Integrated cancer pathway leads to improved experience for breast cancer patients

Wednesday 3 May 2023: Bermuda Hospitals Board (BHB) and Bermuda Cancer and Health Centre (the Centre) today jointly shared information about work on an integrated breast cancer care pathway, which aims to improve the experience and outcomes for breast cancer patients in Bermuda.

At a press conference today, the integrated breast cancer care pathway booklet was made public and handed to the Minister of Health, the Hon. Kim Wilson, JP MP. The Minister had requested BHB to take the lead on developing the methodology for integrated care pathway work in Bermuda, and developing cancer pathways is one of many integration projects across different BHB services, including mental health, maternal/child health, chronic diseases and palliative care. Click here for the booklet.

BHB Deputy CEO, R Scott Pearman, commented: “BHB’s integration programme aims to improve the delivery of care for patients across BHB services and the wider healthcare system. A key part of the programme is the involvement of multiple stakeholders and patients in the planning of these improvements. I’m so very pleased to see the successful development and implementation of the integrated breast cancer care pathway. It reflects the work of 21 patients and 35 clinical colleagues, including oncologists, surgeons and radiologists. This is our first cancer care pathway, and work is already underway to complete a similar process for colon and prostate cancers.”

The development of integrated cancer care pathways within the BHB integration programme has been led by the Medical Director of Bermuda Cancer and Health Centre, Dr Fosker, in collaboration with BHB executive sponsor, Mr Pearman, and the programme’s physician lead, Chief of Psychiatry, Dr Anna Neilson-Williams.

According to Dr Fosker, medical director at Bermuda Cancer and Health Centre, breast cancer was selected as the first cancer to review due to its prevalence in Bermuda. In addition, the availability of most steps of the treatment path on the island makes it an ideal target for review, as it allows for the identification of potential improvements that can be made locally to positively impact patient outcomes. Dr Fosker further explains:

“Putting patients at the centre of the improvement process has been essential. By listening to their feedback about where the system challenged them on their breast cancer journey, we were able to identify areas for improvement and make direct changes to positively impact patient experience and outcomes. One common issue we heard was how long it took to get the next appointment or receive results. Reviewing the process showed us that changing communication and coordination methods could have a significant positive impact.

“To further enhance the patient experience, we have established a breast multidisciplinary team (MDT) that meets weekly. Comprising the Centre’s diagnostic imaging and radiologist, some of the Island’s breast surgeons, BHB pathologists, the Island’s oncologists and the Centre’s Cancer Navigator, this team reviews each patient’s breast cancer diagnoses and determines the best path forward. This approach departs from the previous method, where patients would receive a diagnosis and have to wait to see a surgeon and oncologist. The MDT approach reduces waiting times and ensures that multiple doctors have reviewed the patient’s cancer and agreed on the best next steps.

“While this does not eliminate the need for multiple appointments with different doctors, it was acknowledged that coordinating them can be overwhelming for patients. Therefore, both BHB and the Centre will provide a cancer navigator, a staff member who will assist doctors and patients in moving seamlessly from one-step to the next along the breast cancer pathway. It is the hope of the medical community that by making these changes, we can continue to make a difference in the lives of our patients, and we remain committed to continuing to put their needs first.”

The booklet ‘Integrated Care in Bermuda: Understanding Breast Health’ can be found at bermudahospitals.bm and bchc.bm.

The Minister’s speech from the press conference can be read here.

Faster and more efficient laundry now in operation

Monday 27 February 2023: Bermuda Hospital Board’s upgraded laundry department has come through its testing phase with a clean bill of health.

CEO & President Michael Richmond commented: “Every single patient care area requires clean, sanitised laundry. I can’t emphasise enough how important it is to have an effective and efficient laundry service supplying the required linens, gowns, towels and other items in the delivery of patient care. In fact, about 6,000lbs of it is cleaned, dried and pressed every day at BHB.

“Prior to the upgrade, our laundry staff were hampered by old equipment that was prone to breaking down. They had to work with an infrastructure that hadn’t been properly upgraded in over 60 years. The ultimate beneficiary of the upgrade is patient care, so my thanks go to all involved in making this project a success and special appreciation for our laundry staff for all they do each day to help us deliver the highest quality and safest care to our patients.”

Laundry Manager Kizzy Philips gave special thanks to the laundry staff and the BIU: “We’ve had six months of the upgrade, and many years of working with old equipment and infrastructure. Taking us through to today, the laundry staff have been fantastic, and we couldn’t have asked for a better working partnership with the BIU. I’m excited to see a laundry facility that helps laundry staff support the clinical services across all our campuses. The new equipment makes a huge difference to our productivity and efficiency, and we are proud knowing that we are now meeting international laundry standards.”

Director of Hotel Services Jerome Swainson added: “The laundry processes all linens, gowns and clothes used by newborns through to those near the end of life, the curtains used across the hospital, microfibre cloths used by Environmental Services, as well lab coats and scrubs for staff. For safety and comfort patients and staff need clean laundry items constantly and we can now deliver this through a more efficient service.”

The project started in July 2022 and cost $6.6 million, in line with its original budget. The impact of the costs on BHB, however, was eased by a $1.3 million donation by a single donor through the Bermuda Hospitals Charitable Foundation (BHCF).

Executive Director of BHCF Kim Pratt noted: “We are very grateful to our donor, the Pritzker/Schwartz, Vlock family, who could see the importance of a modern laundry to the delivery of high quality patient care. The donor had originally reached out during COVID to see how they could help, but responded when they heard BHB needed to upgrade and expand the laundry facility. The donor stated that they know this would have a long-lasting effect. The following is a direct quote: ‘We love Bermuda and the hospital as it is such an important resource for the island we love so much.’”

Vice President of Hotel Services, Facilities and Property Management Danny Moore gave special thanks to the facilities staff and vendors working on the project: “Working with such old infrastructure is extremely challenging and this project was not without its surprises and challenges. It’s great credit to all our partners on the project and internal staff that we worked through them, and managed to keep to the budget. The new laundry is a credit to all involved in the project.”

About the BHB laundry and upgrade project:

What is cleaned in the BHB laundry?

All linens, blankets, curtains, clothes, such as patient gowns and babywear, staff scrubs, microfibre cloths and washcloths. About 6,000lbs of laundry is cleaned, dried and pressed every day.

Which areas does laundry support?

All BHB facilities, including KEMH, MWI, group homes, Agape House and the Lamb Foggo Urgent Care Centre

Number of laundry staff

33 including full time, part time and casual

What new equipment is in the new laundry?

• Six new washing machines – one 450lb machine, five 160lb machines and one smaller 55lb machine for baby linens and scrubs. There used to be three machines.
• Six new dryers – five 200lb dryers and one 80lb dryer. There used to be three dryers.
• Two new folding machines.

What were the infrastructure upgrades?

• Changes to infrastructure allow a workflow that means soiled linen is sorted in a separate area away from clean linen
• New hot and cold water lines, steam piping and exhaust ductwork
• Old boiler room demolished, with new building to house the new hot water system to allow the washers to operate more efficiently
• New infrastructure design makes repairs and maintenance easier, with access to the back of the dryers, for example
• New fire suppression system

Project partners:

• Greymane
• BAC
• Noesis
• ABM
• Direct Machinery
• Bermuda Commercial Laundry
• Especially for You Laundry

History of laundry renovations:

• The part of the hospital the laundry is in was built in the 1960s and there have been no major infrastructure upgrades since then
• There was an upgrade in 2004 (18 years ago) when three new 175lb dryers and two new 275lb washers were purchased along with a new air conditioning system, and upgraded steam supply and electrical distribution system
• In 2008 (14 years ago), a large 450lb washer, two folding machines and new software were purchased

BHB looks forward to PEARL benefits

Tuesday 3 January 2022: Bermuda Hospitals Board today outlined what’s in store for the new electronic medical record (EMR), called PEARL (Patient Electronic & Administrative Records Log) and reviewed the project’s success.

Cerner at-the-elbow support helped trouble shoot with staff

PEARL is a replacement for a number of BHB systems, most notably BHB’s main clinical system, which was so old, it was no longer supported by the vendor. Replacing it addressed a critical risk to care, but the full investment in PEARL has been made to catalyse improvements in care across BHB and for Bermuda.

PEARL went live on 29 October 2022 and is now used in all clinical and support areas, and within the billing areas of Finance. Two months following go-live, BHB is transitioning from the implementation phase to a period of optimisation, in which improvements are made based on experience using the system to better work for staff and patients. Future phases are also planned, and this includes the introduction of a portal for patients to view their medical information.

CEO & President Michael Richmond comments: “PEARL is a national investment that has been significantly funded by internal cost savings at BHB, with our capped revenue being flat for the last four years. Our focus has been on ensuring the implementation was successful and that patient quality and safety is enhanced through its use. We are taking this moment to reflect on the programme and look forward to what is ahead. EMR implementations are extremely complex projects and research indicates more than 50% of similar implementations either fail or fail to be properly utilised⁽¹⁾. Given the level of investment required, failure or significant and costly delays were not an option and BHB staff along with our partners have worked tirelessly for over 18 months to deliver the system effectively.

Cerner subject matter expert helps BHB nurses through go-live

“The biggest thank you must go to our staff, who have shouldered a vast amount of work, from design and build workshops to extensive training, and adjusting to a new way of working. They have been working on this project since April 2021, and continued through some of the most devastating COVID waves.

“Although the work leading up to and including go-live was always anticipate to be the hardest part of the PEARL project, this is really just the beginning. We have addressed most of the issues that emerged as we went live with the new system, and our work now focuses on where PEARL can be optimised and improved for staff and patients to create value in the system.”

Chief of Staff Dr Wesley Miller adds: “We did everything required to ensure go-live succeeded, but what happens next excites us the most, not just in the coming weeks and months, but throughout the ten year contracted term. We are very appreciative of the community’s understanding as PEARL has gone live. Improving the care and experience of patients at the very heart of this project, but it does take time. We started looking at how to realise the benefits of PEARL this year, and so we are ready to act and ensure our community gets the best value possible out of the new system.”

The EMR implementation had to navigate numerous COVID waves, including the delta wave which was by far the hardest period for BHB, as well as a hurricane in the countdown to go-live. The project adapted to ensure key milestones were met, and staff had increased support for the implementation to succeed. Activities and issues were all reported through a project governance structure up to the Board.

• About $1.3 million was saved in costs by nearly all the design and build workshops and EMR meetings (over 1,000 meetings in 2021 alone) being hosted remotely, due to COVID-19.
• The go-live date was reassessed once, moving from the beginning of September to the end of October, based on readiness assessments in early summer 2022. This was mostly due to the impact of COVID throughout the project’s duration.
• Additional resources were recruited to support the project as COVID impacted internal resources and increased reliance on partners.

PEARL super user helps acute care unit as PEARL goes live

Chief Hospital Information Officer Keltie Jamieson explains: “Right now, we are going into a period of PEARL optimisation. This is when we take the experience of actually working in the system to identify any additional adjustments and actions to support better processes and staff utilisation of the system. We are also moving towards future phases which will see other parts of PEARL go-live, such as the patient portal. Beyond that, it is about using PEARL every day to make improvements and that continues for the next ten years. We look forward to sharing more in 2023.”

Chief Financial Officer Arthur Ebbin comments: “Every effort has been made to ensure we had a successful go-live so that the project remained affordable. We’ve had a tight governance and accountability framework in place, reporting through senior committees up to the Board. We have also been proactive in getting the support our staff needed to succeed, and worked hard to make the cost savings needed to pay for the project. The major contract with Cerner is paid over ten years, so it is a lot in total, but is affordable for us over time. EMRs help make savings too and the work now takes place to ensure this happens. Cost savings are achieved through system integration, automation of processes, digitisation of records, more efficient services reduced delays and duplications, and the retirement of a number of legacy systems that PEARL replaces.”

EMR background information:

Hospital Incident Command Centres were set up at KEMH and MWI to ensure issues were quickly logged and addressed

Who is the main vendor for BHB’s electronic medical record PEARL?
The main contract is with Cerner Oracle who is the vendor for the electronic medical record, Millennium. The contract runs over ten years to 2030 and includes implementation and operational costs. Phase 1 of the project saw the successful go-live across all BHB locations and services. Future phases of the project will include the implementation of already-paid-for packages, including a patient portal.

How was Cerner Millennium selected?
A competitive request-for-proposal was issued in 2018. Over 100 staff helped evaluation bids and the recommended vendor then went to the Board for approval.

Who are the other vendors associated with the implementation project?
BHB had the assistance of two main vendors, S&P Consultants and Channel 3, who had extensive electronic medical record implementation experience. They provided design, build & project advice, on-the-ground-support, as well as governance and assurance checks to ensure we were ready for a successful go-live. Channel 3 also assisted with a benefits realisation process to help us get the best value from PEARL after go-live. There were a few vendors who helped with system interfaces. Contracts for these vendors went through a competitive selection process.

BHB IT staff ensured the network remained stable and that staff could access the new system as they logged on for the first time

How has BHB paid for the electronic medical record?
EMR implementations are known to be complex and challenging, even outside of pandemics. BHB has managed most of the costs of the project within its capped revenue budget set by Government, which has remained static for the last four years, supported by a programme of cost savings over multiple years. There was one $4.5 million grant for government that was reallocated from an MWI capital project to the EMR in 2021, but there have been no other additional grants or supplemental payments.

How much will the EMR actually cost in total to BHB?
There are many cost savings anticipated, including efficiencies and the retirement of multiple older systems. The net cost of the project over ten years is expected to be in the order of $30 million.

PATI listed contracts in 2022 related to the EMR:

• To support BHB staff, especially with delays and resource issues caused by COVID, BHB entered into contracts with two main support consultants, S&P and Channel 3. Contracts in the PATI listing 2022 were for this support, with contracts for just over $3 million.
• Work with other vendors related to building interfaces that were needed to connect to PEARL accounted for $513,000.
• An executive administrator managed all the meetings and arrangements for the EMR implementation project and go-live of $110,000.
• On-the-ground support and training from our overseas partners in the period leading up to and just after go-live cost $1.7 million. This includes the Hamilton Princess Contract in the 2022 PATI listing, although other hotels and accommodations were used. This was less than the expected $3 million budgeted for on-island support throughout the project as most pre-go-live meetings were held remotely. Intensive in-person support is critical for the success of any EMR go-live, so could not be done remotely. Staff must be fully trained ahead of go-live and needed subject matter experts immediately available to trouble-shoot issues so that care can continue to be safely delivered through the go-live transition. Unlike hospitals overseas, BHB cannot transfer care or emergency services to another hospital during a transition, so continuity of safe services was even more critical. On-the-ground support included over 160 additional people on-island over the go-live period.

Footnote:

(1) Barriers to Electronic Health Record System Implementation and Information Systems Resources: A Structured Review by Jaillah Mae Gesulga, Alamarie Berjame, Kristelle Sheen Moquiala, Adrian Galido

BHB COVID update

Wednesday 28 December 2022: Bermuda Hospitals Board today reports that two of its long term care units are being quarantined due to a number of positive COVID test results in the resident population. There have been both resident and staff positives. As per BHB protocols, all staff in the affected units have been tested.

Family members are being contacted and visitation will be paused until the quarantine is lifted. Anyone who is thinking of visiting a long term care unit resident should call the unit before attending.

Chief of Staff Dr Wesley Miller comments: “We have very well established processes to follow when residents in our long term care units test positive that protect residents, staff and families. While many COVID protocols have relaxed, we have continued with regular surveillance testing for residents on long term care units, as well as testing all patients admitted to acute care areas both at KEMH and MWI. This is a reminder that COVID, along with flu and other respiratory infections are circulating in Bermuda and we still need to protect the people most vulnerable to complications.”

BHB refers queries about exact COVID figures for Bermuda to the Ministry of Health.

BHB updates COVID guidelines

Monday 5 December 2022: Following the end of the public health emergency laws, BHB updated its COVID-19 guidance for patients and visitors from 1 December. BHB has also returned to alert level 1 (the lowest level), for the first time since 2020.

Chief of Staff Dr Wesley Miller comments: “Although public health emergency laws ended on 30 November, COVID-19 and other respiratory diseases, such as flu and respiratory syncytial virus (RSV), are still dangerous, especially to vulnerable people who are older, immunocompromised or unwell.

“The winter months have long been challenging for BHB, even prior to the pandemic, with increased emergency visits and admissions. This means, while we have returned to alert level 1, we remain cautious. We are, for example, maintaining precautions for staff during patient interactions, so people will find that BHB staff are masked when they have their treatments or tests, or if someone enters their inpatient room.

“There is certainly a balance between protecting our vulnerable patients, while accepting that the community is returning to normal practices throughout Bermuda. The public health emergency is over, but if you are visiting a loved one in hospital they may be more vulnerable to an infection due to age or illness. We are asking you to help protect them by wearing a mask in their room as you are in close contact for longer periods of time.

“People should also feel comfortable remaining masked throughout any other areas as a precaution. Masking in communal areas is recommended, though not mandatory, and we will continue testing patients before admissions and surgery, and regular surveillance testing in long-term care areas.”

Overview of precautions for visitors and patients from 1 December:

General masking at BHB:

• Masking is recommended but not mandatory in most communal areas of the hospital outside of patient rooms.
  There will no longer be mask and temperature checks at the door.

When masks should be worn:

• BHB staff will continue to mask for patient interactions, including outpatient consults, testing and in inpatient/resident rooms.
• Patients and visitors who are vulnerable themselves should wear a mask in all areas of BHB.
• For parents and visitors, masks must be worn in the Special Baby Care Unit (SCBU), and masking is strongly recommended in all of Maternity.
• Patients who have cold- or flu-like symptoms must wear masks if they need a service that cannot be rescheduled, for example, a dialysis treatment or emergency visit.
• People visiting patients or long-term care residents who are on isolation must wear the appropriate protection as advised by BHB staff before entering an isolation room.
• People visiting patients or long-term care residents are strongly recommended to wear a mask while in patient rooms as patients and residents are more vulnerable to serious complications of a respiratory infection.

Other protections that will remain:

• Symptom checking surveys will continue for people attending BHB outpatient services.
• Patients who have symptoms or have tested positive for COVID-19 should reschedule hospital appointments if possible. If it is urgent for someone with symptoms to attend BHB (eg a dialysis treatment or emergency visit), they should advise staff and wear a mask.
• All patients admitted to BHB inpatient units and people undergoing a surgical procedure will be tested for COVID-19.
• Surveillance testing for residents in long-term care units across BHB will continue every two weeks.
• Staff, patients and residents in any area of BHB who exhibit symptoms will be tested for COVID-19.

BHB visiting guidelines remain as follows:

Emergency Department and Lamb Foggo Urgent Care Centre:

• Patients will be allowed one support person while in the Emergency Department or Lamb Foggo Urgent Care Centre.
• Vulnerable adults and all children will be allowed up to two support people.
• For patients near the end of life, up to two support people can attend.
• If someone dies in Emergency or is brought to the hospital after passing away, only one person and one support person for that individual can attend. Up to three people can be in the family room. Other family and friends should not attend, as there is not adequate space to gather safely and the ability to offer viewings is very limited.

Acute care patients in the Acute Care Wing units (Ace Barber, Ascendant Partner Re, Catlin Lindo):

• Patients who are not on isolation can have up to two visitors in their room at any one time between noon and 8pm.

Mid-Atlantic Wellness Institute acute inpatient care units (adult, child and adolescent services):

• Pre-identified support people can visit for one hour each day between noon and 6pm.
• Support people must check in at the front desk.
• One person can visit a patient at any one time, and visitation will be in a public space, such as a family conference room.

Long-term care units (KEMH and MWI, including group homes):

• Up to two people (one at a time) can visit each resident for two hours each day between noon and 7pm.
• No more than two visitors are allowed in rooms with more than one resident at any given time.

Isolation patients in all areas of BHB:

• Two designated support people pre-identified by the patient can visit for up to two hours per day, wearing required protection as advised by BHB staff.

Intensive Care Unit:

• Designated support people may visit for two hours between 10am and 2pm, or 4pm and 8pm. Visitors must be on the ICU visitors list.

Maternity Unit:

• Symptom screening is required for support people and visitors. If they have symptoms, they will not be allowed to attend.
• One designated support person may stay as long as needed after the birth.
• If the mother is not discharged within 24 hours, visitors will be allowed to visit between noon and 8pm.

Gosling Unit:

• Up to two parents may visit minor patients.
• Adult patients can have up to two designated visitors (one at a time), between noon and 8pm.

PEARL Implementation Update

Sunday 13 November 2022: Bermuda Hospitals Board today provided an update on its progress with the implementation of its first BHB-wide electronic medical record system, called PEARL (Patient Electronic & Administrative Records Log).

Chief Executive Officer & President Dr Michael Richmond noted that the first two weeks had not been without their challenges, but that activity was beginning to return to normal.

He said: “The success of the implementation has been carried by our staff, external physicians and our partners, who prepared all they could, then have worked through the early expected issues that a major system implementation experiences. It has been a true team effort, as PEARL connects all parts of the hospital from pharmacy, diagnostics, finance and support areas to emergency, acute and critical care at all campuses.

“The good news is that we are on track and, after two weeks of having a slow down in our planned and outpatient activity, services will be running at normal capacity from Monday, including the number of elective surgeries. These are still early days, but issues have been managed, staff are mastering the new system, and we wanted the community to be fully informed about our progress.”

Despite a planned slow down in planned and outpatient activity, over the first two weeks after go-live there were still 3,267 encounters in ambulatory care (outpatient clinics and diagnostics), 150 surgeries (elective and emergency) and 20 babies born. In areas where activity could not be controlled, the normal activity levels were experienced. There were 1,011 people who attended the Emergency Department and Lamb Foggo Urgent Care Centre, and 142 admissions to an inpatient ward. This reflects KEMH and MWI wards.

In the Emergency Department, the average length of time between arrival and discharge did increase in line with expectations in the first week, but has gradually decreased since then (see data below).

Dr Richmond added: “I would like to extend my appreciation to the community for their understanding. We know it has been a challenge at times for patients in Emergency with longer average stays than normal, and elective procedures were reduced in the first two weeks. But the great promise of PEARL is to that as we work through this period we will be able to improve our care, smooth transitions, and use the system to help us deliver a better, safer care experience.”

PEARL went live in the early hours of Saturday 29 October, when information was transferred and then validated. Staff in different departments started using the system from the early afternoon.

The following is the ED length of stay (from arrival to discharge) for each day following go-live. The average length of stay up to 29 October in ED was 198 minutes (3 hours and 18 minutes).

Emergency average length of stay per day (midnight to midnight) in minutes

• Saturday 29 October (partial day): 294
• Sunday 30 October: 405
• Monday 31 October: 442
• Tuesday 1 November: 358
• Wednesday 2 November: 485
• Thursday 3 November: 366
• Friday 4 November: 285
• Saturday 5 November: 289
• Sunday 6 November: 239
• Monday 7 November: 289
• Tuesday 8 November: 190
• Wednesday 9 November: 160