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Important program development updates

09-May-2016

Trauma Program pilot proposal with the Ministry of Health

A proposal for a pilot Trauma Program has gone forward to the Ministry of Health. The rationale for the pilot program is due to the effective management of trauma cases being a complex and resource-intensive aspect of hospital operations within the Regina Qu’Appelle Health Region (RQHR). Recent investments in patient transportation infrastructure (STARS), coupled with a growing population have led to an increase in both the volume and acuity of trauma patients arriving for treatment. The following chart demonstrates trauma volumes experienced by the Region since January 2014.

Note that, while standard processes have been implemented for capturing trauma data, cases continue to enter the hospital system without being formally categorized.

 
 
 
 
 
 
 

TAVI: Ministry of Health Approves Provincial Program

Without treatment, aortic stenosis (AS) may progress rapidly and it can be life-threatening. Surgical intervention is offered as a treatment, however, with AS being more prevalent in the elderly population, many of these patients are deemed non-surgical candidates or to be too high risk for surgery. Treatment options and timing of such, matter greatly to these patients and their outcomes. Trans-catheter aortic valve implantation (TAVI) or replacement (TAVR) allows an effective treatment option to those patients who are unable to have surgery.

Working with the Ministry of Health and with colleagues from Saskatoon, a team from RQHR is developing the implementation plan for a TAVI program for this province.

Currently, patients in Saskatchewan with severe, symptomatic aortic stenosis who are not considered candidates for surgical valve replacement are referred out of province for TAVI. Prior to referral to a TAVI centre (Vancouver, Calgary, or Edmonton) patients are screened in consultation by both a cardiac surgeon and a cardiologist ensuring that all pre-procedure testing is completed. Due to the inability to perform these procedures within Saskatchewan, these elderly and often frail patients and their family members must then travel to the TAVI centre for a consultation which can mean a wait of several months and numerous trips for appointments.

The logistics of travel with elderly patients is difficult and the cost incurred by patients and families is significant. There are patients who have declined the life-saving treatment solely because of the anticipated burden of travel and cost.

Development of a provincial TAVI program to serve the entire province and ensure all patients can receive the appropriate treatment in their home province. TAVI will be restricted to patients who are classified as inoperable or high risk for surgical aortic valve replacement. Patients will be selected on an individual basis by the multi-disciplinary team. The Canadian Cardiovascular Society recommends the following individuals for the heart team: Interventional cardiologists; Cardiac Surgeons; Imaging specialist (radiology and echocardiography); Cardiac anaesthetist; and Nurses.Utilizing a multi-disciplinary team approach for patient selection ensures that patients are appropriately selected. Following referral for TAVI, consensus agreement will be reached on the most appropriate treatment for the aortic stenosis be it medical/conservative, surgical valve replacement or TAVI.

Post-procedure recovery will be initially in the coronary care unit (CCU) or in the surgical intensive care unit (SICU) if significant surgical interventions occurred during the procedure (cut-down or conduit use, vascular access injury repair or transapical access). The trans-femoral (trans-axillary or sub-clavian) implantation procedures will be performed in the cardiac catheterization laboratory.

The program will provide a means to decrease morbidity and mortality in these patients who would otherwise live a median of 2 years. In inoperable patients with severe AS, TAVI improves survival and quality of life compared to medical therapy.

By offering TAVI in Saskatchewan, patients and their families will be able to obtain treatment close to the comforts of their own families and home. Eliminating the need to travel long distances will significantly reduce stress, hardship, and costs for the patients and his/her family.

Accountable Care Unit (ACU) Issues

As you may know on February 24th of this year Unit 4A followed became a closed unit in order to implement the ACU Pilot. The closed unit concept was discussed by Dr Ron Taylor in advance and at length with many Family Physician members of the Department. Dr Taylor went to their offices to discuss the proposed changes with them.

The purpose of the closed unit is to ensure that the principles of the ACU are universally implemented. These four principles are Unit Based Teams, Unit Based Routines including Structured Inter-disciplinary Bedside Rounds, Unit Based Metrics and RN/MD Co Lead Unit.

Since the implementation, there have been a few issues raised by members of the medical staff. Firstly there have been concerns that beds have been available on 4A while patients have been admitted to Code Burgundy. Indeed that is true, however the number of incidences have been few.

Secondly, concerns were raised by members of the Regina Area Hospital Doctors (RAHD) group that patients, admitted to them and prior to the patients being allocated a ward bed, were transferred to a Hospitalist and admitted to 4A without the agreement of the attending RAHD doctor. This is also true.

Thirdly, two concerns were raised by a member of the specialist medical staff that there appeared to be a reduction in the number of consultations from the attending staff on 4A. Whether this is consistent with Hospitalist practice or represents an issue will need data analysis. In any event there is an academic review of the clinical outcomes which should identify any changes in the quality of care. At the same time the cost of the additional resources deployed on the unit was raised as a concern. The thesis from the original article is that quality of care increases, mortality and length of stay decrease, and the costs of care are also reduced in spite of the added investment.

RQHR Commences Left Atrial Appendage Closure Program

With the aging population inNorth America, the prevalence of AF and stroke is expected to double by 2050.In non-rheumatic AF, more than 90% of thrombi develop in the left atrialappendage (LAA), a small sacculation of the left atrium located between the left upper pulmonary vein and the left ventricle.

Anticoagulation is the cornerstone of therapy for AF for patients with elevatedrisk of stroke.

The most recent randomized data of > 700 patients suggests that after 4 years of follow-up among patients with non-valvular AF at elevated risk for stroke, percutaneous LAA closure is more effective in reducing hemorrhagic stroke than warfarin, and significantly reduces all-cause mortality.

At the presenttime, this device is offered to patients who meet the following criteria:

  • Have non-valvular AFIB;
  • At increased risk for stroke and systemic embolism based on CHADS2 or CHADS2-VASc score;
  • At increased risk for bleeding based on their HASBLED score or have had major bleeding while on anticoagulation;
  • Patients must be able to tolerate 6 weeks of warfarin therapy

A closure program is already established in RQHR in which patients are seen by Dr. Dehghani and/or Dr. Booker. After a group discussion including expertise opinion (in form of satellite presentation at video-conference) a consensus is reached about suitability of closure and the patient is consented.

The Cardiology team sees LAA closure as an extension of the system that is already in place. Both Drs. Dehghani and Booker will discuss all patients referred for this procedure. Dr. Murthy has agreed to be the principal echocardiographer for the procedure. Dr. Duffy will see each patient as well and a group consensus will be formulated prior to the case. Approval has been granted for a volume of up to 24 patients for the first 12 months of this program.

Excerpt From: Executive Summary by Payam Dehghani, January 17th, 2016 which is available from Dr McCutcheon