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Physician-led lung cancer pathway reduces time to treatment for patients

Physician-led lung cancer pathway reduces time to treatment for patients

Over the past decade, options for the diagnosis and treatment of lung cancer have expanded rapidly. While that’s good news for patients, the health care system hasn’t always kept pace with the moving parts. Oncologists have been challenged to get the diagnostic information they need in a timely way to start treatment with patients. And with lung cancer, there’s no time to lose.

It's why Dr. Jeremy Ho, an Oncologist at Richmond Hospital (RH) paired up with Dr. Karen Ung, an RH Pathologist, for a Facility Engagement project where they engaged interdisciplinary colleagues in the creation of a new pathway for the diagnosis and treatment of lung cancer. Together, they reduced the average turnaround time from biopsy to treatment from 55.7 days to 34.5 days – a drop of more than 21 days - and stellar success that has potential to be used for other cancers and at other hospitals.

WAIT TIMES FOR PATIENTS: UNACCEPTABLE

Dr. Ho explains that a patient who presents to their family doctor or the emergency room needs to pass through a number of tests and specialists. They might get a CT scan, see a respirologist, get a bronchoscopy, an EBUS or a CT guided biopsy. But it doesn’t stop there.

“It’s not sufficient now to get just a biopsy that says ‘lung cancer’. Cancer care is very protocolized; we have to be strategic in how we plan our treatments. So we need to send tissue off to the BC Cancer Agency (BCCA) for more tests;  to do biomarker or molecular testing and look at the specifics of the cancer itself. That tells us what treatments are best directed at it.”

The back and forth takes time, and Dr. Ho says the process was cumbersome. Ideally, oncologists should have all of the information needed for a treatment plan at the first appointment; but in reality, it could take up to eight weeks to get that information back. 

“That is obviously a very long time when we’re dealing with an aggressive type of cancer. Families don’t understand why things are taking so long. Imagine you get a shocking diagnosis, and someone tells you, ‘we’re going to have to wait another one or two months for your molecular results to come back before we can plan for treatment’.”

“I can try to explain and address their anxieties, but at the end of the day, I agree, it’s too long,” he says. And just because it’s the way it’s always been, it doesn’t mean we just have to accept it.” 

He discussed the problem with Dr. Karen Ung, who drew inspiration from developments in breast cancer diagnosis and treatment. “It used to be all over the place, but now has a standard of care. So how can we do the same for lung cancer?  What can we do to make the process more streamlined to gain some time for our patients?”

ENGAGING COLLEAGUES AND PARTNERS IN SOLUTIONS

With the support of the Richmond Hospital Physician Society Facility Engagement funding and a project manager – they brought together cancer specialists from RH Radiology, Respirology, Oncology and Pathology to talk.  Each typically provided services independently, but this was an opportunity  to work together as a coordinated, comprehensive team to improve diagnoses and management pathway for patients. BCCA joined the discussions as a key diagnostic partner.

Over three multidisciplinary meetings held between November 2019 to February 2020, they laid out the pathway visually to consider barriers and solutions to save time and improve the standard of care:  How long from when the patient first presents with either cough or a lung nodule to when they first get the first treatment? What are the steps? What is the speed of the tumor sample getting to the BCCA?

Discussions were eye-opening. Hearing from each other’s perspectives served to flag mistaken assumptions about what actually happens along the patient pathway, and increased everyone’s knowledge about respective roles and requests. Physicians started to see themselves in the bigger picture and the impact of each of their decisions on the overall patient journey.

They identified where delays were occurring, and where small shifts in each of their roles could make a difference. Examples ranged from having respirologists take multiple biopsy tissue in the initial diagnostic for BCCA molecular testing; to having investigations occur in parallel instead of waiting for one test result before performing the next; to improving coordination of processes with the BCCA.

In 2020, the collective efficiencies started to add up. Dr. Ho says: “I was hearing less of, ‘Why are the results not here yet?’” 

But even more telling was the data. It showed the turnaround time from biopsy to starting treatment had been reduced from 55.7 days to 34.5 days – a drop of more than 21 days. “We didn’t think that we would see something as dramatic as we did.”

LOOKING FORWARD: THE BIGGER PICTURE

What’s next?  Plans include looping in emergency department colleagues, and reaching out to the community family physicians to further refine the pathway.  There’s also potential for scalability.

“This success gives us the momentum to be able to keep doing it for other things – apply to other oncological treatments that might use this similar type of testing,” says Dr. Ung.  “It’s portable and replicable across everyone in the community or in a big centre.”

“While we made individual changes, we’re hoping for more systematic changes. It is good to shine light on the system itself, because ultimately, our patients benefit from it.”

 

WHAT FACTORS MADE THIS PROJECT A SUCCESS?

THE PASSION AND INTEREST OF DOCTORS WHO WANT TO DO BETTER:  Dr. Ung: “A big highlight is that these efficiencies were gained, and in the end it doesn’t really matter if people are remunerated. Because we see that there’s an impact to the hospital, the work, and the patient, ultimately.”

A SUPPORTIVE PROVINCIAL PARTNER:  Dr. Ung: “A BC Cancer Agency partner who was passionate and eager to align goals and priorities. In the past this was not possible.”

RHPS FACILITY ENGAGEMENT FUNDING: Dr. Ung: “Funding was fuel and allowed for a venue to happen.”

A PROJECT COORDINATOR - who pushed for meetings, navigated the project pieces and data gathering (arranged separately from Facility Engagement).  Dr. Ho: “Without that role, it is likely we all would have met, had one meeting, discussed the problems, and then it would likely have languished.”

DATA COLLECTION: Dr. Ung: “It reinforces that we’re on the right track; keeps the momentum going.

 

Finding common ground

Collaboration increasing between VPSA physicians and their health authority

Every month leaders from the 1,900-member Vancouver Physician Staff Authority (VPSA) and Vancouver Coastal Health (VCH) sit down to talk over mutual issues. They come to each meeting with an intentional focus that was agreed to by both groups and they rotate who chairs the meeting between VCH Interim President and CEO Vivian Eliopoulos and VPSA Managing Director Dr. York Hsiang.  There is lots to talk about; both see physician wellness as a priority and they are also both invested in ensuring diversity, equity and inclusion among medical staff, and—for the past year—quickly communicating news regarding COVID-19.

VCH Physician Wellness Steering Committee

Since its start, VPSA has intentionally focused a large part of its work on wellness. In 2019, the health authority suggested combining forces to assess the level of burnout amongst physicians, to find its causes, and to develop collaborative solutions. The VCH Physician Wellness Steering Committee was formed with five health authority representatives and 12 VPSA members.

“We quickly realized we needed to understand what drives physician burnout and how that is different in every department,” said committee co-chair Dr. Zafrina Poonja. “We surveyed members in late 2020 and are now reviewing the data.”

Dr. Poonja credits the interdisciplinary composition of the committee with its ability to move the issues of physician wellness forward.

“We each bring a different perspective and it’s been important to have the support of VCH leadership. The health authority is invested in this issue and wants to do more so we can all be well; they’ve been very supportive. There are no quick fixes; there are issues within our system and within health care that are long standing. But if we can target micro interventions there could be a domino effect. It will take a lot of time and many grassroots initiatives, but my participation on this committee has made me hopeful.”

Communicating unexpected outcomes

Not all medical procedures go as intended and it is often left to physicians to deliver distressing news. It is therefore vital that physicians know how to communicate unanticipated results in a sensitive manner. VCH reached out to VPSA for help with this as it is a concern for both physicians and the health authority. VPSA funded a select group of skilled physicians to attend Communication of Unanticipated Outcomes in Healthcare training in fall 2020, thus developing an inhouse group of experts who will now teach the course to other physicians and health-care teams across the region.

“Partnering with VPSA on this project was paramount to ensuring physician engagement and collaboration,” said VCH Regional Director, Patient Experience Elizabeth Baron. “As we learn more about how to better include physicians as a part of our health-care teams and represent a cohesive approach to communicating with patients and families, we hope to see improved experiences for everyone. The impact of improved disclosure conversations—in addition to it being the right thing to do—has been shown to build trust in the organization, reduce fear of blame, decrease litigation against providers and the organization, and also shed light on organizational opportunities for improvement.”

“This project was a great example of recognizing a problem common to both physicians and the health authority, developing a response, and enacting solutions,” added Dr. Hsiang. “The educational leadership we’re creating will lead to improved communication skills that will ultimately benefit patients and their families.”

Later this year, the physician trainers will begin training their colleagues in communicating unanticipated medical outcomes.

Improving equity and inclusion in medical leadership

In January 2019, VPSA hosted an appreciative inquiry into meaningful leadership experiences and opportunities for women physicians. That work inspired the creation of the VCH Medical Staff Diversity, Equity and Inclusion (DEI) initiative. Eleven physician members sit on the committee along with four VCH medical leaders. The group’s work has earned praise from top VCH leadership including its board and interim president and it has changed the way VCH recruits medical leaders.

Over the past year, the committee held focus groups with women physicians about their experiences during the pandemic and it developed and launched a diversity survey to all VCH medical staff. It is about to begin physician Indigenous, Black and People of Colour focus groups and is planning an International Women’s Day event on gender equity in medicine.

“World events have made an impact on our work and there is broad interest in seeing DEI issues move forward at VCH,” commented committee member Dr. Joy Masuhara. “The health authority has started an organization-wide strategy and has valued getting physician input and feedback. We’ve taken a very co-creative approach and I feel that participating on the committee has helped foster better relationships between our groups. VCH is a large, complex organization and I have a better understanding now of the broader context for this work.”

“Without support from the VPSA committee members, the ability to influence a culture of change within the medical staff would be more challenging,” added VCH Manager of Physician Engagement Neli Remo. “The VPSA members have demonstrated courage and commitment to propel the DEI work to organization-wide levels and they continue to work tirelessly to advance and co-create an inclusive workplace.”

Welcoming new physicians to VCH

VPSA regularly hosts Meet and Greet events for onboarding physicians; its September 2020 event was held virtually via Zoom.

“Over 100 physicians joined our association in 2020 and we felt it was especially important to make them feel part of a community,” said Dr. Hsiang. “The pandemic has isolated us more than ever and we believe it is critical that we continue to take steps to break down silos between departments and divisions.”

VCH senior leaders attend these onboarding events and offer welcoming words. At the February 2019 event, Vivian Eliopoulos made these remarks:

“Our organization is our house and we need to have open and honest conversations about how we can make it the best possible place to be. There are discussions happening today that didn’t exist in a coordinated way before VPSA was formed and there’s a palpable energy encouraging us all to connect, collaborate and care. But [VCH leaders] can’t fix what we don’t know is broken. We want to hear from you so we can partner to make improvements.”

VPSA and VCH are now collaborating to survey newer staff to get a sense of what their pain points are in the onboarding process. The data will be used to craft solutions and improve their experience.

Communicating during a pandemic

There’s nothing like a common enemy to bring people closer together. A silver lining of COVID-19 has been the co-operation that it has brought about between groups like VCH and VPSA.

“We knew we would need to provide physicians with information about the virus that the hospital would be too busy to communicate,” said Dr. Vivian Yin. She and Dr. Sophia Park, who were both VPSA board members at the time, pulled information from the BCCDC and WHO websites and started a WhatsApp forum that touched on many COVID-19-related issues.

“VCH leaders were paying attention to WhatsApp and were impressed with how we were moderating it; they asked us to help them with physician communication. It was a timely request as we quickly outgrew WhatsApp and transitioned to the Slack platform that VCH medical staff continue to use to this day. VCH took over the platform and VPSA continues to provide support.”

The Slack channel has had a tremendous impact on physician engagement with specialists from various departments and divisions sharing knowledge rather than working in silos. Bridges have been built and leaders have emerged; it has also created a sense of community.

Early in the pandemic, VCH offered all-staff townhalls to update workers on the impact of COVID-19 on its sites. However, the information that physicians needed was different from that of, for example, nurses. VCH medical leaders Drs. Patty Daly and Chad Kim Sing understood that perspective and were amenable to suggestions for forums specifically targeted to medical staff. COVID-19 Virtual Medical Staff Forums debuted in March 2020 and have run regularly. Vancouver Acute also started offering a regular VA update.

Drs. Yin and Park were instrumental in the forums’ early days. They worked out the logistics and made sure physicians’ questions were gathered ahead of time.

“We stressed that all questions needed to be answered—even if it was only to acknowledge that they didn’t have an answer,” remembered Dr. Yin. “It’s increased the health authority’s transparency and it’s been new territory for VCH, which isn’t used to sharing so much information.”

“Medical staff communications have been well received during COVID-19 and these medical staff forums are a part of that,” said Dr. Kim Sing. “These efforts have led to deeper and more meaningful engagement and we’ve been able to continually improve our dialogue and communication with and between our medical staff colleagues.”

There is interest in continuing the medical staff forums in the post-pandemic world. The format and frequency may change but, in Dr. Yin’s eyes, COVID-19 has opened the VCH leadership’s mindset to getting more physician input.

Vivian Eliopoulos agrees. “One of the positive things around the pandemic is the networking across the organization that has occurred and it’s something we certainly want to continue,” she said. “My hope is that our forums don’t stop. Eventually we’ll move away from talking about COVID and vaccine planning into other areas of interest for our physicians.”

 

Shifting paradigms

A physician’s learning of the Touchpoints approach helps nurture parent-child relationships

As a family physician working in a maternity clinic in Comox, Dr Theresa Wilson observes families interacting with each other and sometimes witnesses the frustrations related to adapting to a child’s development. This is an experience not unfamiliar to her during some of her visits with families with young children.

“All parents want to do well by their child, and all parents have strengths,” says Dr Wilson, who credits Touchpoints for her understanding that relationships are the foundation for development. 

Dr Wilson first learned about Touchpoints and attended the initial training when it was brought to the Comox Valley by the Pathways to Healing Partnership and a public health nursing coordinator.

Touchpoints is a framework that guides practitioners to intentionally build on relationships between physicians and parents and their families, and between parents and their young children.

Dr Wilson explains that using the Touchpoints guiding principles is a culturally responsive approach to care as it can help practitioners recognize and understand the differences of patients before and during a visit –meeting patients where they are at. Physicians can use the child’s behavior to learn more about where the family is at, and how they are coping with a new developmental change or challenge.  The Touchpoints principles also helps physicians observe interactions for strengths.

“You’re doing what you’re doing, just better. We are genuinely changing how we see people by becoming more self-aware,” says Dr Wilson.

Physicians can shift conversations between parents and children from what is not working to what is working well. Through reflection and practice, physicians work alongside families during predictable periods of disorganization or regression as a child learns or acquires a new skill or milestone.

“I can help parents to see that it’s okay that their child's development fluctuates when the child is working on a learning a new skill,” says Dr Wilson. “I can help normalize the ups-and-down.”

Strengthening the parent-child relationship

Dr Wilson recalls a time when she was with a patient who had just delivered her child. The patient’s partner had rushed into the patient room, missing the birth by eight minutes. Recognizing that the father was disappointed, Dr Wilson was able to help reframe the experience.

“I had seen the baby turn its head to look at the father when he came into the room,” shares Dr Wilson. “So I pointed that out to the father, who hadn’t seen it. I was able to use the language of the baby and narrate its behavior.”

By focusing on the positive aspects of the situation, Dr Wilson transformed how the interaction was remembered by the family.

Reducing physician burnout

By using the Touchpoints approach with patients, doctors can help reduce their own stress and feelings of burnout.

Before a patient visit, Dr Wilson reviews the area of development, looking for what might be seen or expected during the visit and reflecting on potential Touchpoints assumptions and guidelines. With that preparation, she feels grounded and ready for difficult issues that may come up during the interaction.

“My patients have commented about how they appreciate the extra time I’m spending with them, but that’s not the case,” says Dr Wilson. “My visit times have not changed.”

In 2018, Dr Wilson became a registered Touchpoints trainer in BC with the support of the Shared Care Committee (SSC) and Comox Valley Division of Family Practice.

Supported by the Physician Engagement Society of Comox and Courtney, which is funded by the Facility Engagement Initiative, the interactive training is offered to doctors through the Comox Valley Child Development Association (CVCDA). For more information, contact the CVCDA.

Watch the video below to learn more about Touchpoints from a panel of multidisciplinary health practitioners in BC.

The webinar is presented by the Shared Care Committee –one of four Joint Collaborative Committees that represent a partnership of Doctors of BC and BC Government– and the CVCDA.

Simulating emergencies bring invaluable results

In situ simulation helps save the life of a two-week old newborn

Any hospital’s Emergency Department (ED) has seen life-threatening drama and life-saving results – often it is preparation that makes the difference. Dr Matt Carere, an ED doctor at the Victoria General Hospital knows well the importance of being prepared.

During the past year or so, he along with Dr Donovan MacDonald, an emergency medicine resident doing a Fellowship in simulation training, with the support of ED Department Heads Drs Paul Collela and Gavin Jones, and help from the South Island Medical Staff Association's Facility Engagement Initiative funding have brought “in situ simulation” training to the hospital’s ED.

This training allows ED staff and relevant specialties to work, learn and reinforce their skills together in their clinical environment. It also helps identify hazards and deficiencies within clinical systems, the environment and the health team. This is unlike the traditional simulation training conducted at teaching hospitals.

From simulation to real life

A recent in situ simulation helped save the life of a two-week old newborn. Dr Carere, “there is nothing more daunting than having a two-week old premature baby in profound shock and peri-arrest come in. And nothing more satisfying than being able to work in the most efficient way possible to save her because we had just run a simulation a week previously that yielded a number of critical changes to our approach.” 

Over the last year, one to two simulations were held each month, involving not only Emergency Department physicians, but also Pediatric Intensive Care docs, PICU and NICU nurses, pediatricians, hematopathologists, anesthesiologists, adult intensivists, respiratory therapists, ECG and lab technicians, as well as more than 40 different emergency department nurses.

Dr Carere notes, “getting them to come in and give us their input on how we can improve our practices in the ED is invaluable. This doesn’t happen without complete buy in from everyone. In fact, we have a group of nurses who volunteer for these nursing education days. They’re getting examined under a microscope by us and they are all for it.”

“There is nothing more daunting than having a two-week old premature baby in profound shock and peri-arrest come in. And nothing more satisfying than being able to work in the most efficient way possible to save her because we had just run a simulation a week previously that yielded a number of critical changes to our approach.

Each scenario is attended by a clinical nurse educator to summarize the scenario and lessons learned to ensure any insights or needed actions are given to all ED staff. The group also film each simulation so that those not able to attend on the day can still learn from the experience. Dr Carere states, “It’s humbling because I’m in these rooms with all these talented doctors and nurses and every time I personally am learning so much.”

Due to COVID, some practices have been made more complicated. With in situ simulations, even the smallest barriers can be revealed to have a huge impact. For example, a recent simulation involved a cardiac arrest with a suspected COVID patient. One doctor discovered administering CPR in full PPE with glasses, googles and face mask left him unable to see as his glasses continually fogged up.

The South Island Medical Staff Association's FEI funding funding has been inestimable in allowing this work to happen. Feedback has been universally positive from staff to the hospital administration. Dr Carere is working to help make in situ simulation become a natural part of the hospital’s culture.

 

 

Maintaining physician wellness during Covid-19 and beyond

Maintaining physician wellness during Covid-19 and beyond

Doctors are working hard to provide the best care for their patients during the COVID-19 pandemic. These unprecedented times add stress and anxiety to physicians and frontline workers who may already feel burned out.

“I think most of us are just feeling tired,” shares Dr Laura Kelly, department head of Emergency Medicine at Ridge Meadows Hospital. “I'm seeing a fair amount of covert fatigue not just in doctors, but in all health care workers. A lot of people are exhausted.”

Dr Kelly and her colleague Dr Connie Ruffo, a White Rock hospitalist, recognized that doctors were potentially facing their own health crisis.

It’s why the doctors spearheaded swift efforts to prioritize the well-being of themselves and their colleagues through the Fraser Health Physician Wellness Committee, which is co-chaired by Drs Kelly and Ruffo.

As part of its work, the committee declared November as Physician Wellness Month in Fraser Health to keep health and well-being top of mind for all medical staff.

Also, the third annual Physician Wellness Forum held in November pivoted to accommodate pandemic restrictions, changing from an in-person event to a series of virtual workshops throughout the month.

Dr Kelly observed that the virtual sessions tried to accommodate both community- and hospital-based physician schedules, making it easier for doctors and medical staff to pop-in to the two-hour sessions at the end of workdays.

More than 100 doctors and medical staff joined weekly workshops to reflect on how to strengthen their personal wellbeing and of their colleagues. Topics included sources of wellness support, including community wellness teams, energy management, peer support, and compassionate leadership.

The forum is sponsored by the Fraser Health Authority and regional medical staff associations and divisions of family practice, and received funding for the first two years from Facility Engagement, an initiative of the Specialist Services Committee.

“The work we are doing for physician wellbeing highlights how vital Facility Engagement is in supporting physician partnerships with health authorities to nurture system change.”

Collaborating for cultural change

Dr Kelly notes that a doctor’s wellness is more than just caring for personal health through exercise, nutrition, or yoga. It’s also about connecting with peers to support one another. It is also about doctors engaging with the health care system to create changes that reduce the risk of burnout by improving efficiency and effectively delivering patient care.

For more than 15 years, Drs Kelly and Ruffo have been championing a shift in the culture of wellness at the grassroot level. They have been working with their peers, along with local and regional partners including MSAs, divisions, and Fraser Health. Together, these groups are fostering more peer-to-peer conversations, modelling compassionate leadership, reducing stigmas, and creating safe spaces.

In recent years, Drs Kelly and Ruffo have been working with colleagues and health care partners to develop a regional wellness strategy, visions and mission –a first of its kind in BC.

Recalling how she and Dr Ruffo got started, Dr Kelly says they modelled peer support by reaching out to colleagues who were distressed, sad or acting out, and fostered collegiality by hosting wellness activities where there were conversations about suicide, addiction, burnout, and how to look after a patient who's also a doctor.

Dr Kelly’s advice to other doctors is to do for themself and their colleagues as they would for their patients.

“It's just a matter of saying ‘I'm here. How are you? or I'm noticing this; how can I help?’”  

Dr Kelly says that simply taking the time to truly listen and hear a colleague is what peer support is about.

“If you have people in each community that are modelling peer support, then they are seen as advocates for their colleagues,” says Dr Kelly. “And then we have real movement in the culture shift that we're trying to make –that physicians are valued and supported.”

From the ER: Love is Also Contagious

From the ER: Love is Also Contagious

From the ER: Love is Also ContagiousThese are challenging times in BC, and staying positive is more important than ever.

That’s why emergency physician Dr Linda Johannson took action to try to uplift her own spirits, and of her colleagues. 

“Everyone was feeling stressed and real fears about what was to come,” says Dr Johannson. “I didn’t realize how deeply it [the Covid-19 pandemic] all was affecting me until one night on shift when I snapped at a nurse, something that is very out of character for me.  She snapped back, also out of character for her, and we had a terrible shift together.”

After apologizing to the nurse and reflecting, Dr Johannson realized that everyone was feeling anxious, and this was affecting how they treat each other.

She acknowledged she wasn’t doing okay, and attended an online meditation session. The facilitator mentioned that a colleagues’ display of an anxious, fearful attitude is contagious and can spread to the whole team, and the reverse is also true.

This sparked the idea for the “Love is Also Contagious” campaign. 

“I wanted a way to remind people that, because of the fear we are all experiencing, our behaviour may not be consistent with the way we know each other to be,” says dr Johannson. “We can recognize that in each other and in ourselves, offer forgiveness, and choose to behave in a loving way rather than react to the stress that is going on.” 

Dr Johannson shared the campaign idea to spread love, not fear, as an attitude at work with her colleagues. With their overwhelming encouragement and funding from Facility Engagement, an initiative of the Specialist Services Committee,  Dr Johannson started to work on the campaign.

She asked a friend who is a graphic designer to morph an image of the coronavirus into a heart. They turned this friendly image into buttons and stickers and a downloadable window sign.

In full support of the campaign, the Kootenay Lakes Hospital (KLH) administration sent a facility-wide email introducing the campaign and encouraging staff to wear the image as a visual reminder to act from a place of love.

Keeping the momentum going, Dr Johannson regularly distributes “Love is Also Contagious” pins and stickers around the hospital during different shifts. 

“I can really feel the positive energy when I show up with my bag to hand out some love,” says Dr Johannson. “It’s been a lot of fun, and a side benefit has been that I feel much more positive about weathering this storm, both individually and as part of a top-notch team in KLH Emergency.”

Help spread the love. Download the “Love is Also Contagious” window sign. 

Cultural Connections:

Collaborating for Healing in Health Care

In early 2020, Tla-o-qui-aht First Nation community members led a group of Tofino health care professionals through a cultural ceremony where they experienced traditional healing practices first-hand. Together, they wanted to explore how these practices and stronger cultural connections might blend with medical care to support people who experience trauma and pain. 

First Nations Healer Nora Martin and Cultural Worker Chris Seitcher led the ceremony, which included Tla-o-qui-aht members, physicians, nurses, X-ray and laboratory technicians, and a firefighter.

Martin explains that traditional cleansing ceremonies have been used by her ancestors for generations and continue today. “We carry trauma around with us, and sometimes never deal with it,” she explains. “In our community, if there is a serious incident or death, we do these kinds of ceremonies for community members right away. It makes a big difference.”

Those benefits caught the attention of Tofino primary care and emergency room physician Dr. Luke Williston. He had seen for himself how traditional cultural practices helped a group of patients who were struggling to deal with trauma and experiencing substance use that required frequent treatment in hospital. 

“A First Nations Cultural Worker came to the hospital to do a cleansing ceremony for some patients,” he says. “We didn’t see any of those patients for more than a year after. When I would see them in the community, I could see they were doing better. That is hard to ignore."

“While our current medical therapies are good, they do not always hit true with everyone.”

He observes that traditional practices help people reconnect with their identity, community and culture. “That, in turn, can give them more of an anchor and focus, so they can keep on track longer.”

VISION FOR A HEALING COMMUNITY

Williston wanted to learn more. With funding from Facility Engagement and the Rural and Remote Division of Family Practice, he connected with Martin and Seitcher to explore how they could work together to introduce health care colleagues to traditional practices, and over time, create a more connected healing community.

Chris Seitcher has worked in the helping field for many years, including as a care aid with Island Health, and for elders in the Tla-o-qui-aht Nation. He runs a weekly men’s group, which he describes as being a supportive, safe space for community members to share stories, history, traumas, and emotions. Traditional chanting and singing are also incorporated to help change the energy.

“This is how we deal with our trauma, our suffering, our pain,” he explains. “When we have safe space and support where we can share things that are happening inside—things we don’t usually talk about—then things start to slowly change.”

Williston feels that health care workers can also benefit from some of these approaches. “We get exposed to a lot of trauma at the hospital all day,” he says. “We all need to find healing for ourselves.”

EXPLORING THE OPPORTUNITY TOGETHER

A collaborative plan unfolded. Martin and Seitcher arranged to hold a traditional cultural ceremony  that was recorded on video. It incorporated a talking circle, breathing exercises, and drumming and singing led by Hayden Seitcher, also of the Tla-o-qui-aht First Nation.

Pools were set up at Načiks (Clayoquot Heritage Museum at Monks Point in Tofino) for the group to experience cold water cleansing.

 “Any time there was trauma in the community, or family, grief, or loss, we would bring members to the river or ocean to do a cleansing,” explains Martin. “Cold water rebalances us: it refocuses negative energy…to help clear the mind.”

The ceremony was an insightful learning experience for the guests. “It is quite different from our usual kind of medical work—a much slower pace,” says participant Dr. Pam Frazee. “A different part of your brain is working—your emotions are more present.”

STRENGTHENING CULTURAL CONNECTIONS

Over time, the aim of those involved is to introduce traditional healing practices more widely with health care professionals, ambulance crews, firefighters, the coast guard, and police officers—all of whom are exposed to emotional and physical trauma—and to create stronger cultural connections among patients, health care, and emergency professionals.

“These providers work in First Nations communities and may not have that connection yet,” says Williston, who sees benefits of making traditional, non-medical interventions more available to health professionals. He suggests that paramedics, for example, could introduce some of the techniques that help reduce a patient’s anxiety before getting to the hospital. 

Additionally, cultural workers could be integrated into the hospital to perform ceremonies for sick patients and those who are soon to be discharged. “That surrounding care might help [patients] stay better, longer,” says Williston. 

Seitcher also sees many benefits to blending in traditional practices. “Culture is always around us,” he says. “Culture means connection. We can bring our culture to the hospital and create a safe space to connect and work through some tough issues.”

Martin, reflecting on her first time working with the medical community, says she is pleased to see the openness to new ways and new learning.

It supports an aim of the First Nations Health Authority and BC’s health care system to have First Nations communities and members work in partnership with doctors and health care professionals to support people’s health, wellness and care. 

“We have a lot to offer,” she says. We can help each other out – instead of living and working in isolation – and provide more services to many more people.”

Watch: Traditional Cleansing Ceremony>

 

 

This project was supported by Facility Engagement, a Specialist Services Committee (SSC) Initiative, and the Rural and Remote Division of Family Practice, an Initiative of the General Practice Services Committee (GPSC). The SSC and GPSC are Joint Collaborative Committees of the Government of BC and Doctors of BC.

 

Physicians Lead the Way to Hospital at Home

Physicians Lead the Way to Hospital at Home

Victoria Hospitalists Dr. Elisabeth Crisci and Dr. Shauna Tierney have been unwavering in their pursuit of a new kind of care for patients. Now, their passion project is about to become a reality with the BC Government’s launch of Hospital at Home across the province.

With Hospital at Home (HaH), acutely ill adult patients who are at lower risk and have a predictable clinical path can get hospital-level care from a team of professionals at home, safely and effectively. The model has been used for years in countries like Australia and the UK.

Extensive studies, including three Cochrane reviews (Ref 1), show that HaH provides equivalent or better clinical outcomes than standard hospitalization. Length of stay tends to be shorter and there is a higher level of satisfaction amongst patients, their caregivers and healthcare workers. It also shields patients from some of the complications associated with a brick and mortar hospital stay.

Dr. Crisci first saw HaH in action several years ago while doing fellowship training in Australia.  “This was not home and community care. It was acute, hospital-level care: IV medications, blood transfusions, oxygen. There is no doubt in my mind that those patients, if they were back in Canada, would need to be on a hospital ward.”

“A hospital is an unsettling environment, especially for frail and elderly patients,” she says. “I thought, ‘why can’t we do the same in Canada?’ The expertise and therapies that we associate with hospital care are all portable, and so is the hospital staff.”

“It is an opportunity to offer safer, more patient-centered care for our patients and for less cost. It is the right thing to do.”

Back in Canada, she often thought about the HaH model. Then, in 2019, an opportunity came up to take action. Her Hospitalist colleague, Dr. Shauna Tierney, was reading about a HaH program for COPD and was inspired. 

“I saw that we could do better for our patients’ dignity and comfort, and thought, “we have a moral imperative to do this." - Dr. Shauna Tierney

Dr. Tierney reached out to Island Health and her Hospitalist colleagues to see what could be done. Dr. Crisci was ready. “We knew that we needed to join forces to make this happen.”

Left: Dr Elisabeth Crisci.  Right: Dr Shauna Tierney

Collaboration moves the vision forward

The two physicians would need help to develop a HaH program for BC– including the buy-in and support of the Island Health, South Island Hospitalists, the Divisions of Family Practice, and eventually, the Ministry of Health. Funding from Health System Redesign and Facility Engagement made that possible.  

“Over the past year we worked relentlessly to get the level of engagement this project requires, while developing our own HaH program for B.C.” says Dr. Tierney.  It meant that they had to become agents of change, inspire others to think outside of the box, and challenge some old-standing beliefs about how hospital-care can be delivered.  

“The same old thinking will always give you the same old results,” says Dr. Crisci.  “We argue that what should define hospital-level or acute-care is the type of patient and the type of clinical interventions required, rather that adhering to a definition based on the physical location of the patient.”

Taking the hospital team and interventions to the patient's home would require further support, which they sought from the BC Ministry of Health. “We don’t want this to be just another community-based service,” says Dr. Crisci.

“We want a true substitute to a standard hospital admission. For this to be possible, we have to ensure that these patients fall under the governance of the provincial Hospital Act. This means that even if at home, these patients are admitted and under the responsibility of the hospital.”

To their delight, the Ministry was interested in doing much more with HaH, and in September 2020, announced that BC would introduce the model to Victoria, and then spread it across the province.  In part, HaH can help with the government’s COVID-19 planning by freeing up some acute care capacity.

Next steps

While there are details to iron out to pilot HaH at Victoria General Hospital and eventually scale to other hospitals, a full-time project team is in place to take the work over the finish line.  The doctors are continuing as medical leads.

They note that experienced physicians on the ground are uniquely positioned to bring innovative ideas such as this to the fore. But they could not have done it alone. It took everyone’s help to make their vision a reality.

“It has been quite an adventure. It started with two physicians with an idea, and now HaH is one of the priorities for BC’s health care system,” says Dr. Tierney.
     
“The collaborative effort between the Ministry, Island Health and the front-line physicians has been incredible; something I never thought I’d ever witness in my career,” agrees Dr. Crisci. “Here we are, side-by-side, to not only improve the care of patients but also working to make our system a bit more sustainable.”    
    

"I can’t wait to see that first patient’s face when I can say, “you get to go home, and I will come to see you at home.” - Dr. Elisabeth Crisci


Funding for physician engagement in the HaH project was provided by Health System Redesign (HSR), an initiative of the Joint Collaborative Committees (JCCs) – a partnership of Doctors of BC and the Government of BC – and the South Island Medical Staff Association, funded through the South Island Facility Engagement Society and Specialist Services Committee (one of the four JCCs).

See the South Island MSA website for background, rollout and BC Government plans for Hospital at Home>   

 

Ref 1: Cochrane Reviews

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007491.pub2/full

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000356.pub4/full

 

 

 

 

     

 

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