Laboratory Services Expanded in Huntsville and Bracebridge Hospitals: Point of Care Testing Fails to Meet Expectations

Muskoka Algonquin Healthcare (MAHC) has restored a regular night shift in its medical laboratories at the Huntsville and Bracebridge hospitals. This is a victory for viable community hospitals. It is also another example of the chaos caused by the government’s artificial prohibition on hospital labs performing medical laboratory work for community patients, for example, patients of family doctors.

The Huntsville and Bracebridge sites were on the cusp of a mini trend among small hospitals in Ontario replacing some in-hospital laboratory services with point-of-care-testing (POCT).* After two years’ experience the MAHC is reversing this policy and reinstating a regular laboratory night shift removing the need for most POCT.

MAHC’s Executive Officer for Diagnostic and Ambulatory Services gave two reasons for expanding their laboratory hours: 1) the savings from the switch to POCT were less than anticipated; and 2) the physicians complained about a decrease in quick accurate lab results with the reduced laboratory hours.

The recent increase in hospital mergers, regionalization and budget cuts has accelerated the trend to reduced laboratory hours in small and rural hospitals. Laboratories are often put at the top of the list when hospitals consider what services to cut.

Underlying these pressures is the reduction in laboratory volume, and income, faced by many hospitals due to the government’s decades long drive to ensure that all laboratory work for patients outside of hospitals is done in private for-profit labs. As harmful as this policy has been for all hospitals it is particularly devastating and irrational in smaller communities.

When community lab work is shipped out of these communities to centralized for-profit laboratories many of the smaller hospitals find it hard to justify full laboratory hours and a broad range of tests. As well as reducing access for community patients, cut backs in hospital laboratories have reduced services for inpatients and increased the cost to the overall health care budget.

MAHC was very much at the center of this misguided and ideological Ministry of Health policy. The Bracebridge and Huntsville hospitals were part of a pilot project program that funded small hospitals to process community work. A review of this program found that they performed the work for twenty-two dollars per community patient while the for-profit laboratories cost thirty-three dollars. Yet the government ended the pilot projects in 2007. The main reason given was to bring all hospitals into compliance with the government policy that mandated community work be processed by for-profit corporations. (Reference: RPO Management Consultants, “Laboratory Pilot Projects Review: Final Report,” Ontario Ministry of Health, March 31, 2008.)

It was after the ending of the pilot project program that MAHC attempted to meet decreased revenue by shifting some of the hospitals laboratory work to more POCT testing. It is now clear that that change did not improve patient care or save money.

The message in this story is that vital accessible small and rural hospitals need to maintain necessary medical services. The government needs to fund these services and allow communities the flexibility to maximize their use of health care resources. In this case, it means allowing hospitals to process community lab work, but it extends to all medical services.

Congratulations to MAHC for providing more comprehensive laboratory services to its patients. It is now time for the Ministry of Health to fund this needed hospital program and to change its policies to allow integrated, accessible, cost-effective medical laboratories.

*Point of Care Testing (POCT) is medical diagnostic testing performed outside the clinical laboratory in close proximity to where the patient is receiving care. POCT is typically performed by non-laboratory personnel, usually nurses, and the results are used for clinical decision-making. POCT devices are often ‘hand held’ or may be small portable analyzers. POCT is generally more expensive than in lab testing and quality assurance requires through protocols and skilled maintenance. POCT tests available include blood glucose, urine dipsticks, blood gases, chemistry, hematology, coagulation, cardiac markers, and pregnancy tests.

Fragmentation, Private Profit and Home Phlebotomy

Every day there are stories of how the fragmentation of health care hurts patients.  A few, when a patient dies, make the media.  Most often fragmentation causes small inconveniences, but there are many and they affect patients in very real ways.

December 19^th’s story is about a patient with a serious chronic illness.  She lives at home and manages her illness fairly well.  Monitoring her condition requires weekly blood work which is taken by a home care nurse through a PIC line, a semi-permanent intravenous access port. She then walks the blood a fairly short distance to a health center where LifeLabs picks it up at the end of day.

On December 19, as usual, the nurse took her blood then, as usual, left: the nurse is not allowed to transport the sample. Unusually, the blood sample stayed in his house because the patient was not able to walk to the clinic due to an exacerbation of her illness.

At this point in the story, it helps to go back 15 years. When I started as a home care nurse, we drew blood and transported it to the lab, often in a hospital.  Around the same time, Ontario formed the Community Care Access Centers to coordinate home care and put all home care services out to tender.  One of the services contracted was blood taking.  In our area, MDS, the precursor to LifeLabs, won the contract.  The new arrangements were that the nurse, now with a contracted agency, would visit for nursing duties, and, when blood was needed, a MDS phlebotomist would take the blood and bring to back to their lab.  Privatized home care coincided with the move away from using hospital labs and worked synergistically to give more work to the for-profit labs. Since MDS drew the blood all the samples went into their laboratory processing system. Most samples were shipped to Belleville, or more likely, Toronto before results were reported back to Kingston.

This system was even more absurd for my specific job.  I worked on the intravenous team servicing rural areas.  I would drive 20 minute s to see a patient and, if they needed urgent blood work I would draw the blood, and, as now required, leave it for an MDS driver who would also drive 20 minutes out to the patient’s house to pick up the blood.  Certainly one solution to this absurdity was to stop the service and make it the patients responsibility.  For the home-bound-cardiac-patients-in–rural-Ontario this was not the best solution. Nonetheless, as a way to reduce expensive duplication this was the one chosen the government.  Most patients are now expected to go to a bleeding station to have their blood taken.  Or, if you wish, you can pay a for-profit lab to come to your house.

Back to December 19, 2012 and our patient at home with a PIC line and her blood samples.  She did call the clinic and ask for help.  Luckily, a staff person was both available to drive to her house and willing to look the other way ignoring various bureaucratic restrictions around the transportation of blood.  The blood was picked up and the patient will get the results she needs.

This is a small story on the impact of fragmentation due to the division of services into components to facilitate the use of for-profit health care companies. Staff flexibility, concern and minor rule-breaking were needed to give this patient the care she needed, though I expect that” best practice” rules would not agree with this approach.  And, it does not address the needs of the hundreds of thousands of patients who daily suffer from a fragmented for-profit home care system.  Rather than rely on serendipity and the good will of staff maybe it is time for an integrated public non-profit home care service.

More Local Lab Service Cuts

It seems that the government is now using changes in the OHIP fee schedule give more work to the for-profit laboratory corporations.  This reduction in patient access is documented by Rita Marshall in the June 22 edition of the Mitchell Advocate.  Mitchell is a town in the Municipality of West Perth near Stratford Ontario.

Don’t like the fact that Mitchell Family Doctors send patients out-of-town for blood work now? Blame the province, says the office.

“Blood work is an important diagnostic tool and we were pleased to provide that service to our patients so they did not have to leave our community,” wrote office manager Sherry Kraemer in an email.

“It is unfortunate the government does not see value in that.”

The practice stopped performing blood work on patients about three weeks ago after learning about funding changes to the OHIP Schedule of Benefits effective April 1, 2012. Kraemer noted that the province unilaterally imposed the cuts.

“It’s just no longer feasible for us to offer that service,” Kraemer said in a phone interview. “The doctors are upset about it as well but it just seems to be the direction that the government is heading.

“It wasn’t an easy decision and I don’t think anyone’s thrilled about it, but it is what it is.”

Patients who require blood work must now go out-of-town, either to Lifelabs at Stratford’s Jenny Trout Centre or Stratford General Hospital, Seaforth Community Hospital or Clinton Public Hospital.

Kraemer said the waits at Lifelabs may be shorter if patients book an appointment online. Patients can book an appointment through www.lifelabs.com.

Ottawa’s Integrated Hospital Laboratory Service Takes the Next Step

The Ottawa Citizen announced the start of the Ottawa area hospitals integrated laboratory service.  The Citizen somehow links this development to Don Drummond. It has nothing to do with Drummond.  This particular project dates back to 1996, is fully within the public sector and continues a long tradition, back to 1967, of Ontario’s hospitals cooperating to improve laboratory services for both inpatients and community patients.

Whether this initiative will improve laboratory services, especially for the smaller area hospitals, depends on the details, but there is potential.  This development is also not the real story.

The real story is the regulatory limitation on Ottawa’s new laboratory.  Drummond called for more integration and yet Ministry of Health’s policy is to divide the laboratory sector between inpatients and community patients. The two shall never cooperate even if it would work better.  There is no wiggle room only bureaucratic order.  So the new Ottawa project, which could integrate hospital laboratory work  with community laboratory work, and make the whole system more efficient and provide a more complete service to all patients, cannot.  Calgary Laboratory Services, where the CEO of the new lab worked before Ottawa, does just that.  It is a public sector operation that integrates all laboratory services in the Calgary area.

I look forward to seeing the details of the Ottawa operation.  One historical detail that is missing is how much money was paid to Gamma-Dynacare as a consultant on the project before 2006 and a full accounting of its influence.

While we need to wait and see how the Eastern Ontario Regional Laboratory Association works, it once again reminds us that, in the history of Canadian health care, the best solutions have come from the public sector and often involve the integration of many services.  Unfortunately in Ontario, the Ministry is bound and determined to protect the multinational laboratory companies so we are denied the best laboratory services.

Update on Thessalon and St. Joseph Island

The facts as we now know them:

Despite what the hospital web site says there are no lab facilities at the Mathews Memorial Hospital or the Thessalon Hospital. Neither has a laboratory license.

Blood is taken at these facilities by hospital staff and sent to the main lab at the Sault Area Hospital for processing.

Both hospitals have been taking blood from community patients for years under these conditions.

If there is now a concern about the legality of this service there is a simple solution: the Sault Area Hospital could apply for a specimen collection center license at the Mathews Memorial and Thessalon sites.  It is an easy process, with minimal cost – less than the cost of gas paid by all the patients that will now be forced to drive to the Sault each year for their blood taking.  The buildings are all ready there, the equipment is there, the skilled staff is there and the transportation network back to the Sault is in place.  It seems like a no-brainer.

If some solution using the hospitals is not found we could end up with one of those “fact is stranger than fiction” situations.  What we could have in these northern Ontario communities is laboratory specimens being drawn in Mathews Memorial and Thessalon hospitals and being driven numerous times a day back to the main Sault hospital laboratory for processing.  Simultaneously, community patients from these same communities are being expected to get in their cars and drive 80+ kilometres to the Sault so they can have their blood taken at a private lab. And, to add to the traffic on the highway 17, the new best interim solution is that Lifelabs will set up a one hour clinic once a week in these communities and drive the blood to the Sault.

On the way back to the Sault the Lifelabs drivers will probably pass the vehicle driving the blood from the patients in the satellite hospitals as well as all the community patients who were not able to make it to the one hour clinic. The big winners are the oil and gas companies and the private labs.  It is craziness for public resources, patient’s time and access to an essential medical service.

No Legal Requirement to Cut Lab Services

Residents around Thessalon and on St. Joseph Island, both east of Sault St. Marie in northern Ontario, have been recently told that their community hospitals will no longer be taking blood samples ordered by their family doctors. This follows a trend across Ontario to force all non-hospital patients to use for-profit laboratories, even if, as it is in the Algoma region, it is much more inconvenient for patients and more expensive.

The communications officer for the Sault Area Hospital, the mother ship of these two local hospitals, gave as the reason for cutting lab services that conditions of their laboratory’s licence and provisions of the Public Hospitals Act prohibited hospitals from servicing community patients.  According to a newspaper column in the Sault Star this information had been given to the hospital by a spokesperson for the Laboratory Licensing Branch of Ontario’s Ministry of Health.  Nothing about this story rings true.

I can find nothing in the laboratory’s licence, found on-line at http://www.qmpls.org, that restricts what patient’s provide the samples to be tested and it would be very much out of line for the quality assurance service to make this ruling.  Their job is to ensure that the tests results are accurate, not who can provide the blood.  Also, I can find no prohibitions against performing community patients’ tests in the Public Hospitals Act or its regulations.

I also read the current Hospital Service Accountability Agreement between the Sault Area Hospital and the North East Local Health Integration Network (LHIN) and could find no reference to who can use hospital faculties to have their samples taken or restrictions on what tests can be performed in the hospital’s laboratory.

The story from the Ministry of Health also does not ring true because hospitals in Ontario take requisitions from family doctors for diagnostic imaging on a daily basis.  Hospitals in Ontario have been performing tests on community patients since their inception, many since the middle of the last century, and I can find no recent substantive legislative changes that would restrict these activities.

All of these factors point to the conclusion that the hospital’s spokesperson was given misleading information to justify reducing access to needed laboratory services.  The real question is where did this order come from?

The coordination of these service cuts across Ontario strongly suggests that it is a Ministry of Health directive, but so far no one has come forward and provided the evidence.  Until this happens local hospital executives will continue to take the flack and provide stories to cover someone’s butt, probably the Minister of Health’s. So much for openness, accountability, strengthening the public healthcare system and improving access, all stated goals of the Ministry of Health.

Another Local Lab Service Lost

A column in the January 8 Sault Star documents a rural community losing its blood taking services. The Thessalon Hospital, serving Thessalon and area, a satellite hospital of Sault St. Marie Hospital, recently stopped taking blood samples from community patients. Residents in these areas must now drive an extra 85 kilometres to have their blood taken in the Sault. In bad weather conditions this is often a dangerous trip, and it is a long trip for people who are ill, especially cancer patients, kidney patients, heart patients and all others with chronic illnesses that require frequent blood work.

I was struck by a few facts reported in this column. First, Thessalon is being treated unfairly compared to most other rural towns in the province. In most areas, when the community hospital stopped taking blood, one of the for-profit labs opened up close by: at least this is the case in southern Ontario. Often there were reduced hours, but the community still had service.

Second, the columnist, Doug Millroy, argues that the residents of these communities should get use to it because it is happening all over the province. It seems to me that fighting a decision that has increased cost, made it more difficult to provide full services to inpatients and cut services to community patients, should be fought in every community until it is reversed. We should not have to accept ill thought-out changes.

Last, in the article it mentions that this change is mandated by the Public Hospitals Act and the laboratory’s license. Well, I have been researching laboratory policy in Ontario for a few years and this is the first I have heard that hospitals labs are legally barred from taking community patients. Certainly, it has not been mentioned in the many discussions that I have monitored. Nor was it raised in answers to direct questions about the reasons for restricting hospital laboratory services.

It may be that there is a legal requirement though it would have been enacted in the last couple of years. Hospitals have been taking blood from all patients since they were built, in many cases for over 50 years, and no one has been charged or penalized. My understanding was that this development, moving all community blood work to for-profit laboratories, was driven by the Local Health Integration Networks and hospitals which need to save money in tight budget times. Clearly more work is needed to straighten out this story.

In the mean time, good luck to the residents of Thessalon.  As Ontario residents you have a right to reasonable access to essential health services and having your blood taken in your local hospital is reasonable.

Link to Millroy column: http://www.saultstar.com/ArticleDisplay.aspx?e=3428543

Bluewater Health Contracts Private Lab Services

I participated in a Sarnia Health Coalition meeting that reinforced my suspicion that my estimate of a billion public health care dollars a year paid to for-profit laboratory companies is on the low side.  The Bluewater Hospitals ship many of the lab tests they cannot do on-site to LifeLabs or Gamma-Dynacare for processing.  When I asked members of the audience why they were not sent to a larger public hospital, like the teaching hospital complex in London, at least as close as the for-profit facilities, they said there was no mechanisms or structure to support that referral.  The value of these referrals and the contract arrangements are not known. 

This example, which is not uncommon with many hospitals buying services from private laboratories, highlights another serious problem with the use of private corporations by the public health care system: a lack of accountability. We do not know what contracts are in place, how much private corporations are paid or whether public sector alternatives were considered. 

The Sarnia meeting also had a lively discussion on quality in lab services.  Those present who were familiar with the hospital laboratory services made a strong argument that the technical quality of the private labs and the hospital labs was similar.  Both labs use the same reagents, technology and have the same quality assurance programs.  At the same time, some in the audience had complaints about lack of access to the private facilities, long turnaround times and difficulties obtaining results, highlighting the decrease in quality that comes from a system divided between community and inpatient services with competing organizations performing similar work.

Labs Excluded from Prince Edward Integration

I spoke on laboratory services at the April 21 general meeting of the Friends of Prince Edward County Health. They have experienced a noticeable reduction in services since the local hospital was stopped from seeing community patients and all the work is now done by LifeLabs.

At the meeting there was also a speaker from the Local Health Integration Network (LHIN), the regional health authority. Her talk was on the proposed redevelopment of health care services in the community and how they planned to integrate most services into in one facility for the ease of patients and to improve quality. She talked about how a patient would be able to see a family doctor then walk down the hall, visit an inpatient and get an x-ray done: all in one trip.

The irony did not escape the meeting: the LHIN is same organization that made it impossible for the local hospital to provide laboratory services to the community.

How much quicker it would be if the test was processed on site. How much less likely the chance of error or harm to the sample since it does not have to travel hundreds of kilometres to a for-profit lab. How handy for the physician to be able to go the lab and talk with a laboratory specialists if they have a question. How helpful for the hospital lab to have the extra volume so they could hire more staff and better equipment.

Talk about integration is cheap when private health care is involved and not likely to happen.

Sarnia Patients Shut Out of Hospital Labs

Bluewater Health, the non-profit corporation with hospitals in Sarnia and Petrolia in South Western Ontario, has severely reduced laboratory access for patients who are not admitted to hospital. The media release from the hospital states:

As of April 1, 2011 the laboratory will only service the following community outpatients: urgent cases; prenatal patients; difficult draw or special circumstance cases (patients with a physical or mental disability); children under the age of 5; and those who require some specialized testing not available elsewhere.

This means that most community outpatients must visit a community laboratory to have testing completed.

The surprising aspect of this reduction in access is that it happened this year. Most hospitals in Ontario closed their doors to community patients before 2010.

When Ontario’s regional health authorities, the Local Health Integration Networks (LHINs), were formed, laboratory services for community patients were left out of their mandate. The LHINs have fixed budgets which they impose on hospitals in their region. Any service they can stop providing is money saved, so good bye community laboratory services which are shifted to for-profit laboratory corporations that fall under a different part of the province’s health care budget.

In Sarnia the two private laboratory corporations that benefit from this privatization of laboratory services are LifeLabs and CML (Canadian Medical Laboratories). Most of the Sarnia samples taken by CML staff will be processed in Mississauga while LifeLabs will ship most specimens to London or Toronto.

The ‘Integration’ in the LHINs title is a smoke screen for systemic disintegration rooted in Ontario’s Ministry of Health