TECHNOLOGY IN MEDICINE The Development of a Replacement Pathology Service in a Community Hospital in Quebec Using Telepathology & Supportive Service Corridors ABSTRACT Santa Cabrini Hospital is composed of 369 acute care beds, with a separate pavilion providing services for 100 long term care patients. The hospital is situated in the northeastern part of Montreal, and provides services to an area that encompasses approximately 750,000 people. Santa Cabrini Hospital is also a trauma centre and a primary (local) cancer centre. The hospital has functioned with two pathologists. The two pathologists resigned abruptly for personal reasons leaving no one to replace them. The manner, in which they were replaced, reflects on both the organisation of the Quebec health and social services system and the collaborative effect of the many players, and resources in the network. It involved close administrative collaboration of all partners in the health sector, in laboratory and pathologic medicine under the direction of the Agency involved, and manpower and resource allocation, to meet all the demands. It also required participation of multiple hospital centres. Telepathology was incorporated into the replacement model, again supported by the pertinent partners in the process. The exercise led to short and intermediate term solutions and allowed the hospital to rebuild its pathology department, again through collaborative recruitment. KEYWORDS: pathology service, community hospital, telepathology, Quebec ABOUT THE AUTHORS I.W. Kuzmarov MD FRCS(c), 1 S Trifiro MD FRCPC, 2 Bich N. Nguyen MD FRCPC, 3 1 Director of Professional and Hospital Services, Santa Cabrini Hospital, Department of Surgery (Urology) McGill University, 2 Department of Pathology, Santa Cabrini Hospital, 3 Department of Laboratory Medicine, University of Montreal Hospital Centre.
Santa Cabrini Hospital is composed of 369 acute care beds, with a separate pavilion providing services for 100 long term care patients. The hospital is situated in the northeastern part of Montreal, Canada and provides services to an area that encompasses approximately 750,000 people. Santa Cabrini Hospital is also a trauma centre and a primary (local) cancer centre. The operating room is very active with over 7,250 surgical procedures per year. There are approx. 43,500 patient visits to the emergency department each year, of which 42% of the patients are 75 years and older. In 2011, there were 8,406 admissions to the hospital. The hospital staff includes 112 doctors, of which there are 4 oncologists who manage a busy oncology clinic Figure 1: The Organisation of Quebec Healthcare Central REGIONAL Local level of over 12,500 patient visits per year. The pathology service has one fulltime and one part-time member. Annually, the service receives over 12,000 histological specimens and approx. 28,000 cytological specimens. Over 900 new cancer cases are diagnosed each year. Colon cancer, breast, lung and prostate cancers are the most frequent solid tumours that present to the hospital. The hospital has functioned with two pathologists for many years. The two were highly efficient and produced a large volume of pathologic units that could have easily necessitated three full-time pathologists. The two pathologists resigned abruptly for personal reasons leaving no one to replace them. The manner, in which they were replaced, reflects on both the organisation of the Quebec health and social services system and the collaborative effect of the many players in the social healthcare network. This will be described below under several headings: 1. the organisation of health and social services in Quebec 2. the specific corridors of service with the partners in the network 3. the introduction of telemedicine, specifically telepathology The Organisation of Health Services in Quebec Healthcare is universal in Canada, administered by the provinces but under the federal umbrella 23 Journal of Current Clinical Care Volume 3, Issue 2, 2013
via the Canada Health Act, which describes the conditions to be met by the provinces in order to receive the transfer payments that help The Quebec model divides the province into sectors with each sector having full complement of both acute care and chronic care facilities, including out-patient clinics. support it. It must be accountable and portable from one province to another. The health and social services in Quebec are under a single administration. There are three management levels, central, regional and local, whose governance is results-oriented (Figure 1). The central level is the ministry under the elected minister of Health and Social Services. It establishes policy and evaluates the results obtained according to the goals set. At the regional level, the health and social service agencies (of which there are 18 across the province) are responsible for establishing the services necessary in their territory. This includes the development of policy direction, regional priorities, and most importantly, facilitating the deployment and management of the local network of services, and providing the budget necessary to achieve the objectives. The local level unites all the partners in the region to ensure comprehensive multidisciplinary care. Furthermore, there is a horizontal Integrated University Health Network system in the province of Québec (Réseau Universitaire Intégré de Santé RUIS) which divides the Quebec map into 4 territories connected to 4 Faculties of Medicine: Laval University, University of Sherbrooke, McGill University and University of Montreal. Santa Cabrini Hospital is within the territory of the latter. The Quebec model divides the province into sectors with each sector having full complement of both acute care and chronic care facilities, including out-patient clinics. This healthcare system, under the control of the Agence de la Santé et des Services Sociaux de Montréal or the regional Agency, reports directly to the Ministry of Social Services and Health. This allows for regional support of institutions in times of need, and rapid communication when needed. The absence of pathologists led to an immediate communication to all the pertinent partners for aid. In addition, a request was made to the Agency and the Ministry to provide help (if necessary). Communication between the levels can be horizontal or perpendicular, depending on the objectives and needs. It is obvious that collaboration within the Network can be easy and efficient. 24 Journal of Current Clinical Care Volume 3, Issue 2, 2013
The Establishment of Service Corridors in Pathology The regional organisations involved in medical manpower are the Agency responsible for the territory, the University and the Federation of Medical Specialists, via the Pathology Association. All three are involved in manpower allocation (Figure 2). In a health care system with an oversupply of physicians, one could easily replace physicians by other available physicians. In an environment, where the number of physicians is tightly controlled, it is not a feasible solution. The more logical solution is to establish service corridors, where one hospital or more provides support to the hospital in need. This can be by providing Figure 2: Potential Service Corridors. University Agency Potential help in establishing service corridors Federation & the Pathology Association manpower support on a regular basis or a temporary basis. In our hospital the large surgical volume (both inpatient and out patient) and the importance for appropriate response times for pathological support, made this demand, for full medical manpower replacement impossible to obtain. Several different service corridors were established after consultation with our partners in the region: University of Montreal Hospital Centre (Centre Hospitalier de l Université de Montréal CHUM) and Sainte- Justine Hospital, both belonging to the RUIS of University of Montreal. They provided either pathologists on site for frozen sections and dissection of organ specimens arriving from operative cases or accepted histological slides for tissue diagnosis at their respective hospital. Gynaecological cytology slides as well as non gynaecological slides were sent to various pathologists participating in the temporary service corridors. A few pathologists from non university hospitals also accepted to read both histological and cytology slides ( Fleury,Granby,Gatineau).In addition, a private Québec pathology Laboratory was employed for approximately 13 weeks at the onset of the crisis. Digital Pathology/Telepathology Intraoperative consultations with or without frozen section, are indicated when a tissue diagnosis is 25 Journal of Current Clinical Care Volume 3, Issue 2, 2013
Figure 3: Telepathology System Figure 4: Telepathology System Figure 5: Telepathology System required to allow the surgeon to make an intraoperative decision regarding further surgery during that operative event. This service is particularly critical for oncology cases to access margins status and plan for future treatment resources. Traditionally, tissue samples are sent to the pathology laboratory, then snap frozen and mounted on glass slides for immediate microscopic examination by a pathologist on site. In the situation described, the coverage of intraoperative consultations was temporarily done by several pathologists from the CHUM over a six month period, while a system of telepathology or digital pathology and a videoconferencing system were rapidly put in place. Digital pathology once functional provides direct visualization of the specimen and verbal communication between sites are possible with a videoconferencing system. This system is composed of a digital camera, a digital sound system and a digital board. The latter allows the off-site pathologist to delineate the area of interest with a digital pen thus guiding sampling of the on-site specimen under direct supervision. The tissue samples mounted on glass slides are then transformed into digital images with a slide scanner. These images can be shared electronically by care providers. In the situation described, off site pathologists from the 26 Journal of Current Clinical Care Volume 3, Issue 2, 2013
Models of integrated universal healthcare systems with centralized pyramidal or longitudinal structures can meet many challenges. CHUM can provide care to both Santa Cabrini Hospital patients and CHUM patients with great efficiency. Obviously, digital pathology is an asset in settings other than intraoperative consultation: to request an opinion from an expert, to share interesting cases, for tumour boards linking different hospital sites. This system of Telepathology was instituted in our hospital in the setting described above. The government quickly approved the project and provided the budget and the equipment needed to rapidly institute the system (Figure 3). This completed the replacement of the departed pathologists and reinstituted coverage of hospital needs in all sectors. The corridors of service were temporary in nature, but allowed the hospital the time to recruit new pathologists for the service. This healthcare system can deal with issues that range from emergency management, to resource distribution, to the establishment of critical care pathways in all sectors. This organisation allowed our community hospital to provide quality care to patients and laboratory results with important response times while under the duress of an abrupt loss of pathology manpower. References 1. Kuzmarov I, The Aging Male, 2009,12 (2-3) 37-40. 2. MSSS, Ministry and Network- Health and Social Services 2012. 3. The Quebec Health and Social Services Network Integrating Public Health and Local Healthcare Governance in Quebec Organisation and Perspective,Health Policy 2009 February 4(3) 159-178. 4. Santa Cruz Daniel J. editor, Seminars in Pathology, Telepathology, vol 26 No4 November 2009. Conclusion Models of integrated universal healthcare systems with centralized pyramidal or longitudinal structures can meet many challenges. 27 Journal of Current Clinical Care Volume 3, Issue 2, 2013