- Physician-led engagement results in a clean air solution in PFT Lab
Left to right: Dr Heather Clark, Repirologist, Carmen McClymont, Senior Respiratory Therapist, Jodi Zimmer, Supervisor, Respiratory Ambulatory Programs - with the Ambius air filtration unit.
Like many older hospitals, the Royal Jubilee Hospital (RJH) in Victoria has clinical spaces that began as patient rooms. The Pulmonary Function Testing (PFT) Lab is located in such a space. When COVID hit, the lab was challenged: how do you conduct PFT when patients can’t wear masks and the room is not properly ventilated?
During the first couple of months of COVID, the lab remained closed, except for emergencies. Then the Canadian Thoracic Society came out with regulations for the safe resumption of lung function testing.
To meet these regulations, PFT at RJH resumed on a limited basis. A room had to be closed down for three hours between each patient to ensure any airborne viruses had settled.
Dr Heather Clark, a respirologist and the medical director who oversees PFT knew they needed a better, long-term solution.
Facility Engagement funding
A Facility Engagement (FE) project looking at patients with long COVID symptoms accelerated a solution. Lung testing was part of this FE project. “In talking with a colleague who was requesting these tests and explaining our issue – he suggested I apply to FE for funding to help us," says Dr Clark.
Dr Clark successfully applied for FE project funding to improve the air exchange in the PFT lab, which consisted of three rooms. “Applying for funding turned out to be easy. Clara Rubincam, FE Project Manager was a great help," she notes. "Physicians are so busy – I’d like them to know it is easy to apply for the funding, and there is a lot of guidance and assistance available.”
Engaging stakeholders in solutions
Dr Clark began by gathering a group of relevant stakeholders, such as PFT lab supervisors, ambulatory care administrator, facility maintenance to participate in a number of Zoom meetings. The meetings helped solidify a solution, which initially would have involved renovating each of the three testing rooms over a period of three to four years.
Cross-site knowledge sharing
Dr Clark connected with a colleague at Providence Health Care and asked him what they were doing to address the aerosolization of viruses and air exchanges. It turns out they were looking at other technologies, such as air filtration.
“He connected me with the facility maintenance manager at Providence and their pulmonary diagnostics coordinator, and I introduced them to our facility maintenance person. The air filtration units became the right solution. Rather than air exchanges, they now have air filtration, filtering the air through HEPA and carbon filters to achieve the equivalent cleaning of the air."
Part of Dr Clark’s success was due to Charlotte Bowey, an Island Health administrative assistant who was working on her Master’s Degree in project management, who scheduled the meetings, attended and took notes. “She was crucial to my success," says Dr Clark. "She knew who I should involve. She also knew just when to send out meeting notes to keep everyone engaged.”
“I’m pleased we solved the problem and I wouldn’t be losing sleep at night. My patients are compromised, often they are on immuno-suppressors and I need these tests to know if the therapies are working and how to adjust them if they are not.”
Solutions save costs
One advantage to this project is having the Providence Health Care solution already evaluated and approved before an investment was made at RJH. In addition, the cost savings are quite significant. Initially, $100,000 was earmarked to renovate one room. In the end, the costs for the health authority for air filtration systems for all three rooms were about $45,000.
Dr Clark’s adds an observation about obtaining FE funding. “I didn’t understand that it could be applied to this project – I thought it would have to be more directly tied to patients. I think it’s important to let physicians know that it is not difficult and that people want you to succeed.”
For about 20 years, the Royal Columbian Hospital (RCH) was the unofficial referral centre to help treat Placenta Accreta Spectrum (PAS), a serious pregnancy condition that occurs when blood vessels and other parts of the placenta grow too deeply into the uterine wall.
During delivery, a PAS patient may experience an average blood loss of about two to three litres with a need for a transfusion of up to 4-1/2 units of packed cells. There’s an 85% chance of a hysterectomy and a 50% chance of urological injury to the ureter or bladder.
In 2020, Dr Sara Houlihan, an obstetrics and gynecology surgeon at RCH applied for funding from Facility Engagement (FE) to help establish RCH as the provincial PAS Clinic.
“There is extensive research supporting this excellence of care model to reduce serious complications and deaths.” - Dr Sara Houlihan
Dr Houlihan engaged a small multi-disciplinary team to collaborate on overlapping processes such as ultrasounds, iron infusions, surgical interventions, and so on. “
There are so many wheels to put in motion when a patient gets referred to us,” says Dr Houlihan.
Clinic and website
The multi-disciplinary PAS Clinic is now officially open, along with a PAS Clinic website, which is available to both care providers and the public. The website educates about the condition and provides referral forms to access services.
"We have reduced blood loss and decreased transfusion rates; we’ve reduced length of hospital stays – which is amazing for patient care."
Timely detection and risk factors
Timely management of this condition is imperative. The condition is often first detected on an ultrasound, usually at 22 or 28 weeks. Dr Houlihan notes, “it is a devastating condition that can have major ramifications for patients and the quality of their lives.”
If a radiologist suspects there is an abnormal placenta during a routine ultrasound – they suggest a referral and evaluation to the primary care physician, who can then refer the patient to the PAS clinic.
There are also risk factors that can pre-dispose a patient to have PAS, such as prior C-sections (the more C-sections, the greater the risk), placenta privia (placenta overlying the cervix) and any previous uterine surgery.
These pre-existing conditions can trigger a referral, which is why the PAS Clinic is working to raise awareness about these risk factors with care providers.
Why Royal Columbian?
Dr Houlihan talks about why RCH is uniquely qualified. “To be a centre of excellence you must have obstetrics ultrasound technicians who has experience in PAS, you need a capacity to do MRIs and radiologists who have experience in PAS, a level three maternity and nursery, ICU, obstetrical anesthesiologists, transfusion medicine and specialized surgical teams," she notes.
"Our biggest ace are our maternal fetal medicine sonographers. They are the ones who do the ultrasound, determine risk levels and triage for appropriate care."
“We are consultants on this issue – so the primary care provider continues the prenatal care – we stratify the patients’ risk with imaging, optimize patients with referrals to specialists and sub-specialists, and for high risk patients, we perform their surgery at RCH.”
Awareness and education
Education is important – so Dr Houlihan and her team are spreading the word about the PAS Clinic and its resources through discussions with the Obstetrical Societies in BC. For family physicians, plans are in the works to do in person education sessions. In addition, all the information has been uploaded to Pathways, which includes referral forms and patient handouts.
Progress and looking ahead
The long-term goal for the PAS Clinic is to navigate PAS patients through every step of their journey, including comprehensive after care that would address both the physical and psychological impacts of this condition.
Asked what she is most proud of, Dr Houlihan said, “I’m happy about the gains we have made in patients’ outcomes – we know we have reduced blood loss and decreased transfusion rates; we’ve reduced length of hospital stays – which is amazing for patient care.
"We all want to provide excellence in maternity care and everything we have been doing has made a positive difference.”