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Research/Quality Practices

2001 First Place

Title:

Non Clinical Savings Help Keep Dollars in Patient Care

Author:

Bruce Gorman

Director of Materiels Management, Health Care Corporation of St. John's

Entry:

Increasing financial pressure in healthcare has forced all health boards to examine expenditures. The Materiels Management Department of the Health Care Corporation of St. John’s has been acutely aware of these pressures, and the significant savings and efficiencies of this support department have enabled the Corporation to limit budget decreases in clinical programs. Moreover, the Materiels Management Department has not only achieved this within its own functional responsibility, but has contributed to the efforts of other departments and programs by coordinating standardization and efficiency initiatives.

The Health Care Corporation of St. John’s was formed in April 1995 from the consolidation of seven separate organizations covering nine physical sites. The Materiels Management Department was formed in September 1995 with the appointment of a regional director.

The first objective of the department was to develop and implement a structure that would serve the needs of the new health organization. The Health Care Corporation of St. John’s currently has a program-based system, consisting of sixteen clinical programs and sixteen corporate departments. The site-based, service-delivery model was changing, and the Materiels Management Department needed to change with it. The department was reorganized with three functional areas: purchasing; inventory and distribution; and materiels processing (CSR).

The next step was to consolidate information systems. Each site had a different version of the Meditech MM System, with different dictionaries, vendor information, item information, and so on. The largest of the systems, the General Hospital, was chosen as the core system, and a process of matching duplicate information from the other sites began.

Although there were many identical vendors and items, each site system had assigned its own identification numbers, and the matching process required extensive manual work. The Information Management and Technology Department developed a matching program that flagged exact matches based on vendor catalogue numbers and item descriptions, but there were still many duplications. Consequently, the Manager of Inventory and Distribution had to review all items to ensure that flagged items were, in fact, duplicates, and that the many items not flagged did not indeed have duplicates, which in many cases they did. This process was ongoing for quite some time as duplicate items were discovered when inventories began to merge.

The end result is a corporate-wide Materiels Management information system. Each vendor and supply item has a unique number that is used across the organization. As storerooms are still maintained at most sites, it is important that items can be tracked and identified. Staff members are now able to access any of the site inventories and locate items no matter where they are stored.

The next step in the move to improve efficiency was a physical one - centralizing all purchasing staff at the Corporate Office. Before Materiels Management began to unify services, purchasing staff were located at each site. With a corporate-wide information system, however, this was no longer necessary. By centralizing staff, workload efficiencies were gained, resulting in labour savings. Enhanced communications, online requisitioning, and improved delivery of service demonstrated to consumers at each site the value of this change.

Standardization of supplies and services became a major goal during the next stage. There were numerous contracts at different sites for the same products, often at different prices. In addition, there were multiple brands of the same product because of site-specific preferences.

A process was put in place to consolidate contracts for identical brands being purchased from the same vendor at different contract prices into one contract at the lowest price currently being paid. Vendors were very cooperative on this issue, and an immediate reduction in the overall purchase costs of these items was realized. For those same or similar items being purchased from different vendors, re-tendering began as contracts expired. Volumes were combined to improve purchasing leverage, and new contracts for these consolidated items also reduced purchase costs.

In March 1996, when inventories were first consolidated, the Health Care Corporation of St. John’s carried 4,250 line items with a value of $1,850,000. Inventory turned on average 7 to 8 times annually. Only 5 years later, in March 2001, the corporation now carries 3,510 line items - a significant reduction of 17%. This reduction has occurred even though hundreds of items have been added to inventory that were previously ordered by programs and departments directly. An item-by-item review, based on new stock guidelines, was completed. Our inventory value is now $1,280,000 - a reduction of 30% - with an average turnover of 12 to 14 times annually.

Consolidation and standardization has also occurred for a variety of services including snow clearing, banking, courier, legal, and auditing. In each case, consolidation has produced contracts substantially below the previous total cost for the separate organizations. For example, in 1995 we paid approximately $130,000 annually for audit fees, while in 2001 we pay $39,000.

The Materiels Management Department does not achieve this consolidation and standardization in isolation. The cooperation of the end users is required, and significant evaluations and reviews of the various products and services are performed. A Product Evaluation and Standardization Committee was formed very early in the reorganization. Chaired by the Director of Materiels Management, the committee relies on representation and input from the following areas:

A formal policy on product evaluation was drafted and approved by the committee, along with an evaluation form. This form ensures that all appropriate issues are addressed in any evaluation, including cost, utilization, ease of use, patient impact, patient outcome, safety, ergonomics, risk and infection control. As product evaluations are required, evaluation sub-committees are formed.

The Product Evaluation and Standardization Committee deals with standardization issues also. This ensures that product duplication is limited to instances where appropriate justification is present, and not simply on the basis of individual preference.

Consolidation and standardization of supplies and services has produced more than just positive financial results. Staff are able to move throughout all sites, programs and departments of the Health Care Corporation of St. John’s without having to become familiar with different products. This reduces orientation and training costs, and improves efficiencies. Additionally, a concentrated effort to standardize clinical forms has resulted in the reduction of approximately 450 forms. This has a significant impact on both forms, management costs, and clinical processes. The creative thinking that goes into standardization enhances patient care.

Two success stories are surgical implants and hemodialysis. In the case of surgical implants, the corporation had been using three different systems. With the cooperation of the surgeons, proposals were accepted from a number of vendors in an attempt to consolidate contracts and systems. The successful contract resulted in a unified approach that includes both orthopedic and plastic implants, and will save about $350,000 over a three-year contract.

Hemodialysis is a service that is continually growing with escalating costs. Previous contracts were based on an item-by-item price that continually rose as volumes increased. A new contract was negotiated with a vendor based on a fixed cost per patient per day, regardless of the amount of supplies used. There is a shared responsibility between the corporation and the vendor to monitor this contract, which saves $160,000 annually. As there is a fixed cost, the time and expense of issuing individual item purchase orders has also been eliminated, and only one invoice per month needs processing. This contract was a first for hemodialysis services in Canada.

In total, the Corporation has estimated annual savings of over $3 million from the consolidation and standardization of supply and service contracts. In addition, the Materiels Management Department has reduced its own annual operating budget by over $1 million. This significant savings has been accomplished through process standardization, centralization of some functions, and improved efficiencies such as Electronic Data Interchange, automated inventory replenishment, and modernized decontamination/sterilization equipment. The Materiels Management Department expects further efficiencies to be gained from expanded online requisitioning of supplies, centralized inventory operation, and e-procurement. These efficiencies, combined with the initiatives already achieved, will help reduce cost pressures in clinical areas.

Quality patient care is a priority of the Health Care Corporation of St. John’s, and Materiels Management continues to make important contributions through initiatives that are fiscally responsible, efficient, and innovative.

2001 Second Place

Title:

Central Venous Access Devices Versus Peripheral Intravenous Catheters In the Oncology Setting

Jocelyn Farrell, R.N.    

Staff Nurse, Dr. H. Bliss Murphy Cancer Center.

Entry:

A cancer diagnosis is like the first in a long series of dominoes. The confirmation of the diagnosis begins the fall, and the subsequent information provided by medical practitioners continues the cycle. When an individual is told he has this disease, the news begins badly and usually becomes worse before it gets better, with the most devastating information often being how the cancer will be controlled or cured.

Cancer is treated with three major modalities, alone or in combination; namely, surgery, radiation, or chemotherapy, either intravenous or oral. Both solid tumors and hematological disorders frequently incorporate intravenous chemotherapy as the initial method of treatment.

The dilemma a patient faces before intravenous treatment begins is whether or not his peripheral venous access is adequate to sustain him through numerous administrations of the medication and the repeated blood tests required to monitor hematologic status during chemotherapy. Many suffering from cancer have compromised venous access viability due to disease, or related to surgical treatment of disease, such as poor nutritional status leading to weight loss, amputation, edema, or infection. These patients require patent intravenous access for both phlebotomy and administration of chemotherapy, and often, after repeated attempts, access cannot be established. The trauma of repeated skin punctures is detrimental to both patient and caregiver, establishing an environment filled with anxiety and fear that is frequently more difficult for the patient to endure than the initial diagnosis.

There are many options available today to prevent this all too common problem facing both patients and the medical practitioners involved in their care. The focus of this article is the central venous catheter. These catheters are used far too infrequently in the ambulatory oncology setting because a large majority of patients are resistant to the idea of the placement of an indwelling device for an extended period of time. In discussion with many patients receiving systemic chemotherapy, I, in my capacity as an oncology nurse, have determined the greatest concerns are insertion, infection, and the daily care of the apparatus. In this article, I will discuss the variety of central venous catheters available, methods of insertion, and general usage and care. Patients often resist the use of these devices because of abstract anxiety, which can be dispelled with the presentation of the facts through education by medical practitioners, and support from patients who have experienced the benefits of a central line. This discussion is my attempt to provide patients presented with this treatment option a guide to both the advantages and disadvantages of a central venous catheter versus a peripheral access device for the administration of systemic chemotherapy.

Peripheral venous access refers to the familiar "IV" line used for the administration of medications, blood products, and fluids in the hospital or outpatient setting. A short (most catheters for peripheral use are approximately one inch long) beveled needle is sheathed inside a flexible catheter. Once the catheter is established in a vein, the needle is pulled back through the catheter and discarded. These devices require changing every three days, depending on hospital policy, to prevent infection at the insertion site. A transparent dressing is placed over the insertion site, and in cases when the intravenous is not continually required, a heparin lock may be placed at the end of the catheter to maintain access for the next use. A flush of normal saline or heparin is necessary daily to prevent blood clotting in the catheter.

Peripheral catheters are practical in the hospital setting for short term use because medical personnel are available to monitor their patency and general condition. Changes may be frequently required due to dislodgement, or irritation to the vein from medications. Because the peripheral veins are small, and the blood flow around the catheter while it is in the vein is minimal, irritation is common when administering rapid infusions or known irritant medications. Many commonly used chemotherapy drugs are vesicants, meaning they are capable of causing tissue destruction along the vein in use if dislodgement or vein deterioration occurs during its administration. Vesicants are continuously monitored by nursing staff during their administration, but in chronically-accessed veins, deterioration is inevitable. Peripheral catheters are impractical for use at home because the patient must keep the insertion site clean and dry, movement is limited in the arm housing the catheter if dislodgement is to be prevented, and blood cannot be drawn from the catheters, except upon insertion.

There are three commonly used central venous access devices currently used in the Province of Newfoundland and Labrador. Firstly, and most familiar, is the tunneled central catheter, generally known by the brand names, Hickman or Groshong. This type of central line is inserted in the outpatient day surgery department by a surgeon, using light sedation and local anesthetic. A needle, sheathed by the catheter, is threaded through a vein in the neck (that is the external or internal jugular vein), or a vein under the collar bone, called the subclavian vein, via a small incision in the upper chest. It is further threaded into the superior vena cava, the largest vein leading directly to the heart. The tip of the catheter remains in this vein, but the other end is inserted or "tunneled" under the skin of the chest for approximately six inches, exiting below the collar bone, making the tubing externally accessible. The needle is removed after insertion.

A chest x-ray is necessary post insertion to ensure correct placement, and once this is established the catheter is ready for use. The insertion procedure is safe, with the possibility (in less than five percent of cases) of the needle puncturing the lung, or causing bleeding into the chest. Both these complications are short term and can be effectively medically-managed without long term patient detriment. Often, after such complications, patients revisit the surgeon for repeat placement of the central line without difficulty.

The exit site of the catheter will require a sterile dressing twice weekly after the initial post insertion regime of daily dressings until the placement sutures are removed at seven days from the entrance site and fourteen days from the exit site. The area is easily accessible and is cleansed proximally to distally with Stanhexidine, and covered with a sterile dressing that is anchored in place with Hypafix tape. The catheter itself will require flushing twice weekly to coincide with the dressings, with either normal saline or a combination of normal saline and heparin to prevent blood clotting in the tubing. The common long term complications of the tunneled central venous catheter are infection and blockage. Infection, whether local or systemic, will indicate antibiotic therapy, and in the case of persistent infections, the removal of the line may be necessary. Blood clotting can occur in the tubing, preventing infusion or phlebotomy. Often the use of Urokinase, a thrombolytic medication injected directly into the catheter, can dissolve a clot and restore function to the line. However, as with persistent infection, if the clot cannot be eliminated, the central line must be removed.

The advantages of the tunneled central venous catheter are many and varied. Firstly, the elimination of frequent needle sticks to establish patent intravenous access, and for blood drawing, greatly decrease patient discomfort and anxiety. Irritants, vesicants, and all other intravenous medications can be administered via the catheter quickly and safely due to the large amount of blood flow around the line which effectively dilutes the drug being administered. Parenteral nutrition, including hyperalimentation and lipids, as well as other fluids and blood products, can be given via the line. Blood drawing from the catheter is safe and effective; however, in some cases, proteins can deposit at the tip of the tubing, making blood removal difficult, if not impossible, by pulling into the catheter tip when suction is applied. These proteins simply fan out from the catheter tip during the insertion of fluids, so they do not impede the performance of the central line in administration.

The care of the catheter is easily learned, but if the patient is unwell, or reluctant to accept responsibility for it, Community Health and Services nurses are available for home visits to assess and care for the central line. The tubing visible on the outside is generally no more than six to eight inches long, and can be safely looped into a small circle and taped to the dressing, making it invisible under most apparel, and securing it from dangling and possible entanglement in clothing, bed linen, etc. The presence of the catheter has no impact on activities of daily living, such as bathing, exercise, sexual activity, and virtually all other pre-insertion activities are permitted.

The second type of central venous access device used in this province is the implanted port, an internal catheter. The port is a small reservoir with a rubber connection that is fixed to a catheter entering the subclavian vein. The apparatus is surgically implanted under the skin in day surgery with local anesthetic and mild sedation. These devices are referred to as internal catheters because they are completely located under the skin, and are visible externally as a small raised area under the clavicle. The site is located by palpation and accessed with a curved needle called a "gripper". The port may be accessed each time it is to be used, or the gripper needle may be secured in the port with a transparent dressing that requires weekly changes. The implanted ports can withstand up to two thousand needle entries, but the puncture is usually not uncomfortable for the patient. However, some patients prepare the port site for puncture by applying Emla cream, a topical anesthetic. These devices require no dressings if the gripper needle is not in place, and heparin and normal saline flushes are necessary after use, or monthly, whichever is applicable. Blood may be drawn from the port, but the success rate is lower than with the tunneled catheters. Long term complications are rare with implanted ports. Infection is not a significant problem with intermittent use, for which the port is recommended, but daily access may lead to skin deterioration at the puncture site and possible infection via the excoriated area. Blood clotting may occur and is treated in the same manner as with the previous mentioned central line. Medication, including chemotherapy, fluids, parenteral nutrition, and blood products may be given through the port, as with the tunneled catheter, without the regular care it requires, but for frequent use the tunneled catheter would be indicated.

The third type of central venous access device to be discussed in this article is the Peripherally Inserted Central Catheter, or "PICC". These catheters are inserted peripherally, meaning they are inserted into a vein in the arm, generally at the antecubital fossa; that is, the bend at the elbow. Physicians or nurses insert these devices, depending on hospital policy, in the same manner as a peripheral intravenous line, without necessitating the use of either sedation or local anesthetic. The needle is inserted and the catheter is threaded through the vein until the tip reaches the superior vena cava. The catheter is sutured in place and a chest x-ray is performed to confirm correct placement. The insertion site is covered with a transparent dressing, and dressing changes are required weekly. The catheter is flushed every twelve or twenty-four hours, depending on hospital protocol, with either normal saline or a combination of both normal saline and heparin. The PICC may be used for blood drawing, but proteins can adhere to the catheter tip as with other central lines, and may make this procedure difficult.

These central venous access devices tend to place more restrictions on the patient in terms of activities, due to the limited movement required in the accessed arm. Extreme movements of the arm could cause displacement or damage to the catheter, and because the insertion site must be kept clean and dry, care must be taken when bathing. Catheter care is awkward because it must be performed with one hand, and most patients cannot do the care independently for this reason. The position the PICC is in on the body makes it highly visible when the patient is wearing short sleeves, and therefore is not as discreet as the other central lines.

The decision to use a central venous access device ultimately belongs to the patient. Indwelling central venous access lines require a commitment to their meticulous care, and the responsibility of their maintenance cannot be expected of a patient who is debilitated, extremely anxious, or simply not motivated to care for a central line. Central venous access devices require care outside the hospital setting, and this is not for all patients; therefore, the decision to use these devices must be made with patients, their families, and their health care providers, as a team. The most important contribution a medical practitioner can make to a patient facing the possibility of long term intravenous drug therapy is to provide him with the information and education necessary to make an informed, appropriate decision that will make his experience as positive and beneficial as possible. The decision the patient finally makes regarding a central venous catheter is not as significant as the fact that he was made aware of their functions and possibilities, and made an informed decision based on his own personal capabilities and opinions. Information is power, and when the dominoes begin to tumble with the cancer diagnosis, the patient who has been informed of all his treatment options is the patient able to regain some control of where he falls.

2001 Third Place

Title:

When is a Crisis Really a Crisis?

Author:

Mohamed Ravalia

Family Doctor in Twillingate

Entry:

Canada is consistently rated the best country in the world in which to live, but a close look at the tension and acrimony in the Health Care System here would lead one to believe that the wheels are about to fall off the chariot of health care provision.

Have we reached a historical crossroads at which point we need to evaluate how health care is provided and prioritized, and does the focus need to shift the way we think about health care, or will we line up with the doom and gloom naysayers and allow our system to end up on the scrap heap?

We have placed disproportionate emphasis on a Curative Model that is further gelled into the psyche of the television-viewing public by dramatic high tech procedures and technology that certainly dazzle, but are they really all necessary? Why does prevention consistently lag behind cure – why do we rush around in high adrenaline mode for the "sudden" heart attack, and yet ignore obesity, social ills, poverty and childhood neglect, all of which are critical factors that eventually cost the curative system billions of dollars?

Do we have the courage to take a serious look at these issues without the all-too-powerful lobby groups and the all-too-fickle politicians continuing to call the shots?

The dawn of the millennium is indeed a time that is ripe for the population of our geographically diverse and culturally rich province to ask penetrating questions about our Health Care.

Statistics clearly show a rise in cardiovascular disease, chronic obstructive lung disease and malignancies – an informed public with ready access to educational and preventive programs should allow us some latitude to devise a plan that emphasizes prevention and embraces beneficial emerging technologies, such as genetic research.

An aging population with the attendant health burden should force us into thinking about dementia, home supports, creative means of supportive community living, and caregiver stress issues, but the ever present "crises" continue to demand the lion’s share of resources as we chase waiting lists for cardiac bypass procedures.

Can we take the giant leap forward and allow some debate on how the system should and could be sustained, if only the emphasis on our true needs as health care consumers is to be met? The path of least resistance would appear to be yet another Royal Commission that will fill more space in our National Archives gathering mold and dust!

An idea can only become a reality if the population of our democratic nation is willing to become informed about alternative ways of delivering health care. This population must be given an opportunity to visualize a realistic and attainable goal. The ever present negativity which currently consumes health care provision is an infectious modality that ultimately will become a self-fulfilling prophecy – the system will "collapse".

We are constantly bombarded by large numbers of studies, papers, analysis and discussion groups that focus on measure of health care and outcomes based on arbitrary factors, such as percentage of GDP spent on health, numbers of MRI’s per one thousand of the population, or access to tertiary care.

In focusing on cure, we repeatedly are blinded to the reality that prevention and promotion of wellness could make on our global health status.

The overwhelming acuity of our health pressures is borne out of disease processes that can be directly attributable to smoking, obesity, sedentary lifestyle, childhood poverty and neglect, and accidents. Burgeoning costs have finally forced bureaucrats and politicians to begin to fund programs that look at alternative methods of delivering health care. One such program is the Primary Health Care Project that has established itself in this province at three Pilot Project Sites (Goose Bay, Port aux Basques, and Twillingate).

Not another pilot project, they say; we have had enough of these projects. Maintain the status quo – money, more money, lots more money is what will get this rusty old Cadillac back on the road…

Is that familiar gut wrenching aura of doom and gloom consuming your consciousness? There is hope – come and visit historic and beautiful Twillingate where a new model and partnership in Health Care Provision is perhaps but one way in which we look at the future.

Twillingate is an island community that juts out into the fierce North Atlantic, and over the years its people have attained a culture of pride and independence: an island people with compassion, caring and altruism. These same people have seen and faced adversity and tragedy as their livelihood has centered around the abundance of the ocean.

A key cultural component of this island psyche has been the health care of its inhabitants. From the early pioneering and inspirational foresight of visionaries such as Olds, Parsons, Woods, and, more recently, Dennison, Woodruff, Sheldon, and the like, the social focus and endearing psychological cushion in the minds of most citizens comes from the pride of the island – a Memorial Hospital. Originally built in memory of the huge emotional and personal losses of the Great War, this institution, in its more modern guise, reigns supreme over the community - a Goliath of modern architecture that commands an almost mystical presence above a rich mosaic of pristine homes and rugged rocks that pose a fairytale vision to the virgin eye.

This is a community ravaged by mismanagement in the Fishery, out-migration of almost an entire generation, and loss of surgical services in an institution which once stood as the capital of the North. Those in need (with suitcases packed) arrived from all parts of Newfoundland and Labrador where the work of the pioneering physicians saved so many lives – their stature grew as they became legends in their own time.

The hated concept of regionalization took surgery away from this institution in the mid-90’s, and with its loss the citizenry felt a profound loss – "there’s nothing left up there", they cried, and an almost hopeless sense of grief descended upon these people – a people not unfamiliar with adversity, but with a sense of helplessness as the inevitable "path to progress" meant yet another nail in the rich and historic tradition of the heart and soul of this proud community.

A diagonal shift in the thinking of federal bureaucrats has now created a window of opportunity which, if grasped, could re-establish this proud community as a leading light in the provision of health care.

Primary health care (perhaps a buzzword to some) is visualized as a model of partnership between community and health care providers to focus on community wellness. A cornerstone of this program (funded and supported by Federal financial incentives) is for a community in concert with its Health Care Professionals to foster a relationship which identifies the medial needs of a community and allows a blended partnership of multiple disciplines where teams of individuals focus on these needs and act in a concrete long term plan to improve wellness.

The community today sits on a threshold of rich possibilities – an integrated health care model which grows with its community as a partner. Critical needs can all be addressed by a team of individuals where hierarchical boundaries have broken down, and where prevention, research, teaching, and empathy become the platforms from which ideas germinate and grow.

The cynics look at this model and apathetically brush it off as yet another illegitimate child of a crazy Ottawa plan hatched by pencil pushers. Those who see the potential, however, encourage the community and its partners to look at the model, and come together to foster and nurture its possibilities.

What are the alternatives? Can any nation continue to forever support the burgeoning cost of a health care monster that is out of control?

Grasp this little seed of prevention, partnership and possibility. Nurture it and watch it blossom – the results may surprise us all.