses enter data about the mom’s allergies, information about the delivery (date/time, type of delivery), test results for RH, HIV, Hep B, Rubella, and they have a 500 character note field for more detailed descriptions.
For the babies, we collect gestational age, apgar score, birth weight and current weight (weight loss % is automatically calculated), feeding status, blood glucose and bilirubin levels, baby location (whether they are on the ward, NICU, etc) and a 500 character note field as well.
In short, this project has increased nurse productivity, improved patient safety, improved shift to shift communication on WRS3 and has laid the foundation for the development of other data collection and reporting systems at HSC. We estimate about 5-9 hours of nursing time is saved per shift, or about 1.8 eft worth of time that is freed up for more value added tasks. Moreover, the system eliminates the issue of handwriting legibility, which is an important patient safety concern.
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