Welland hospital begins ‘best practice’ breast cancer surgical treatment

By Patty Welychka

There are four words that strike terror in every woman’s heart. They occur when a doctor tells you, ‘you have breast cancer’.

What the physician can now also tell patients in Welland, Ont., is that there is a new, innovative method being used in a pilot program at the Welland County General Hospital that may be the best way of treating breast cancer the world has seen thus far.

Stereotactic biopsy and lymphatic mapping are on the cutting edge of breast cancer treatment and happening locally, thanks to the initiatives of many staff members at the Welland Hospital.

If a woman detects a suspicious lump in her breast, her family physician will most likely send her for a mammogram. If something shows up on the x-ray, a stereotactic biopsy can be taken right away.

The stereotactic instrument, new at the hospital here, attaches right to the mammography unit. In a very quick movement, five small needles take samples from the lump —- one from the centre and four from around the perimeter. Samples are then analyzed in the lab to ascertain whether or not a malignancy is present.

Dr. Peter Willard is spearheading lymphatic mapping in Welland. To say he’s excited would be an understatement.

It’s like this, really: lymph nodes drain the breast. When cancer cells are detected in the lymph nodes, a patient’s survival rate drops dramatically.

The standard procedure has been to remove the majority of axillary nodes. With lymphatic mapping, only the lymph nodes draining the site are sampled.

The use of radioactive material (a minute amount, Dr. Willard says) and a special blue dye can help surgeons locate these lymph nodes. By looking more closely at them, doctors can see subtle signs of cancer spread, which might otherwise go undetected. With the use of new technology, “a navigator probe” is used to identify which areas of tissue need to be further examined. This probe is used in the operating room as the surgeon carries out the procedure.

Dr. Willard says he became enthusiastic about the procedure approximately two years ago while taking courses in San Diego.

“We want to minimize the amount of pain people have. Our goal is not to cause pain, but to relieve disease,” Dr. Willard says. “With Sentinel lymph node biopsy, we remove the node that is draining the tumour and see if the disease is spreading. It is extremely exciting.”

The procedure has been performed on 17 patients in Welland over the last few months, the first in June of 1999. The trial entails 20 people. Dr. Willard has hopes the procedure will become a day surgery.

With complete axillary node dissection (removal of all the lymph nodes around the breast tissue) women can suffer nerve damage or lymphedema (the swelling of the arm). With lymphatic mapping, major motor nerves are not cut – critical for a positive healing. In fact, the ideal procedure only involves an incision that’s about an inch long.

“When you know exactly what you’re aiming for, there’s no tissue disturbance or major nerve cutting. The patient won’t need a drain and there will no longer be a need for home care services afterwards,” Dr. Willard adds.

The pre-op clinic consists of blood work, a chest x-ray and an electrocardiogram. Next comes the visit to the diagnostic imaging department, where the patient will receive an injection of a “weak” radioactive dye in about six areas around the breast.

A Gamma camera (also new at the hospital) will take pictures of the area and the radiologist will mark the sites on the woman’s skin. It’s crucial that the site of the injection be massaged vigorously for about 10-15 minutes.

Next day, in the operating room, the surgeon will inject a blue dye around the tumour site. The sentinel node will be removed, and then a radioactive detector probe will help find other lymph nodes that also need to be excised. The entire procedure takes about 45 minutes to an hour. Dr. Willard hopes to have that whittled down to about a half-hour.

Women should not be alarmed if they notice a blue-green colour in their urine afterwards (from the dye). This is normal and will not last long.

If women and their significant others tap into the Internet to try to find out more about lymphatic mapping, Dr. Willard suggests they discuss their findings with their physician. No one “polices” the information on the Internet and much of the information found there can be misinterpreted, if not discussed with an appropriate medical professional.

“As a young physician and being computer literate, I can appreciate the Internet. But many people talk as if what they find there is the gospel,” Dr. Willard says. “It allows people to see and read about different treatment options, but often people will believe their talk show host over their doctor. People shouldn’t take much of what they find on the Internet as sound medical advice”.

Dr. Willard is proud that lymphatic mapping is well on its way in Welland. “In some ways, we were able to start our program faster because there are fewer layers of bureaucracy,” he says.

One key to the successful implementation of the program was the use of clinical and patient pathways. Clinical Pathways were used to streamline communication between departments, provide consistency of information between care providers and used as an educational tool for staff in understanding a new surgical treatment.

The patient pathways were given to patients in the pre-surgical clinic. These pathways were expressed in laymen’s terms and explained the new procedure and what to expect as far as the new procedure itself, hospital stay, information about the Internet, home care visits and follow up protocols.

The Clinical Resource Management Program has undertaken the responsibility of keeping a formalized database for all patients having the procedure. Patient outcomes will be followed and monitored at certain intervals over a five-year period. This initiative will enable surgeons in our area to identify short and long-term outcomes for this particular patient procedure.

The Welland County General Hospital continually identifies opportunities for improvement. Lymphatic Mapping definitely has Welland on the leading edge of best practice treatments and protocols for patients in the community that we serve.

Patty Welychka is Co-ordinator of the Clinical Resource Management Program at the Welland County General Hospital. This story was written with files from Dianne Ujfallussy, Welland Tribune.

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Communication is the key to success in a high-quality, drug-checking system

By Andy Shaw

We don’t have a body count for Canada yet, but in the United States adverse drug events or medication errors are related to at least 48,000 deaths annually. Some estimates run as high as 180,000. Given the 10-to-1 population ratio usually used to equate statistics between our two countries, a reasonable guesstimate would still leave Canadians dying unnecessarily in the thousands each year from the wrong drug, or the wrong amount, administered at the wrong time, or to the wrong patient.

The latest technology and pharmaceutical dispensing systems are not by themselves a fail-safe against these sad numbers. Even in hospitals following sound unit-dose practices where nurses can only administer one pill at a time to a patient because automated dispensing machines meticulously label and package individual doses for individual patients, human eyes and hands must still keep careful watch. Every now and then, an individual’s package turns up with two different pills in it, with no pills in it, or with two different labels on it and must be plucked manually from distribution.

Still, there’s some impressive equipment out there already cutting down on those potentially fatal margins of error. At the Sunnybrook and Women’s College Hospital in north-end Toronto, a robotic arm in the pharmacy department has been selecting drugs from bar-coded bins more than a million times over without error. At the West Park Hospital in Toronto, Autros Hospital Systems Inc. of Toronto, is casting the last link in the country’s first end-to-end automated medication management system. For more than a year now, West Park, a long-term care facility, has had a wireless point of care system from Autros at work which links the nursing teams and hospital pharmacists at the patient’s bedside.

A pass by the nurse of a hand-held infra-red scanner over a patient’s wrist band, the bar-coded medication and the nurse’s own ID card just before the pill is popped, confirms that the right medication is being administered to the right patient at the right time and, just in case something does go wrong, by whom. Now, Autros has completed the chain by enabling physicians to make the order entry of the prescribed drug electronically.

“We know that 55 percent of medication errors come at the order-entry point. But doctors don’t have much patience when it comes to technology,” says Eric Paul, a former pharmacist and president of Autros. “So it took us a long time to design a piece of (order-entry) equipment that involved minimal key strokes and was very user friendly.”

Within six months, Paul says, Autros will have made its first foray into markets south of the border and installed similar doctor-friendly systems at five sites in the United States.

Michael Cohen will be very glad to see them.

Cohen is president of the Institute for Safe Medical Practices (ISMP), a nonprofit organization headquartered in Huntingdon Valley, Pennsylvania. At the annual Canadian Society of Hospital Pharmacists (CSHP) forum in Toronto in February, Cohen told a packed session how the misinterpretation of a physician’s hand-written drug order resulted in a 10-fold overdose and consequent death of a Denver infant.

“We made a study of that incident and found, as we so often do, that it really wasn’t the physician’s nor the administering nurse’s fault,” said Cohen. “We identified 54 separate events that if any one of them had occurred differently, the process would have been diverted and the child would not have died. But tragically not one did. And that’s the point. So often the media single out the doctor or the nurse but, in most cases, they are not to blame. It is the whole system from the drug manufacturers to the bedside that’s at fault.”

One missing piece in the Canadian system is the absence of any organization like the ISMP. In co-operation with the United States Pharmacopeia, ISMP collects medication error statistics and cases voluntarily submitted by American hospitals.

“We go to great lengths to guarantee our contributors anonymity, and that’s what makes a voluntary system work,” explains Cohen.

Armed with the data, Cohen and his group can make presentations to regulators, hospital administrators and drug companies in the hopes of preventing future tragedies and reducing the huge costs associated with less serious adverse drug events. The incident in Denver involved confusing two very similarly named drugs. Cohen says the ISMP has been beseeching the American government’s Food and Drug Administration for some time now to ensure that pharmaceutical manufacturers call their products distinctly different names.

Cohen is currently helping CSHP officials to design a Canadian-style safe medical practices watchdog. Meanwhile, the CSHP has launched a Medication Error Task Force under Dr. David Rosenbloom at McMaster University Medical Centre in Hamilton, Ont., to identify how medication error information might be gathered countrywide.

“Most hospitals have appropriate pharmacy software modules and a very good reporting system within the institution,” says Bill Leslie, the CSHP’s executive director in Ottawa. “But for a number of reasons, liability not being the least of them, that information is not being shared. So we are not learning from the mistakes of others. We need to be able to collect information about incidents that does not identify the patient nor the caregivers but simply the situation. We hope our task force will come up with a framework for doing that by the end of the year.”

Leslie says most pharmacy software, however, is still not fully up to scratch. Geared to catching allergic reactions or drug interactions, the software does a faithful job of comparing the scheduled medication against the patient’s computerized profile.

“The catch-22 is that such programs will often flag a great number of potential interactions for a given drug, most of which are of no great significance under normal circumstances,” says Leslie. “What we need, and there have been attempts at it, is smarter technology that will do a degree of sorting and point out the more critical adverse events that are likely.”

One of those attempts, the first of its kind to be patented, was developed by Dr. Timothy McNamara, MD, and registered last year in the United States by Multum Information Services Inc., where Dr. McNamara serves as a vice president of research and development. As reported in the April 1999 issue of Health Management Technology, the patent, “ identifies systems, methods, apparatuses, and computer program products that Multum has developed to generate: dosage recommendations, side effect information, allergies, drug interactions, reproductive information, pharmacological data and cost information.”

The company says its system will actively take into account patient characteristics such as age, kidney and liver functions, and the disease being treated.

But mention Multum even at a pharmacist’s convention and few have heard of it.

Nonetheless, it is the kind of “push technology” Eric Paul at Autros believes will become the decision support standard for hospitals, one hopes, in the not too distant future.

“The problem in the past is that the physician, the pharmacist, the lab, and the nurse are not communicating in real time,” explains Paul. “Let’s take the example of a nurse at the bedside, where about 35 percent of medication errors occur. A doctor has ordered the medication, but in the meantime, a lab test has come back. So, unless the nurse goes to wherever the lab result is stored and checks it, he or she might end up administering a medication which is inappropriate.

“In a real-time electronic system, the lab result is automatically pushed at the nurse on a communication device, such as the Palm Pilot that our system uses, whenever the lab values are out of range. When the nurse scans the patient, a warning will come up not to administer the drug or recommend certain checks be made first. So you get a much higher degree of decision support for caregivers.”

Such a system also makes sure the pharmacist is in the decision-making loop. Paul says 40 percent of orders submitted by doctors need re-work in paper-based ordering – usually after the prescribing doctor is long gone. (Cohen tells the story from one ISMP incident of how a paper-ordered drug that the doctor prescribed rather unclearly was to be administered on the first and the eighth day of a patient’s stay. Instead it was administered, nearly fatally, on all eight days.) But if the pharmacist receives the order electronically, and if there are any issues in it, the pharmacist can communicate with the doctor immediately or soon after via email. Such interventions can also be tracked by the system and pushed back to the physician suggesting how to medicate in a better way.

Cohen reports that adverse drug events are reduced by 66 percent when the pharmacist is actively involved this way in the medication decision process.

“It’s a better way to make use of a pharmacists’ six years of brilliant education other than counting and packaging pills,” comments Paul. “They are capable of being more than just ‘lickers and stickers’.”

Concludes Michael Cohen: “When you’ve got a closed-loop pharmaceutical system, such as computers enable, you not only reduce medication errors, you go from: Who did it?, to the much more important, What allowed it to happen?

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Radiologists say $1 billion investment needed for imaging

By Jerry Zeidenberg

MONTREAL – To avert a looming crisis in diagnostic imaging, the Canadian Association of Radiologists has urged Ottawa to create a $1 billion investment fund to bring Canada’s relatively feeble stock of medical imaging equipment up to world standards of quality and quantity.

Recent studies by the CAR and the Vancouver-based Fraser Institute found that Canada is lagging most of the industrialized world in the availability of high-tech imaging equipment such as CT scanners, MRI machines and nuclear medicine devices. The growing waiting lists for diagnostic tests result from this shortage, the studies asserted.

According to the CAR, “There are widespread reports of patients being sent to the United States for treatment, and Canadians who can afford it, seeking access in the U.S. to advanced diagnosis. Also, well-connected individuals who know people often jump the lines while everyone else waits and ultimately pays the consequences.”

The CAR report noted that, “High-tech equipment can diagnose medical problems at their earliest stages, when they can be most effectively treated. Long waiting periods often lead to a diminished quality of life and ultimately, to the loss of lives.”

Indeed, in terms of MR machines per capita, Canada ranked 19th out of 28 industrialized nations. When it came to CT scanners, Canada finished 21st on the list and was dead last for bone mineral density (BMD) machines and positron emission tomography (PET) scanners.

What’s more, it was discovered that a good deal of existing equipment is out of date, slow and unreliable.

“The results of objective studies in Canada show a shocking deficiency in high-tech diagnosis equipment and some dangerously aging X-ray equipment,” said the CAR’s recent white paper, titled Vision 2000: Radiology Services in Canada.

“The number of critical diagnostic tools such as MRI units, CT units, BMD machines and PET scanners per capita are among the lowest in the western world and compares with supplies in underdeveloped countries.”

For example, X-ray systems in certain parts of the country are up to 37 years old, when most medical imaging equipment is considered obsolete after 12 years.

The generally poor levels of diagnostic technology currently available to the public could lead to a relative decline in the quality of medical care, industry leaders say. “If the diagnosis is inefficient, the treatment is going to be inefficient,” commented Normand Laberge, CEO of the Canadian Association of Radiologists. Unless adequate supplies of modern equipment are available to hospitals and the public, Laberge said Canadians face the problem of delayed and possibly inaccurate diagnoses.

“The current state of affairs is dangerous to the public,” said Laberge.

In addition to an immediate $1 billion investment in new technology, the CAR estimates that an additional $730 million in operating costs will be required in the first three years.

Just as serious as the technology dilemma is the shortage of radiologists to provide readings of exams. The CAR says there are currently 150 vacancies for radiologists across the country, and the association forecasts a shortage of 500 radiologists by 2004.

At the present time, there is one radiologist in Canada per 18,000 population, when the federal government itself has recommended a ratio of one radiologist per 13,000 population.

According to the CAR, between 30 and 40 radiologists per year intend to retire in each of the next few years, and close to 10 percent of the workforce is already more than 65 years of age.
At the same time, the Canadian population is expected to increase by 18 percent over the next 20 years.

To combat the increasing shortage of radiologists, the CAR says we must:

• Increase immediately the number of residency positions in Canada by at least 25 percent.

• Offer more flexibility in career choices for medical students across Canada by allowing changes in training programs during residency.

• Increase re-entry positions in radiology, allowing and facilitating practising physicians the opportunity to enter a residency program.

• Provide temporary accommodation and facilitation for more International Medical Graduates in residency programs.

• Create a retention and repatriation program for Canadian radiologists.

The Canadian Association of Radiologists also urged federal Health Minister Allan Rock to create a national diagnostic imaging advisory committee, consisting of representatives from: the CAR, organized radiology, heads of academic radiology departments, Health Canada and provincial ministries of health, and the medical imaging industry.

Laberge contrasted the poor levels of technology in the Canadian healthcare system with the state-of-the-art computer technology found in the banking sector – technology that has helped the financial sector become extremely efficient.

“Healthcare did the opposite, we didn’t invest, and the result is the waiting periods that are common today,” observed Laberge.

“Healthcare in Canada is like an automobile that’s gone off the road,” he said. “It needs a towing to get back on the highway. That’s what the $1 billion investment in diagnostic imaging would do.

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West Island Telehospice: PEI launches Canada’s first telehospice project

By Andy Shaw

Prince Edward Island’s groundbreaking telehospice project owes at least a small debt to France’s space program. In December, Digital Telehealth Inc. based in Dartmouth, N.S., announced it had been named the project leader of an 18-month start-up of Canada’s first network dedicated to palliative home care.

Contracted by the West Prince Health Authority, Digital has worked with the Canadian Palliative Care Association, Island Tel, Island Hospice, and West Prince Hospice in a joint effort to bring both cost-savings and improved care to terminally ill patients. Co-funded by Health Canada, the $126,000 project operates on what Digital CEO Wayne Bell terms low-bandwidth POTS (plain old telephone service) lines.

A U.S. Food and Drug Administration-approved Aviva System bedside patient unit from American Telecare enables 15-frame-a-second video transmission (compared to 30-frames for full-motion video) over those POTS lines.

This allows caregivers working from the system’s central unit, back at the healthcare facility, to see the patient and vice versa. The interactive “peripherals” of the system can also keep round-the-clock watch on the patient’s temperature, blood pressure, pulse, heart and lung sounds, as well as do glucose, blood oxygen, and electrocardiogram testing.

“The nice thing about these units is that all their data are automatically uploaded to the patient’s chart at the central station,” says West Island’s telehospice co-ordinator, Myra Ramsey. “So there is no room left for error either on the healthcare professional’s or the patient’s side. Nothing has to be copied down or read back. So it is 100 percent accurate.”

It’s also accurate to say that the project is a reflection of the experience, dedication, and training of the various project partners. Ramsey has been interested in palliative care since the beginning of her nursing career and did exhaustive research on suitable systems for the project.
Dr. Rod Elford of Calgary, a principal business partner of Bell’s at Digital, brought a unique combination of medical and technical expertise to the work.

“When he graduated from medical school in Alberta he went on to study space medicine in France and that got him involved in telemedicine,” explains Bell. “When he came back home he wanted more training, the university put together a unique two-year graduate program that saw him study telehealth in the United States, Norway, and under Max House in Newfoundland. So he became the first in the world, so far as we know, to hold a master’s degree in telehealth.”
Under Bell’s direction Digital will also provide the training needed by the home-based caregivers to run their end of the network.

“We’re independently developing educational programs for the caregivers in the home,” says Bell. “We’re looking at the best way to do that but initially we’re thinking it will be Internet based because of its convenience for people.”

Patients referred by West Prince physicians for palliative care services are eligible for telehospice hook up. Initially the system will handle just 12 remote patients. But even at that size, the world is going to know about it. Digital will be exhibiting its telehealth developments in the Canada Pavilion at the new millennium’s first World’s Fair in Hannover, Germany beginning in June. Some 200 countries are participating and over 50 million visitors are expected at the five-month long event.

But it’s not the big show that motivates most, says Bell. It’s the little 15-frame-a-second bedside images that will appear somewhat intermittently, but clearly, to PEI’s telehospice nurses on their central station screen. (Privacy is assured. At the patient end, a button must be pushed before any bedside images are transmitted.)

“It seems that home care has been down the list of telehealth projects in Canada, yet the greatest volume of patients are actually in the home,” says Bell. “So home care is where you’re going to get the greatest bang for the healthcare technology buck. This has to be more than just about major hospitals connecting with each other.”

Bell adds that when you “put the microscope on” such major, high-cost IT projects, it’s difficult to identify what savings or other tangible benefits are being achieved. But when a dying patient, for example, can be cared for professionally via an inexpensive telehospice network at home rather than at the hospital, the benefits to the patient, to his or her family, and to provincial health care costs are obvious.

“I’ve had the daughter of one patient already tell me how grateful the family is that we’ve been able to leave her mother at home and yet still know and see what her condition is,” says Ramsay.

Ramsay describes the breadbox-sized Aviva unit as having a camera eye on its upper edge, a speaker-phone, a small computer-like screen for video and a read-out interface so that the patient or home caregiver can also see the readings being transmitted back to the central unit. Two simple buttons operate the device.

Both Bell and Ramsay fully expect the telehospice network and its simple, low-cost technology to carry on long after its initial 18-month pilot stage. It can be readily extended, they say, to other types of patients at further cost savings to the healthcare system.

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