The following article was featured in Canadian Healthcare Technology on November 8, 2018. Written by Dianne Daniel.
Community hospitals have also invested in new software, enabling physicians, care partners and patients to access information more easily
Complex cardiac care in Ontario is no longer limited to major urban teaching hospitals. New technologies and management techniques – coupled with strong partnerships – are strengthening advanced regional programs, bringing excellent care closer to cardiac patients where they live and dramatically improving medical outcomes.
Royal Victoria Regional Health Centre (RVH) in Barrie launched its regional cardiac program in partnership with Newmarket’s Southlake Regional Health Centre in January, enabling its cardiac team to perform angiograms and percutaneous coronary intervention (PCI or angioplasty). The program is supported by 10 cardiologists, a dedicated seven-bed coronary care unit, two catheterization labs (cath labs) accompanied by a 16-bed recovery unit, and a 32-bed cardiac/renal unit for general cardiac care.
Planning for advanced care delivery began in 2012 and was based on a strong vision to create a comprehensive, centralized electronic system specifically for cardiac care. “We really felt our solution needed to describe the patient’s cardiac journey and that journey should be available essentially anywhere in the world a physician would need it, if they needed access to that information,” said Selma Mitchell, operations director of the Simcoe Muskoka Regional Heart Program & Regional Renal Program.
To streamline workflow throughout its cardiac care program, RVH partnered with Philips, implementing the IntelliSpace Cardiovascular image and information management solution along with supporting applications for nursing documentation and patient monitoring. Physicians log in to see all patient test results, including echocardiograms, electrocardiograms, cath lab exams and holter monitors, and the system is integrated with RVH’s existing Meditech electronic health record system.
As Mitchell explained, it’s not only the diagnostic report that’s available, but the live image too. “Our patients love it. We pull this up at the bedside, after the patient has had the procedure, and their physician will show them what their angiogram looked like,” she said. “It’s really interesting for them to see their images in real life.”
The advanced system is accessible beyond the walls of RVH. If a patient is transferred to Southlake for a more complex procedure or surgery, for example, the treating physician there is able to access and view all prior diagnostic testing.
“You can’t just deliver a hardware system,” explained Mitchell. “You need to be able to connect it to the patient and the software piece is integral … that was probably the most important aspect for us, having a system where we could connect all of the dots.”
The “dots” are also being connected between RVH and the smaller regional hospitals within its catchment in the Central local health integration network (LHIN). Recently, RVH integrated its electronic cardiac system with the Huntsville District Memorial Hospital site of Muskoka Algonquin Healthcare, enabling physicians there to share images and reports with cardiologists at RVH.
“A few years back, if a patient had to be referred to another physician, we would have had to taxi a CD down to that partner hospital which took time,” said RVH Cardiac IT team member Stef Keown. “Now they can access it in seconds versus hours.”
By 2020, the new regional program will operate 24/7 with paramedics transporting North Simcoe Muskoka heart attack patients directly to RVH for treatment, providing lifesaving intervention within 90 minutes for most patients. In the meantime, the plan calls for a cautious, phased ramp-up of cardiac services, supported by ongoing partnerships with Philips for infrastructure and Southlake for tertiary and quaternary services, including advanced cardiac surgery and heart rhythm interventions.
Janice Allen, director of Southlake’s Regional Cardiac Care Program, said the most important objective of the regional focus is to deliver excellent cardiac care while reducing patient travel. “It truly is one program with two sites,” said Allen, adding that the Southlake cardiac surgery team conducts satellite clinics at RVH as needed for complex patients. “It’s really great from a regional perspective to be able to offer this cutting-edge care closer to home for our patients. Otherwise they would have to be travelling to academic centres,” she said.
In February 2018, Southlake completed a redevelopment of its cardiac labs, providing more efficient care for patients in need of complex cardiac interventions across the region. The third largest cardiac centre in Ontario, it now operates three cath labs outfitted with state-of-the-art imaging systems for diagnostic angiograms, angioplasty and structural heart procedures, and three dedicated electrophysiology suites for heart rhythm diagnostic studies, ablations and implantable devices such as pacemakers and defibrillators. The new equipment – which includes the latest in 3D imaging and mapping – creates opportunities for future growth, said Allen.
Since inception, the centre’s Regional Cardiac Care Program has treated more than 160,000 patients, completing 93,370 diagnostic tests and exams last year alone. In addition to more than 6,000 diagnostic catheterization procedures, 1,000 surgeries, 752 electrophysiology studies and 687 cardiac ablations, the centre performed 71 transcatheter aortic valve implants (TAVIs) in 2017 and is awaiting approval from the Ontario Ministry of Health and Long-Term Care to add mitral valve clipping procedures.
“The other procedure we’re looking at doing is left atrial appendage closure for patients who have Afib (atrial fibrillation), who are at high risk of bleeding on an oral anticoagulation therapy,” said Allen.
Remote monitoring of patients is another part of the regional program which is contributing to fewer hospital readmissions and reduced lengths of stay. Patients who receive pacemakers or implantable cardioverter defibrillators (ICDs) and who provide consent for remote monitoring are able to download information from their devices daily for review by nurses. Monitoring is also provided for congestive heart failure patients, who track their weight, oxygen saturation levels, heart rate and blood pressure.
“If patients are trending in the wrong direction – if their weight is going up or their oxygen saturation is trending down – they may not be symptomatic at that point, but our team can pick up on that and call them,” she said, noting that the same monitoring service is provided to elderly patients who reside in long-term care settings.
An added advantage of the regional program is that Southlake is able to bundle contracts with industry partners and vendors into one “innovative procurement with multiple streams,” Allen said. Innovative procurement means vendors don’t simply sell products, they work with the hospital to improve quality performance indicators such as readmission to hospital, length of stay and mortality rate. “It was a lot of work,” she said. “We’re very proud because we were able to deliver benefits to our patients through a procurement strategy. We haven’t seen that before.”
St. Mary’s Hospital in Kitchener is also aiming to use innovative procurement to support its strategy for a new regional cardiac program. As Chief of Cardiovascular Services Dr. Brian McNamara described, the approach is more about outcomes than widgets.
“Traditionally, hospital procurement has been ‘we use 2,500 stents per year, we promise to buy them from you at this price,’” he said. “This is more about ‘we want to have a lower stent thrombosis rate, or a shorter door to balloon time or a shorter length of stay. How can you help us do that?’”
The hospital will meet with local technology companies and leaders in October to provide them with an outlay of its plan for a Waterloo Wellington Regional Cardiac Program – an expansion strategy that is supported by the Waterloo Wellington LHIN and is currently seeking funding approval by the Ontario Ministry of Health and Long-Term Care. Dr. McNamara said the need for additional services is “irrefutable.”
Over the past 15 years, St. Mary’s Hospital has grown its cardiovascular services to the point where it is now completing more than 6,000 cath lab procedures each year. Nine years ago, the centre performed 900 PCIs per year; this year it completed more than 1,800. Yet the underlying infrastructure hasn’t changed, meaning the two existing cath labs are used around the clock, straining equipment and resources.
“A few years back St. Mary’s leadership and the Board instituted a Lean management strategy to try to extract the most value from the resources we have – both physical and financial – and those efforts have squeezed absolute maximum capacity out of the existing infrastructure,” he said.
Services provided by St. Mary’s include pacemaker and ICD insertions, coronary artery bypass and valve surgeries, catheterizations and PCI procedures, Transcatheter Aortic Valve Implantation (TAVI) and diagnostic coronary angiography. There is a very busy pacemaker and ICD and CRT Program. The Cardiac program is supported by 18 cardiologists, four surgeons, five cardiac anesthetists and a dozen nurse practitioners. According to a 2017 national report on quality outcomes at Canada’s 38 cardiac centres, St. Mary’s is performing better than the national average and is among the top three.
“For a small place, we do PCI and cardiac surgery at a level that’s commensurate with the top three places in the country and some of our metrics are better,” said Dr. McNamara. For example, Canadian average mortality rates following cardiac procedures range from 1.3 to 2.3 per cent whereas St Mary’s rate ranged from 0.5 to 1.6 per cent. The average readmission rate following PCI was 7.4 per cent; St. Mary’s was 5.8 per cent.
In addition to the hospital’s strong cardiac performance, the community is now better served due to changes in outpatient care delivery. The cardiologists are aggregated together into one, large outpatient clinic. Before, family doctors would fax referrals and send consult requests all over the Kitchener-Waterloo region. Now the entire service is staffed out of one clinic and each cardiologist leaves a few openings in the weekly schedule to treat emergency patients.
“It’s much more responsive to the community and it has completely transformed outpatient cardiology access,” said Dr. McNamara.
St. Mary’s Hospital, in Kitchener, Ontario, is performing better than most cardiac centres and is among the top three in Canada.
Moving forward, the expanded plan includes developing a “hub and spoke” model for advanced cardiac care delivery, with St. Mary’s Heart Function Clinic as the main resource for guidance, order sets and care of the highest risk and sickest patients in its catchment area.. The “spokes” will be satellite services provided in smaller communities, but under St. Mary’s guidance, he explained.
St. Mary’s regional cardiac program serves over 20 hospitals in a geographic rectangle stretching from Simcoe to Tobermory, along the coast of Lake Huron to Goderich and east to Guelph. One of the goals of the expanded Waterloo Wellington Regional Cardiac Care program – which includes the addition of an electrophysiology lab to treat advanced heart rhythm disturbances as well as remote cardiac rehab – is to develop a comprehensive digital strategy.
Concurrent with its strategic plan to expand regional cardiac care services, St. Mary’s is in the midst of a large Cerner electronic medical record implementation in conjunction with Grand River Hospital. Dr. McNamara expects the new system will enhance the flow of information between satellite sites so that a physician at one location can get an ECG in front of an on-call cardiologist at St. Mary’s in a secure manner that protects patient privacy.
“It’s one of those Tower of Babel situations. The hospitals we work with all use different platforms for diagnostic imaging, records; it’s difficult to talk to each other,” he explained. “The hope is one EMR will enhance the to and fro of information to our partner hospitals in a more seamless way.”
St. Mary’s General Hospital has introduced a minimally invasive heart procedure for patients with severe aortic stenosis who are at a higher risk for undergoing a valve replacement through traditional open heart surgery.
Known as Transcatheter Aortic Valve Implantation (TAVI), the procedure is being performed by a team of interventional cardiologists and cardiac surgeons on patients who are carefully screened for eligibility. Until this month, St. Mary’s was the only cardiac surgical centre in Ontario not offering the procedure.
Each year about 50 patients from Waterloo Wellington must travel to centres in London, Hamilton or Toronto for TAVI, waiting an average of 90 days. With the support of the Waterloo Wellington Local Health Integration Network, the Ministry of Health and Long-Term Care approved funding for 50 procedures to be completed at St. Mary’s before March 31, 2019.
“We are currently sending patients to centres with long waiting lists, so we are very excited to begin offering timely access to TAVI close to home,” says Andrea Lemberg, St. Mary’s Cardiac Program Director. “Our team spent months planning for this and our initial cases have gone very well.”
The aorta is the main artery responsible for pumping blood to the rest of the body. The aortic valve usually opens when blood is pumped from the heart to the rest of the body. With aortic stenosis, the valve becomes extremely narrowed and does not open properly. This can put extra strain on the heart. Symptoms can include chest pain, trouble breathing, dizziness and fainting spells.
Traditional open heart surgery requires patients to be put to sleep with general anesthetic. A large incision is made in the patient’s chest and the rib cage is opened to access the heart. Patients recover for about five days in hospital and for about three months at home.
With TAVI, a balloon-expandable aortic valve is implanted over the diseased valve using a catheter inserted through a small incision in the groin and passed through the femoral artery into the heart. Patients are given a moderate sedative and anesthesia that allows them to be awake during the procedure, have their pain controlled and recover more quickly. If all goes well, discharge occurs within 24-48 hours.
“TAVI is now the established technique for select patients with severe aortic stenosis,” says Dr. Jaffer Syed, an interventional cardiologist at St. Mary’s and Physician Lead for the TAVI Program. “It can greatly improve quality of life and improve survival.”
Ray Whittemore was the first patient to undergo the procedure at St. Mary’s on September 20 and went home late the next day. His wife Sandra, says of his recovery “when you think about open heart surgery and all that entails, this seems like a walk in the park. His incision has healed. It’s really quite something.”
“This team is so dedicated and passionate,” she added. “What they are able to provide at St. Mary’s is such a gift to the community.”