Division of Hematology Department of Medicine Compendium of Divisional Activity 213-214 division of HEMATOLOGY 87
DIVISION OF HEMATOLOGY Physician Resources 1 Hematologists (7.45 FTE) 7 full-time 3 part-time Division Highlights Our Patient Care The Division continues to see, assess and care for a large number of inpatients and outpatients. For the 2 year, there were 2,17 new patients and 8,964 return patients seen in clinics, 1,826 patients assessed and treated in MDU, 938 inpatient consultations, 656 admissions and 69 blood and marrow transplantations. The Division of Hematology in Halifax has been cited more than once in the last year as having the highest centre accrual for both national and international studies. The Division employs 17 full-time research staff through grant and contract research support. Our Education Collaborative clinics at the IWK Health Center and in Moncton and St. John s continued on a monthly basis. A new program for the management of patients with venous thromboembolism who are prescribed novel oral anticoagulants (NOACs) is under development with the Emergency Department. Our Research Dr. White was an author of the FIRST trial examining lenalidomide and decadron in patients with myeloma. This was presented at the Plenary Session of the American Society of Hematology Meeting in 213. Dr. Anderson continues to lead the national CIHR-funded EPCAT II study: Extended Venous Thromboembolism Prophylaxis Comparing Rivaroxaban to Aspirin Following Total Hip and Knee Arthroplasty. Dr. Couban continues to lead the Terry Fox Research Institute study looking at the role of novel biomarkers in patients with MDS and AML. Division members continue to participate in more than 4 active investigator-initiated and industry-sponsored clinical trials in the management of patients with hematologic cancer and venous thromboembolism. Dr. Andrea Kew has stepped down as Program Director, Hematology after completing a 6 year term. Under her leadership, the program blossomed with 8 trainees and a laudatory review from the Royal College. Dr. Darrell White has stepped down as Program Director, Internal Medicine after a very successful term. We are very pleased to have him back! Dr. Sudeep Shivakumar has stepped down as Undergraduate Education Director and as leader of the hematology section of the undergraduate curriculum. Welcome to Dr. Mary-Margaret Keating in her new role as Undergraduate Education Director (February 214) and to Dr. Sudeep Shivakumar in his new role as Postgraduate Program Director (January 214). Dr. Katherine MacInnes was accepted to the Hematology Fellowship Training Program to start on July 1, 214. The Division hosted 7 distinguished speakers in 2: including Drs. Margaret Rand, Andrew Davies, Thomas Nevill, David Chui, Dick Wells, Peter Lin and Cyrus Hsia. 88 Department of Medicine Compendium of Divisional Activity 213-214 division of HEMATOLOGY
Our Team The Division includes 7 full-time hematologists (Drs. David Anderson, Stephen Couban, Andrea Kew, David Macdonald, Sue Robinson, Sudeep Shivakumar and Darrell White) and 4 part-time hematologists (Drs. Wanda Hasegawa, Ormille Hayne, Mary-Margaret Keating and Andrew Padmos). The team works collaboratively with Capital District Health Authority staff including individuals from nursing, pharmacy, social work, psychological and spiritual supports. The Division is supported by four administrative assistants including team leader, Ms. Cheryl Peever. Welcome back to Sveta Withrow who rejoins our Division. Fond farewell and best wishes to Randi Griffin. New Programs, Partnerships & Innovations Dr. Sudeep Shivakumar is working with Dr. Sam Campbell and the Department of Emergency Medicine to develop a new treatment approach for patients diagnosed with venous thromboembolism who can be treated with a novel oral anticoagulant. This will reduce the number of urgent referrals to the Hematology Clinic. Dr. Couban continues to collaborate with Dr. David Simpson and his colleagues in the Division of General Internal Medicine in redirecting referrals for anemia from the Division of Hematology to the Division of General Internal Medicine since many patients with anemia have problems best assessed and managed by a general internist (approximately 1-15 patients per month). Dr. Mary-Margaret Keating has joined Dr. Sue Robinson in a collaborative Bleeding Disorders Clinic. Dr. Robinson is a recognized national expert in bleeding disorders and has led the CDHA Bleeding Disorders Clinic for many years. Dr. Keating is a welcome addition who will increase our capacity to see patients with bleeding disorders. Work for Nova Scotia Department of Health & Wellness Quality & Patient Safety Dr. Wanda Hasegawa is the medical lead of the process at the Capital District Health Authority for the Blood and Marrow Transplant Program to achieve Foundation for Accreditation of Cellular Therapy (FACT) accreditation. This is an international standard which all transplantation centers will be required to achieve in order to continue to perform transplantation procedures. She has also been the medical lead to prepare for accreditation by Health Canada. In addition, Dr. Hasegawa chairs the Hematology Quality Committee and leads quarterly Morbidity and Mortality Rounds. Under her supervision, members of the Division review all deaths of inpatients on the hematology service and other morbidity and mortality events as appropriate. The Division continues to undertake certain types of autologous and allogeneic transplantation on an outpatient basis. In addition, Day 1 transfer of recipients of autologous transplant to Moncton General Hospital continue. Efforts are underway to replicate this process for patients returning to the George Dumont Hospital in Moncton. Division members continue to work with colleagues in nursing, pharmacy and social work to expedite discharges and facilitate appropriate transfers and discharges. Public Education DIVISION OF HEMATOLOGY Dr. Anderson continues to co-lead the Nova Scotia Provincial Blood Coordinating Program. Members of the Division participate in public education endeavors including participating in the advisory boards of patient advocacy groups such as the Aplastic Anemia and Myelodysplasia Society (Stephen Couban) and Myeloma Canada (Darrell White). Department of Medicine Compendium of Divisional Activity 213-214 division of HEMATOLOGY 89
DIVISION OF HEMATOLOGY Issues of Appropriateness of Care Issues of appropriateness of care continue to be addressed through quarterly reviews of morbidity and mortality supervised by Dr. Wanda Hasegawa. Clinical Services Inpatient Services (General Hematology and BMT) There are 2 inpatient beds designated to the General Hematology Service and the Blood and Marrow Transplant (BMT) Service. Table 1 Unit/Designation Beds 8A/8B General Hematology & BMT 2 Figure 2 Hematology Average Bed Utilization by Fiscal Year QEII Health Sciences Centre, 29-214 2 Beds 15 1 Division members provide secondary, tertiary and quaternary care for patients with benign and malignant hematological disorders. This includes the administration of chemotherapy and stem cell transplantation procedures for patients with leukemia, lymphoma and multiple myeloma, along with diagnostic and therapeutic services for patients with thromboembolic and major bleeding disorders. The Division runs an inpatient service at the Victoria General site as well as delivering outpatient care through the Hematology Clinic and Medical Day Unit and through satellite clinics in Moncton, Sydney, St John s and the IWK Health Centre. Current and historical occupancy rates and bed utilization on Hematology and BMT Nursing Units have been merged to more fully reflect the Hematology Inpatient services in this report. The average occupancy rate (according to midnight census) for 2 was 96.7%. The bed utilization shows an average of 18.1 beds used, with 18.7 available. Figure 1 Hematology Inpatient Bed Average Occupancy Rate by Fiscal Year QEII Health Sciences Centre, 29-214 12% 5 29-21 21-211 211-212 212-213 213-214 Total Used 16.6 17.3 18.3 18.7 18.1 Available 17.3 18.3 18.8 18.6 18.7 465 patients were admitted to the Hematology Inpatient Services during 2, representing a 6.8% decrease from the previous year. Additionally, 191 patients were transferred to Hematology care from other parts of the QEII HSC for a total of 656 admissions and transfers for the year. Average Length of Stay (ALOS) was 14.3 days. Emergency Coverage Hematologists provided 24-hour, 7-day / week emergency and on-call inpatient consultation service for the QEII Health Sciences Centre (QEII HSC). Hematologists provided advice and urgent consultation services to physicians in the Maritime Provinces. ancy Percent Occup 1% 8% 6% 4% 2% % 1.5% 95.9% 94.7% 97.% 96.7% 29-21 21-211 211-212 212-213 213-214 Figure 3 Hematology Inpatient Admissions and Transfers In by Fiscal Year QEII Health Sciences Centre, 29-214 8 ns and Transfers Admission 7 6 5 4 3 2 1 29-21 21-211 211-212 212-213 213-214 Tranfers In 19 188 172 25 191 Admits 54 484 472 511 465 Total 694 672 644 716 656 9 Department of Medicine Compendium of Divisional Activity 213-214 division of HEMATOLOGY
s Figure 4 Hematology Inpatient Average Length of Stay (Days) by Fiscal Year QEII Health Sciences Centre, 29-214 16 Day 14 12 1 8 6 12. 12.5 14.5 13.1 14.3 Figure 6 Hematology Inpatient Admissions Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, 213-214 Out of Province: 8 Capital District: 199 Blood and Marrow Transplant Program (BMT) The Blood and Marrow Transplant program has served patients throughout the Maritimes since 1992. There were 17 blood and marrow transplants completed in 2, an increase of 9.2% from the previous year. Figure 8 DIVISION OF HEMATOLOGY 4 2 Non Capital District: 186 Blood and Marrow Transplant QEII Health Sciences Centre, 29-214 12 29-21 21-211 211-212 212-213 213-214 Of the Hematology inpatient admissions in 2, 59% were male and 41% were female. 4.% of admissions came from Nova Scotia Health Districts outside of Capital while an additional 17.2% came from other Atlantic Provinces. These ratios are reflective of the tertiary and quaternary nature of the service. Figure 5 Hematology Inpatient Admissions Percent Distribution by Gender QEII Health Sciences Centre, 213-214 Figure 7 Hematology Inpatient Admissions Distribution of Patient Residency by Atlantic Province QEII Health Sciences Centre, 213-214 Newfoundland: 9 Prince Edward Island: 33 New Brunswick: 36 Nova Scotia: 386 Transplants 1 8 6 4 2 29-21 21-211 211-212 212-213 213-214 Autologous 47 51 52 48 62 Related Allogenic Myeloablative 1 22 9 12 13 Related Non-Myeloablative 6 7 16 5 Matched Unrelated Myeloablative 7 9 7 16 7 Matched Unrelated Non- Myeloablative 4 6 12 17 25 Syngenic Transplant 1 Total 74 95 97 98 17 Source: Data Administrator, Oncology Services Female 41% Male 59% Department of Medicine Compendium of Divisional Activity 213-214 division of HEMATOLOGY 91
DIVISION OF HEMATOLOGY Inpatient Consultations The figure below depicts a combination of activity on the Hematology Inpatient Consult service and service to the Medical Teaching Unit (MTU) and Internist Emergency Department Call Rotation by division members over the past 5 years. There were 938 inpatient consults at the QEII Health Sciences Centre reported for Hematologists in 213-214, representing a 5.% decrease from the previous year. Figure 9 Ambulatory Care There were 11,95 patient registrations to the six subspecialty outpatient services during 2, which represents a 2.8% increase relative to the previous year. Of the 2 clinic visits, 19.% were new consults. Patients undergoing chemotherapy require many return visits. Data includes visits to non-physicians such as nursing and pharmacy. There were an additional 2,74 chart checks performed in 2 not reported in the following figures. Figure 1 Special Service Commitments 19 patients were seen in the Moncton BMT Clinic during 2. Figure 12 Hematology Clinic Visits Moncton Clinics, 29-214 175 Visits 15 125 1 Hematology Inpatient Consults QEII Health Sciences Centre, 29-214 1,2 1, 1,54 987 956 938 896 8 # Consults 6 4 2 29-21 21-211 211-212 212-213 213-214 Source: Physician Services Hematology Ambulatory Care Registrations QEII Health Sciences Centre & Cobequid Community Health Centre 29-214 12, Registrations 1, 8, 6, 4, 2, 29-21 21-211 211-212 212-213 213-214 Autologous B 1 33 33 1 Hereditary Bleeding Disease 239 415 443 412 323 Blood & Marrow Transplant 585 685 811 622 657 Deep Vein Thrombosis 1,81 97 1,137 1,144 1,129 Hematology 2,647 3,347 2,588 2,64 2,85 Oncology 5,87 5,265 5,954 6,52 6,9 Total 9,639 1,683 1,966 1,795 11,95 75 5 25 29-21 21-211 211-212 212-213 213-214 New 2 6 1 1 Return 126 115 153 152 19 Total 128 121 154 153 19 % New 1.6% 5.%.6%.7%.% Source: Divisional Data 15 patients were seen in the Newfoundland and Labrador BMT Clinic during 2. Figure 13 Figure 11 Hematology Clinic Visits St. John's, Newfoundland, 29-214 Hematology New and Return Ambulatory Care Registrations QEII Health Sciences Centre & Cobequid Community Health Centre 29-214 14, 175 15 125 12, 1, Visits # 1 75 istrations 8, 5 Regi 6, 25 4, 2, 29-21 21-211 211-212 212-213 213-214 New 2,238 2,89 2,57 2,14 2,17 Return 7,992 8,555 9,539 8,781 8,988 Total 1,23 11,445 12,19 1,795 11,95 % New 21.9% 25.3% 21.2% 18.7% 19.% 29-21 21-211 211-212 212-213 213-214 New 18 9 21 17 18 Return 144 19 95 122 87 Total 162 118 116 139 15 % New 11.1% 7.6% 18.1% 12.2% 17.1% Source: Divisional Data 92 Department of Medicine Compendium of Divisional Activity 213-214 division of HEMATOLOGY
47 patients were seen in the High-Risk Pregnancy Clinic for Women with Hematological Disorders at the IWK Health Centre in 2. Figure 14 Hematology Clinic Visits IWK PNC Hematology Clinics, 29-214 7 Axis Title A 6 5 4 3 2 1 29-21 21-211 211-212 212-213 213-214 New 27 35 24 3 3 Return 17 31 16 12 17 Total 44 66 4 42 47 % New 61.4% 53.% 6.% 71.4% 63.8% Source: Meditech Wait Times & Outpatient Through-put All patients referred to the Division of Hematology are triaged centrally by a Hematologist. Urgency is assigned using criteria in the table below. It should be noted that effective October 29 the division began a pilot providing written advice to referring physicians in place of a clinic visit for certain less-urgent referrals. Guidelines for Triage of New Referrals to Hematology Outpatient Clinics Emergent (C1) Examples include: New diagnosis of acute Leukemia Severe thrombocytopenia Severe Anemia Severe Leukopenia Urgent (C2) Examples include: New diagnosis of Lymphoma/Hodgkin s disease Semi-urgent (C3) Examples include: New diagnosis of Myeloma Moderate Anemia, Moderate Thrombocytopenia New diagnosis of chronic myeloid leukemia (stable) Non-urgent (C4) Examples include: Homozygous HFE C282Y Hemachromatosis Mild cytopenias Duration of anticoagulation New diagnosis of chronic lymphocytic leukemia (stable) Personal or Family History of previous thrombosis Standard Wait Time Within 48 hours Within 2 weeks (14 days) Within 6 weeks (42 days) Within 13 weeks (9 days) DIVISION OF HEMATOLOGY Department of Medicine Compendium of Divisional Activity 213-214 division of HEMATOLOGY 93
DIVISION OF HEMATOLOGY Figure 15 Hematology Emergent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 212-214 3 Days 2 1 Figure 17 Hematology New Semi-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 212-214 5 Days 4 3 2 1 Of the outpatient clinic registrations in 2, 38.5% reside in Nova Scotia Health Districts outside of Capital while an additional 5.5% came from outside Nova Scotia. Figure 19 Hematology Clinic Registrations Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, 213-214 Out of Province: 67 Average Wait Time 1. 1. 1.2 1.6.7 1.2.9.5 Standard Wait Time 2 2 2 2 2 2 2 2 Count 74 47 51 54 82 7 6 62 Minimum Wait Maximum Wait 1 11 18 3 1 26 6 4 % Within Standard 95% 94% 92% 94% 96% 91% 93% 97% Source: PHS Data Average Wait Time 29.2 33.1 29.9 35.4 34.8 33.9 28.7 32.4 Standard Wait Time 42 42 42 42 42 42 42 42 Count 16 163 135 169 176 146 158 144 Minimum Wait 1 2 2 1 1 1 Maximum Wait 189 111 18 387 348 168 12 123 % Within Standard 83% 74% 82% 8% 76% 78% 82% 79% Source: PHS Data Non Capital District: 4,269 Capital District: 6,219 Figure 16 Figure 18 Hematology New Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 212-214 15 Hematology New Non-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 212-214 12 1 1 8 Days Days 6 5 4 2 Average Wait Time 12.1 9.2 11.9 13.6 12.7 11.7 14. 12.5 Standard Wait Time 14 14 14 14 14 14 14 14 Count 133 17 119 114 123 131 89 118 Minimum Wait 1 1 1 Maximum Wait 45 25 98 62 58 62 32 53 % Within Standard 68% 88% 69% 73% 76% 79% 76% 65% Average Wait Time 85. 89.8 75.4 61.1 83.1 83.6 76.6 1.6 Standard Wait Time 9 9 9 9 9 9 9 9 Count 117 177 189 186 145 19 246 21 Minimum Wait 1 2 1 6 1 2 2 Maximum Wait 219 389 377 47 45 56 52 544 % Within Standard 6% 61% 71% 81% 7% 7% 69% 65% Source: PHS Data Source: PHS Data 94 Department of Medicine Compendium of Divisional Activity 213-214 division of HEMATOLOGY
Medical Day Unit (MDU) Most ambulatory Hematology care at the QEII HSC occurred in the Medical Day Unit. This activity accounted for 65.9% of the activity of the MDU during the year. There were 16,576 patients registered in five subspecialty programs in the Medical Day Unit in 2, representing a.6% decrease in total activity from the previous year. Figure 2 Hematology Medical Day Unit Proportion of Total Medical Day Unit Registrations QEII Health Sciences Centre, 29-214 18, tions 16, 14, 12, 1, Figure 22 Hematology Medical Day Unit Registrations Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, 213-214 Out of Province: 1,126 Capital District: 7,28 Education All hematologists were involved in the provision of medical education during the year. Hematologists provided 4 weeks of attending service on the MTU, 35 shifts as Internist on-call to the Emergency Department during the 2 academic year. Undergraduate Medical Education The division provided 32 core and elective rotations and over 136 hours of undergraduate education. DIVISION OF HEMATOLOGY Registra 8, 6, Postgraduate Medical Education 4, 2, 29-21 21-211 211-212 212-213 213-214 Total Medical Day Unit 13,68 14,518 15,761 16,678 16,576 Total Hematology 9,388 1,124 1,65 11,648 1,918 Percent Hematology 71.8% 69.7% 67.6% 69.8% 65.9% Non Capital District: 2,764 58 residents rotated through the Hematology service during the 2 academic year, including 19 externals from Pathology, Nuclear Medicine, Family Medicine, Hematologic Pathology, Anaesthesia, Radiation Oncology and Neurology residency training programs. Figure 21 Hematology Medical Day Unit Ambulatory Care Registrations QEII Health Sciences Centre, 29-214 14, Division members delivered 9 hours of Academic Half Day teaching, 9 hours of CaRMS Selection Process and 1 hours as examiners for the Resident OSCE in the 2 academic year. Registrations R 12, 1, 8, 6, 4, 2, 29-21 21-211 211-212 212-213 213-214 MDU Bone Marrow 1 298 MDU Oncology 35 21 588 3,47 MDU Apheresis Bone Marrow 46 6 8 26 279 MDU Apheresis Hematology 182 149 179 159 42 MDU Hematology 9,16 9,934 1,253 1,874 6,514 Total 9,388 1,124 1,65 11,648 1,918 Subspecialty Medical Education The Division of Hematology offers a two-year Hematology residency training program, fully accredited by the Royal College of Physicians & Surgeons of Canada. Dr. Sharif completed Hematology residency training December 17, 213 and is now working at George Dumont Hospital, Moncton, NB. Dr. Zed completed Hematology residency training June 3, 214 and is now working at Saint John Regional Hospital, Saint John, NB. Dr. Katherine MacInnes was accepted to the Hematology Fellowship Training Program to start on July 1, 214. Department of Medicine Compendium of Divisional Activity 213-214 division of HEMATOLOGY 95
DIVISION OF HEMATOLOGY Continuing Medical Education Hematologists were active in the provision of continuing medical education, with 31 sessions presented to general practitioners, specialists and other trainees in 2. Research Division members continue to maintain positions of prominence within the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG). Members are also leaders in clinical research in thromboembolic and major bleeding disorders 16 peer reviewed, 1 non-peer reviewed publications and 16 abstracts were presented at National/International scientific meetings in 2. Hematologists provided referee and editorial services for 4 journals/granting agencies during 2. The Division generated $2,716,794 in research grants and industry contracts during 2. Administration Hematologists performed the following administrative activities: Division Head, including all responsibilities of the position. Division members act as Directors/Head/Chairs for: Director, Bleeding Disorder Program Medical Director, BMT Program Quality Director, BMT Program Chair, Hematology Research Finance Committee Chair, Hematology Residency Training Committee Chair, Hematology Tumor Site Group Chair, Hematology Morbidity & Mortality Committee Director, Postgraduate Medical Education Committee Director, Thrombosis and Anticoagulation Program Director, Undergraduate Medical Education Chair, Resident Research Committee Co-Chair, Research Ethics Board Chair, Thrombosis Canada Fellowship Committee Director, High Risk Obstetrics Clinic 96 Department of Medicine Compendium of Divisional Activity 213-214 division of HEMATOLOGY