Teaching goes high-tech

Surgeons at Greater Niagara General Site launched a new training program in May with a telementoring initiative. From left, Dr. Anantasivan Subramanian (back of head visible) observes Dr. Kreasan Rajagopaul during the surgery, who is assisted by Dr. Craig Muir, right.

The lights are off, there’s no blood but there is a voice coming from somewhere. Welcome to the high-tech world in the Operating Room, as surgeons in Niagara Falls take up a new method of learning surgical techniques. The goal – less invasive surgical procedures to improve patient outcomes.

To keep pace with medical advancements, surgical specialists must constantly refresh and learn new skills in a high-tech operating environment. Laparoscopic surgery is a procedure that is used in more and more surgical procedures.

Minimal Access Surgery

“Laparoscopic or keyhole surgery is a minimally-invasive procedure used in abdominal surgeries, where scopes go through small incisions and attachments such as micro-scissors, blades and fibre-optic cameras fit on the end,” explains Niagara Health’s Patty Welychka, Surgical Program Director. “Laparoscopic procedures are commonly used for gall bladder removal, appendectomy, hernia and other abdominal surgeries.”

A new focus is using this minimal-access type of surgery to remove cancerous tumours. The traditional way of performing colorectal cancer surgery is with a 20 to 25 cm (eight to 10 inch) incision down the centre of the abdomen. Taking about three hours for this open surgery, the portion of the bowel that contains the tumour is removed, called a bowel resection. The bowel is then stapled together and the patient spends seven to 10 days recovering in the hospital and about six weeks total recovery time before he or she can get back to normal.

The laparoscopic scissors (just one cm long) are visible on one of the monitors in the OR, as surgeons cut the section of the bowel that contains a cancerous tumour. The camera which allows surgeons to see deep into the abdominal cavity is attached to the end of another scope inserted in the patient’s abdomen.However, the laparoscopic procedure of making only small incisions makes this surgery much more manageable for the patient. Just three or four keyhole openings for the scopes and one five cm (two inch) incision are made to remove the small section of bowel. Not only is the surgery time reduced to about two hours, the patient has less post-op pain and discomfort, explains Dr. Kreasan Rajagopaul, a Niagara Falls general surgeon.

“The control of cancer is the same for both types of surgery, but the advantage to laparoscopic surgery is that bowel function returns faster, the patient is in hospital for only three to four days and the total recovery time is just three weeks,” he says. “It’s better for the patient and ultimately, this reduces the strain on the hospital system, both in the OR and in the surgical inpatient unit.”

Telementoring Program – Teaching via Audio/Video Link

An innovative way for surgeons to learn the keyhole procedure is through a new mentoring program for surgeons. For the first time in Niagara, a surgeon from McMaster University’s Centre for Minimal Access Surgery is providing instruction remotely through an audio/video link, called telementoring, that connects St. Joseph’s Healthcare Hamilton with Greater Niagara General Site. Dr. Rajagopaul is the telementoring lead at Greater Niagara General Site to help bring this technology-based program to the ORs, through a different learning methodology. Other surgeons in the NHS at St. Catharines and Welland perform this same procedure but this is the first time the NHS has used telementoring as a teaching tool.

The telementoring program uses the tie-in the Niagara Health System has to the Ontario Telemedicine Network, which connects hospitals with healthcare partners throughout Ontario. Through the Telemedicine Network, hightech fibre-optic equipment allows specialists in other locations to see exactly what the surgeon sees. The mentors can provide instruction remotely on new techniques. This is the way of the future to train surgeons already familiar with minimally-invasive surgery.

Partners Throughout Ontario

Thanks to special funding from Cancer Care Ontario, Niagara Health has so far upgraded OR suites at a cost of about $150,000 in Niagara Falls and St. Catharines, with Welland’s ORs to also get the necessary hardware and software in the coming months.

“We’ve been working on the telementoring program for about a year, and it is exciting to get it off the ground in Niagara,” Dr. Rajagopaul says. “We work with Dr. Mehran Anvari, the Director of the Centre for Minimal Access Surgery at St. Joseph’s Healthcare Hamilton, and it is his voice and expertise we hear during our surgeries in Niagara Falls. We’ve done two cases now with his help remotely, and they have both been excellent.” “The world of surgery has changed irrevocably through the years, with continuous advancements in technology,” says Dr. Anvari. “Telementoring is just one new and effective way of progressing surgical advancements at multiple sites remotely.”

The Centre for Minimal Access Surgery has been using telementoring for over 10 years to help support surgeons from various community hospitals across Canada. This is the first routine clinical use of telementoring to improve quality of cancer surgery across the whole province. This initiative has been made possible by the collaboration of Cancer Care Ontario, Ontario Telemedicine Network, Juravinski Cancer Centre, St. Joseph’s Healthcare Hamilton and a number of hospital systems including Niagara. If successful, it will enable more community hospitals to offer the latest cancer surgery and avoid the need to refer patients to larger cancer centres.

“Patients want laparoscopic surgery more and more, because they’re confident in the knowledge that there are a great many benefits,” Dr. Rajagopaul says.

Other surgeons in the NHS at St. Catharines and Welland perform this same procedure but this is the first time the NHS has used telementoring as a teaching tool.

Debbie Sevenpifer,
President and Chief Executive Officer

I hope you will find this integrated, more frequently published newsletter helpful in keeping up with the fast pace of change within the Niagara Health System. Since our last publication, the first of early opportunities for the Hospital Improvement Plan (HIP) have been implemented within the surgical program. This involved consolidating all inpatient and outpatient surgery to St. Catharines, Welland and Niagara Falls sites. To the physicians, nurses and OR technicians who were impacted by the changes, a sincere thank you for your patience and cooperation throughout this time of change. For those nurses who have chosen to take early retirement, thank you for your many years of providing dedicated, compassionate care to the residents of Niagara. I wish you all the best in your retirement.

The next HIP changes involve the conversion of the 24/7 Emergency Rooms in Port Colborne and Fort Erie to 24/7 Urgent Care Centres. We are targeting July for the conversion in Port Colborne and September for Fort Erie. The staff in the Emergency Program are working closely with Emergency Medical Services (EMS) to plan for a smooth transition.

A comprehensive communications effort is now underway to help residents in the lakeshore communities understand the changes taking place and the healthcare services that will be available to them after the changes take place. Many residents are under the unfortunate and incorrect impression that the Fort Erie and Port Colborne sites are closing.

On pages 4 and 5 of this issue of Niagara Health Now, you will find more about the future vision and the important services that will continue to be provided at these two sites. We are running ads in the local newspapers. An insert will be distributed to households outlining the differences between emergency and urgent care, when to call 911, and much more. Public information sessions have been booked, and presentations to service clubs and other groups are underway to explain what these changes will mean to the local communities. During this time of change, we understand and appreciate the concern, the passion and sometimes anger of our communities, our physicians and staff. As we move forward, I would like to assure you that we remain committed to ensuring all of our stakeholders have the information they need to work within, and be served by, our hospital and to working collaboratively with staff, physicians and the community to implement the vision articulated in the HIP for a sustainable hospital system in Niagara.

Medical School

A couple of weeks ago, Niagara received great news with the announcement of an additional 13 spaces for medical students attending the Niagara campus of the Michael G. Degroote School of Medicine. This means that by 2011, the Niagara campus will have 84 medical student spaces!! This is wonderful news, particularly when you consider the fact that Niagara is currently short over 90 family physicians. Our hope is that many of the medical students who are educated and trained in Niagara will stay in Niagara.

At the announcement, I had the opportunity to speak to a number of the 15 current medical students who are in their first year at the Niagara campus. They could not say enough about how welcomed they felt within the Niagara Health System and also by our region’s Mayors and the communities they visited as part of their training. These eager and enthusiastic students also commended the calibre of the medical teaching they are receiving from the physicians teaching at the Niagara Campus.

Our affiliation with the Michael G. DeGroote School of Medicine is a great asset for all of us, and I look forward to watching our Niagara Campus Class of 2012 flourish as they work towards completing their education right here in Niagara.

Registered Nurse Rita Loeffen cares for a patient in the Welland ER.

A new unit in the Emergency Room at the Welland Site is designed to improve flow through the ER and reduce wait times for many of the less urgent patients.

With the opening of a Clinical Systems Investigation (CSI) Unit, more patients can be assessed and treated at the same time. A nurse can speed up a patient’s assessment process using standardized medical directives to order blood tests, X-rays or other procedures. Traditionally, patients must first wait to see the physician, who then orders blood work and other tests in order to make a diagnosis. The CSI process expedites the ability to get ER doctors the information they need before they see the patient for the first time.

“The CSI Unit is an innovative approach to accessing more timely care in the ER,” says Anne Atkinson, Niagara Health System Vice President Patient Services.

A similar unit opened at the St. Catharines General Site in October 2008 and has cut wait times virtually in half for patients triaged as Canadian Triage Acuity Scale (CTAS) Levels 3, 4 and 5 (Level 1 is life-threatening and Level 5 is non-urgent). At the St. Catharines CSI Unit, 277 patients were seen in March 2009. Total average wait time was 3.5 to 3.8 hours per patient, compared to 6 to 8 hours in the previous year prior to the opening of the unit. Planning is underway to open a similar unit at the Greater Niagara General Site in the near future.

The CSI Unit is able to re-route patients that would typically occupy a stretcher for several hours while waiting for test results or other information. CSI patients only occupy the stretcher while receiving direct care or assessment from the physicians or nurses, or they may have an Intravenous or other care initiated while sitting in a comfortable recliner. While waiting for tests or results, the patients wait in a dedicated CSI waiting room, freeing up the limited number of stretchers for other ER patients. “ERs are incredibly busy places, and we are proud of the doctors and nurses for their success in reducing patient wait times,” says Pat Morka, Regional Director, Emergency Medicine Program. “We anticipate the wait times will continue to improve as the doctors and nurses get more used to the new CSI process.”

Other strategies to improve wait times in local ERs include the recent hiring of nurses dedicated to managing patients coming in by ambulance to the St. Catharines, Welland and Niagara Falls ERs. In addition, the St. Catharines ER received a second round of funding last month — $1.1 million — to continue with the Pay-for-Results Program, part of the province’s Wait Time Strategy for ERs. «

With that in mind, the District Stroke Program of Niagara Health launched Stroke Awareness Month this month by partnering with an international expert to speak with students about the importance of making healthy choices now to prevent and reduce the risk of stroke, heart disease, diabetes, and other chronic diseases. About 300 students attended the presentation by Dr. Robert Ross, a Queen’s University Professor in Kingston and recognized leader in the areas of obesity, physical activity and metabolism. Dr. Ross spoke to Grade 9 and 10 physical education classes from Denis Morris and St. Francis secondary schools.

The focus of the presentation was on achieving a healthy lifestyle with an emphasis on increasing physical activity and decreasing risk factors such as obesity and smoking. This includes eating a healthy diet, choosing foods that are low in sodium, exercising, maintaining a healthy weight, not smoking, reducing stress and having regular blood pressure checks.

“This is an exciting new initiative for our program as we have always targeted adult audiences,” says Leanne Hammond, Coordinator of the regional District Stroke Program, located at the Greater Niagara General Site in Niagara Falls. “We feel that it is so important to target the younger population to motivate them to make healthier choices now to minimize the risk of developing chronic disease when they are older.”

The presentation was so successful that the stroke program is already discussing next year’s stroke awareness event, once again involving high school students.Dr. Ross gave each student a pedometer, and they were encouraged to wear it daily. According to follow-up from one of the teachers, the students enjoyed the presentation, had great discussions in class afterwards, and couldn’t wait to try out their pedometers.

The Stroke Program team was pleased with the reaction to the presentation.

“Our typical patients are adults who have already had a stroke and have multiple chronic diseases like hypertension, diabetes and obesity, which put them at high risk for another stroke,” says Connie McCallum, Nurse Practitioner with the District Stroke Program. “We’ve always felt that teens were a critical target audience, but we never really knew how to reach them. This is true prevention.” The District Stroke Program of Niagara Health provides a variety of stroke-related services to thousands of patients across the region every year. «

What’s changed as of today?

As of May 19, as one of the Early Opportunities in the HIP, the small volume of surgical services is no longer provided at the Douglas Memorial and Port Colborne sites. Eye surgery moved from these two sites and Greater Niagara General as a first step to creating a single surgical Centre of Excellence in Ophthalmology at Welland Site by 2013. Until then, eye surgery will be provided at Welland and Ontario Street sites.

Also on May 19, Plastic surgery moved from the Welland Site to two specialized surgical centres located at Greater Niagara and St. Catharines General sites as these two sites currently have the highest volumes of trauma care. Dental surgery, previously provided at Douglas, Port Colborne and Welland, is now centralized at Greater Niagara General Site.

Conversion of Emergency Departments to Urgent Care

The 24-hour Emergency Rooms (ER) at Port Colborne and Douglas Memorial sites will become 24-hour Urgent Care Centres (UCC), open seven days a week year round and staffed with doctors and nurses who are certified in Emergency medicine. The Port Colborne Urgent Care conversion is targeted for July. The Douglas Memorial Urgent Care conversion is slated to take place by late September.

It is estimated that most (up to 95%) of the adults and children who currently go to these small site ERs will continue to go to the Urgent Care Centres for treatment.

“Adults and children who have non-life threatening illnesses and injuries such as lacerations, sprains and strains, ear infections and mild or moderate asthma can be appropriately treated in an urgent care setting,” explains Marcia Ladouceur, clinical lead for the UCC conversion and ER Clinical Manager for the Welland and Port Colborne sites.

Some patients who present at the UCCs may be determined by the physician to require admission to an acute-care bed. These patients will be stabilized and then transferred to the most appropriate facility where they will have access to high-tech diagnostics tests, on-call physician specialists, intensive care and surgical care should they require.

“Regardless of where you live in Niagara, individuals suffering from chest pain, shortness of breath, severe abdominal pain, dizziness, numbness in arms or hands and serious injuries should call 911,” Marcia explains. “It’s important to know that our Urgent Care Centres will be staffed and equipped to respond to the unexpected – the person who walks in and collapses suddenly or is having a heart attack. If residents experiencing these symptoms come to the UCC, we will stabilize and then send patients by ambulance to the most appropriate acute-care site. This is not very different from what currently happens now at Port and Douglas. This is also the case at the Prompt Care Centre in St. Catharines since the Ontario Street Site’s ER was converted to Urgent Care nearly four years ago,” adds Marcia.

Building Renovations at Port Colborne Site for Urgent Care Centre

“We are also working simultaneously on renovation plans for the Port UCC. We’re looking at two location options for Port UCC – renovating and remodeling the existing ER space on the ground floor or moving the centre to the west side of the first floor.”

Under the proposed first floor option, the Urgent Care Centre would include a children’s play area, a nursing station, an area for patients who need fluids or need to stay for a short period of time, more patient and public washrooms, a fast track area to maximize patient flow, a trauma room, a suture room, an isolation room with negative pressure for patients who require a separate air flow, a working area for physicians and new patient rooms.

“We’re getting further input from our doctors and will be incorporating their feedback. Our team is really excited about the renovation and are looking forward to selecting the plan that we will proceed to build,” adds Marcia.

Complex Continuing Care Beds at Douglas and Port Colborne

Inpatient services will be offered through Complex Continuing Care units, with 40 beds at Douglas Memorial Site and 46 beds at Port Colborne Site.When the Hospital Improvement Plan is fully implemented there will be 46 Complex Continuing Care (CCC) beds at Port Colborne Site and 40 CCC beds at Douglas Memorial Site. CCC patients have two or more complex conditions requiring them to have round-the-clock hospital-based care. The majority of CCC patients are elderly residents.

Patient Testing Diagnostics and Clinics

Many different patient care tests, procedures and treatments will continue to be provided as part of the future vision for Port Colborne and Douglas sites. This includes X-ray, ultrasound, ECG, blood work and other laboratory tests, pharmacy, etc.

“Our health-care teams at both sites will continue to provide this broad range of patient tests and treatments for outpatients and for the complex continuing care inpatients who are hospitalized there,” explains Debbie. “This is similar to what is provided at the Niagara-on-the-Lake Site.”

Clinic services will also continue. It’s currently estimated that over 70 per cent of the outpatient clinics now offered at the sites will continue to be provided, including the diabetes clinic, orthopaedic clinic and the Ontario Breast Screening Program for the early detection of breast cancer in women over the age of 50. «

The Niagara Health System Board of Trustees is made up of volunteers who live and work in Niagara. Each Board member brings unique skills and expertise to this leadership role. The Board is responsible for governing the NHS and providing strategic direction to the Hospital to ensure it meets the health-care needs of the community within the resources that are available.

Community Board members serve terms of three years, and can serve a maximum of three consecutive three-year terms. They devote a minimum of 10 to 15 hours a month to their Board role and do not receive any remuneration for their work.

Niagara Health Now is publishing a series of question-and-answer profiles on individual members of the Board to help our readers get better acquainted with them. This week’s profile is of Mary Turner, First Vice-Chair of the Board.

Where were you born?
St. Catharines

Number of years living in Niagara:
Grew up in St. Catharines, moved away for university and lived and worked in Hamilton, Burlington and Toronto for 25 years. Returned to Niagara about 15 years ago to work at Canadian Tire Financial Services in Welland. Live in St. Catharines.

Occupation:
Vice-President of Credit Risk Management and Chief Operating Officer of Canadian Tire Bank.

What are the greatest rewards from your job?
Working with great people to build a world-class business in Niagara.

What influenced you to become a member of the NHS Board of Trustees?
When I returned to Niagara, I was concerned about the healthcare available compared to what I was used to in Hamilton and Toronto. I wanted to understand Niagara’s issues and help to improve healthcare in Niagara.

How many years have you served on the NHS Board?
Joined the Board in March 2003.

What is your greatest achievement or reward as a member of the Board?
Bringing much-needed new services to Niagara, including enhanced cancer treatment, mental health services and cardiac care, as well as the replacement of the aging hospital facilities in St. Catharines.

What is the greatest opportunity for the NHS?
Great things are happening in Niagara; our new health-care complex, the Niagara Health and Bioscience Research Complex at Brock University, the new Applied Health Institute at Niagara College, the Marilyn I. Walker School of Fine and Performing Arts, the new Convention Centre in Niagara Falls, the 406 expansion and more. These projects will be a significant boost to the Niagara economy, particularly in the area of human health sciences. The NHS will play a key role in this growing sector.

What is the NHS’s greatest challenge?
The shortage of doctors, nurses and other health-care professionals is a huge short-term and long-term challenge for the NHS. We will have to continually challenge how we do our work, now and in the future, to provide the best possible healthcare for Niagarans with the limited resources available.

What community causes are closest to your heart?
Improving the quality of life and future prospects for Niagarans. I support many organizations that help families in need in Niagara as well as Brock University, Niagara College and of course the NHS.

Other involvement as a member of a volunteer Board, past or present?
Past Chair of Niagara Grant Review Team – Ontario Trillium Foundation; past member of the Board of Niagara Community Foundation. Currently serving on the Boards for Brock University, Niagara Economic Development Corporation, Canadian Tire Jumpstart Charities.

How would you describe yourself to someone who doesn’t know you?
I say what I mean and mean what I say.

What is your greatest personal achievement?
My family – my husband and I have been married for almost 34 years, and we have two wonderful sons. «

We also owe a huge thank you to Nick Jancsar, Regional Director of Hospitality, and the entire hospitality services team. Thanks to Nick and his dedicated and enthusiastic staff, we are able to get Niagara Health Now out at our sites and quickly recycle any newspapers left from the previous issue – clearly teamwork in action. Thanks also to our volunteers who are distributing at a few of our sites.

You may have also seen the web-edition of Niagara Health Now. We were thrilled to learn that more than 2,000 readers read the first web edition. We encourage all web-edition readers to take a second and click on the icon at the end of each story to tell us if they want more or fewer stories on specific topics. As well we welcome our web readers to click on the subscribe link so we can get you on a direct mail out list and make sure you don’t miss any issues of the paper.

Happy reading !!! «

Christine Clark, Chief Communications Officer