May 28 30, 2015, Montral, Qubec Implementation of the First CT
Scanner in the Eastern Arctic
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Disclosure Statement: No Conflict of Interest May 28 30, 2015,
Montral, Qubec I do not have an affiliation, financial or
otherwise, with a pharmaceutical company, medical device or
communications organization. I have no conflicts of interest to
disclose ( i.e. no industry funding received or other commercial
relationships). I have no financial relationship or advisory role
with pharmaceutical or device-making companies, or CME provider. I
will be discussing the results of ____ (off-label use), which is
currently classified by Health Canada as investigational for the
intended use. I will not discuss or describe in my presentation at
the meeting the investigational or unlabeled ("off-label") use of a
medical device, product, or pharmaceutical that is classified by
Health Canada as investigational for the intended use.
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Implementation of the First CT Scanner in the Eastern Arctic
PRESENTED BY: JENNIFER SHARPE MANAGER OF DIAGNOSTIC IMAGING,
QIKIQTANI GENERAL HOSPITAL
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Iqaluit, Nunavut Iqaluit - - 'Place of many fish' City of
Iqaluit is located on Baffin Island, at the northern end of
Frobisher Bay, near the mouth of the Sylvia Grinnell River. Iqaluit
is the territorial capital of Nunavut, the largest and fastest-
growing community in the territory. The landing strip is long
enough to land the space shuttle, so it is often used for cold
weather testing of the world's largest new aircraft. Formerly known
as Frobisher Bay, the modern city of Iqaluit is rich with
traditional Inuit culture. The friendly people of Iqaluit the
'Iqalumiut' love to go out on the land, sea and ice at all times of
the year to enjoy a variety of outdoor activities.
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POPULATION 7,250 60% Inuit Languages Inuktitut, English, French
From May through August, days are long and sunny, averaging 16
hours of daylight with temperatures of 5C to 25C. The city enjoys
nearly 24 hours of sunshine in late June and early July, with
beautiful twilight skies for two hours around midnight. The
shortest days of December have four hours of daylight, with the sun
hovering on the southern horizon. Northern Lights are frequently
seen from October to April. Winter temperatures of -10C to -50C are
common. Iqaluit, Nunavut Iqaluit - - 'Place of many fish'
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Where the heck is Iqaluit, anyway?
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Qikiqtani General Hospital QGH is a 35 bed acute care facility
in Iqaluit. The hospital serves the approximately 16,000 people in
the Qikiqtani (Baffin) Region, which is home to 12 communities
spread over approximately one million square miles! It is the only
hospital located in the territory of Nunavut.
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Relevant Statistics Lung cancer is the leading cancer amongst
Nunavummiut, accounting for 32% (247cases) of reported cancer
cases. 60% of Nunavummiut aged12 years or older report smoking,
which is three times higher than the national average. 62 % of
Nunavummiut diagnosed with lung cancer died within one year of
diagnosis. A CT scan can reveal small lesions in the lungs that
might not be detected on an X-ray. Colorectal Cancer is the second
leading cancer in Nunavut, accounting for 19% (136 cases) of
reported cancer cases. Risk factors include alcohol and tobacco
use, diet and obesity. 26% of Nunavummiut who were diagnosed with
colorectal cancer died within one year of diagnosis.
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Relevant Statistics Since its inception as a Territory in 1999,
Nunavut has faced the highest reported tuberculosis (TB)incidence
rate in Canada. The rate of TB infections in Nunavut is 62 times
the Canadian average. Crowded housing conditions, poor nutrition
and high smoking rates partly contribute to the high rate of TB
incidents. TB primarily attacks the lungs and can be deadly without
treatment. HRCT scanning in the investigation of TB may be helpful
in differentiating active TB from LTBI more reliably. Lung mass is
not visible on conventional X-rays unless they are larger than 5-6
mm in diameter. Modern CT machines can detect lesions up to 1-2 mm
in diameter. CT is more sensitive than chest radiography and can
accurately detect tumor site, size and invasion to adjoining
structures such as mediastinum, chest wall, etc.
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Referrals South Transportation by scheduled commercial airline
for elective referrals ($1400 approx. cost of return flight to
Ottawa). Approx. Duration of stay for patients transported to
Ottawa averaged 12.8 days ($2600 approx. cost for accommodation and
expenses for this duration). Length of stay is due to wait times
for diagnostic work-ups prior to specialist visits or scheduled
appointments being cancelled. Standard process allowed 3 to 4 days
between diagnostic testing and clinic visit to ensure results are
available before seeing specialist. Medevac for emergent cases,
service includes physician or nursing escort as appropriate
($25,000 approx. cost for flight and crew PER RETURN FLIGHT!) Over
400 patients were flown south for CT examinations in 2010. Approx.
11% of these were medevac patients due to trauma. About 50
transports were for scans to rule out head and neck injuries.
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Impact on Patients Wait times were often 3-4 months for a CT,
despite preferential treatment by Ottawa for Iqaluit patients.
Physicians related situations where wait times for CT diagnostics
were so long that the patients conditions moved beyond treatment.
Extended stays (up to 12 days) in Ottawa can cause anxiety for
residents of the Baffin Region as many are unfamiliar with or do
not speak English. Patients from communities have to first travel
to Iqaluit and then on to Ottawa (depending on which community,
flights to Iqaluit can be anywhere from 2-5 hours). Have to travel
alone or with one escort depending on severity of symptoms.
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Coroners Inquest Reiterates Need for CT Machine in Iqaluit
Elisapee Michael, 52, fell head-first down the stairs outside the
Nova Inn on Aug. 9, 2009. Police put Michael in a cell where, hours
later, they discovered that she was unresponsive. Michael was then
medevaced to Ottawa, where she died Aug. 13 from her head injury.
If CT was available at the time, injury could have possibly been
diagnosed sooner.
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Challenges Around Implementation of CT Only possible if a PACS
is in place so that radiologists can effectively guide its
operation and promptly interpret CT studies. Web presentation is
limited by Government of Nunavuts (GN) bandwitdh; GN network must
be upgraded. Network is run on Satellite, which slows transmission
times and limits amount of traffic. No Radiologist on site.
Inappropriate to expect family physicians to conduct even
preliminary interpretations on CT exams due to breadth of
pathologies for which CT is applicable and unique orientation of
images. Staffing: recruitment and retention of CT technologists may
prove difficult. Geographic location!
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Benefits Patients More accurate diagnosis Shorter wait times,
particularly for elective Reduced travel (fewer trips and shorter
duration of stay) Reduced dependency on inclement weather for
emergency travel Service closer to home in familiar environment
Increased confidence in local health care Fewer lost work days due
to medical travel Physicians Increased confidence in diagnosis
Improved communications with Specialists Ability to treat more
local patients Improved diagnostic capabilities during clinic days
Early diagnosis and improved outcomes Shorter turnaround time for
Radiology reports (1 hour for Stat cases VS 3-4 days) Department of
Health/QGH Platform to offer additional specialty clinics Improved
public perception of Nunavut Health Services Possibility of
attracting and retaining permanent physicians Early diagnosis leads
to reduced administrative costs Reduced travel costs
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The Process Established new Radiology contract with The Ottawa
Hospital (TOH) to incorporate PACS solution and increased
availability of Radiology service. Network upgrades completed in
2013 to handle increased traffic on GN network and availability of
increased transmission times for Iqaluit. Dedicated server to
accommodate PACS integration. RFP generated to include provisions
unique to geographic location, Turnkey Operation and White Glove
Delivery. Workflow created to include community films (still wet
processing) due to lack of Network infrastructure outside of
Iqaluit. Job Shadowing with Rob Chatelain at Civic Campus of TOH to
enhance understanding of overall functionality of CT program.
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And So It Begins Construction for the renovations required to
implement CT machine began in September 2013. All supplies, tools
and equipment needed for renovations had to be flown up with the
construction crew due to lack of availability in Iqaluit. When the
hospital was built in 2007, considerations were already made in
anticipation of acquiring a CT machine. Renovations to CT room and
Control room were completed by early December 2013. As I headed to
Milwaukee, WI to participate in training, the CT machine was being
prepared for travel to Iqaluit.
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The Delivery The CT machine weighs approx. 10,000 lbs. Only
possible way to deliver machine was by air cargo. Had to be flown
up with 2 SCI passengers to ensure safe transportation of machine
and all necessary equipment for installation. Transportation of CT
machine alone was in excess of $50,000! QGH ambulance bay was used
to receive machine and all of its parts. Provisions had to be made
to ensure machine was kept at a constant temperature due to the
risk of components freezing in our extreme cold environment!
Installation was completed within 2 days of arrival.
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History is Made! Due to lack of on site Radiologist, the
process of protocolling CT requests was not feasible for TOH to do.
January, 2014 I spent a week in Ottawa training with a radiologist
to learn how to protocol these requests. On February 2, 2014, the
applications specialist was on site and the first ever CT scan was
performed in Nunavut! At this point, PACS went live for Iqaluit,
but was still not quite ready for integration with TOH PACS. CT
examinations were burned to CDs and mailed to TOH for Radiologists
to report. Final reports were then faxed back to DI department in
Iqaluit for distribution to physicians.
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Photo: Qikqitani hospital acquires long-awaited CT scanner
Excerpt from Nunatsiaq News, February 17, 2014 Jennifer Sharpe,
manager of diagnostic imaging at Qikiqtani General Hospital in
Iqaluit, operates the hospitals new computed tomography, or "CT"
scanner, Feb. 14. In operation since Feb. 3, the $2.1-million CT
scanner helps medical staff make more accurate diagnoses and is
expected to reduce patient wait-times, now that Nunavummiut do not
have to travel south for the procedure, Nunavuts health department
says. The hospital will share records from the scans by April of
this year with a hospital in Ottawa through a network connection.
(PHOTO BY PETER VARGA)
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Nunavuts first CT scanner starts service at Qikiqtani Hospital
Qikiqtani General to link patient records with The Ottawa Hospital
Theyre very comfortable to be able to come to their own hospital,
and get the exam done, versus going to Ottawa, and having to find
their way around three huge hospitals, Sharpe said Feb. 14. It
reduces some trips to Ottawa, for sure, MacDonald said. Its $25,000
a medevac thats a lot of money. You would only have to save $2
million of those dollars to pay for the CT scanner. No one else in
Canada operates a CT over a satellite network, and equipment
vendors never had to deal with that before, he said. So you have to
educate (them) as they come through. And when something like this
works out, its absolutely impressive.
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PACS Goes Live With TOH April 2014, Nunavut and TOH PACS go
live. Xrays and Ultrasounds have transmission of less than 5
minutes. CT Head: ~8 minutes CT Abdomen & Pelvis: ~20 minutes
CT Lower Extremity Runoff: ~30 minutes Films from 12 communities in
Baffin Region are sent to Iqaluit via air cargo, digitized, and
sent to TOH through PACS. Significant increase in turn around time
for reports both in Iqaluit and communities. Remarkable increase in
patient care, especially in Emergent Situations.
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Demographics Since acquiring the CT machine in February 2014,
QGH has completed 1750 CT examinations!
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Only in Nunavut
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a polar bears bite is 1,200 pounds per square inch; a shark has
a psi of 669 and a Rottweiler dog, 328 When it was biting my head,
I could see inside its mouth. It was all black and smelly. I could
see the tooth biting just beside my eye, 50-60 stitches 10-foot,
six-inch bear Nunavut Polar Bear Attack Survivors Thankful to be
Alive!
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What The Physicians in Iqaluit Are Saying Having CT in Iqaluit
has decreased our miss rate on potentially serious diagnosis,
improved patient care, and easily paid for itself by saving costs
on flights to Ottawa. Dr.Greg Devet Despite initial worry that we
would be keeping sicker patients than we would have without a CT it
has become an excellent resource which has taken much guess-work
out of clinical care. My work is principally in outpatient care and
CT has been invaluable in managing many cases where the diagnosis
was suspect but not critical and would not warrant a trip to
Ottawa. It is also sometimes an alternative to have access to when
Ultrasound is delayed. Dr.Alison McCallum
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References www.gov.nu.ca/health www.gov.nu.ca/health
www.nunatsiaqonline.ca www.nunatsiaqonline.ca www.cbc.ca/north
www.cbc.ca/north JRS Partners Inc. Martin Joy, Director IT,
Government of Nunavut
www.nunavuttourism.com/regions-communities/iqaluit
www.nunavuttourism.com/regions-communities/iqaluit Thank you to Rob
Chatelain, OHRIA, Karina Burt, Imad AlChikie, Sandra Clark