Filippo Del Grande, MD (left), Ermidio Rezzonico (middle), and Matteo Merli, CAT scan technician (right), Ospedale Regionale di Lugano.
Two hospitals in Ticino, Switzerland, one serving an urban area of 100,000 people, the other a town of about 15,000, confront the demands of an aging population, increasing patient loads, and disruptions in patient scheduling when emergencies arise. Can a new approach make them increasingly efficient and attractive?
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Photos: Mattia Vacca
Nestled among alpine trees in a green valley by Lake Lugano is the Ospedale Regionale di Lugano – Civico e Italiano (Lugano Regional Hospital). It is part of the EOC, the Ente Ospedaliero Cantonale of Ticino, Switzerland, and epitomizes the crisp modern efficiency of Switzerland’s medical system, one of the world’s best, operating in one of the world’s wealthiest countries. Lugano’s patients are sophisticated – and older than the patients of an average regional hospital: Swiss men are the longest living in the world, according to the OECD, and Lugano is located in Ticino, with the country’s oldest population. Kidney disease, gout, stroke, heart attacks, and other cardiovascular ailments are common in such aging populations. So the hospital is particularly attentive to these diseases.
When a patient comes in with suspected kidney stones, for example, the standard procedure has been to ask him or her to filter his urine and “catch” a stone. The stone is analyzed and a therapy prescribed, based on the composition.
A similar situation confronts a smaller regional hospital in northern Ticino, Ospedale Regionale di Locarno. It is a linear, grey 200-bed general hospital located in a town near the northern nose of Lake Maggiore, and serves a local community of 15,000. “We have a little of everything,” explains Jürgen Heinkel, MD, Chief Radiologist in Locarno. He oversees a radiologist and two technicians specializing in CT exams.
By contrast, Lugano’s Civico has 300 beds, hosting patients with major medical problems such as trauma, neurology, stroke, vascular issues, and abdominal surgery. Both Lugano and Locarno are part of EOC – the others being Ospedale Regionale di Bellinzona e Valli, Ospedale Regionale di Mendrisio, Clinica riabilitazione di Novaggio, Istituto Oncologico della Svizzera Italiana, and Neurocentro della Svizzera Italiana.
Two hospitals, similar needs
The two regional hospitals have differences and similarities in terms of several common needs: Managing processes to maximize efficiency, remaining competitive with other hospitals in their market, and solidifying a good reputation to attract patients and staff. Like all Swiss hospitals, both facilities adhere to strict national rules regarding standardized medical protocols and low radiation doses, so acquisitions must facilitate adherence. The right equipment purchases can help address these needs and specifications. Lugano has had a top-of-the-line imaging device since 2010 with the SOMATOM Definition Flash, frequently used for cardiology patients. The exams of cardiac patients are performed in collaboration with cardiologists of the close located Cardiocentro Ticino who report the cardiac part of the exams. Problems arose when the needs of scheduled patients conflicted with emergency cases, and so the hospital decided to supplement existing equipment to minimize such disruptions. It planned to locate this new addition by the emergency room, but expected to use it for kidney, gout, and vascular patients, and others as well.
Locarno was looking to replace an older imaging device with something newer and faster, and planned to redesign the physical layout of its radiology department to accommodate its increasing patient loads. It had one changing room; it wanted to add a second – provided the equipment which fast enough to handle the load. Since older patients have more metal prosthetics, such as artificial limbs or teeth, both hospitals shopped for imaging equipment that would not be compromised by metal artifacts.
Improved appointment process and patient flow
Between 2016 and 2017, EOC decided to purchase a Siemens SOMATOM Definition Edge CT, equipped with TwinBeam Dual Energy (TBDE), for each of the two hospitals. Lugano already had a SOMATOM Definition Flash and bought the SOMATOM Definition Edge to replace an older Siemens model.
Lugano was familiar with the technology and its advantages: Sharp contrast images, minimal doses, metal artifact reduction, and versatility with a variety of optional applications. The purchase was made with emergency radiology (ER) use in mind, and has dramatically improved patient handling, according to Filippo Del Grande, MD, Chief Radiologist. His Head of Medical Technicians, Ermidio Rezzonico, seconds his observation: “With the Edge we improved our appointment process and our overall management of patient flow. The impact has been very positive.” While the SOMATOM Definition Flash would continue to be used for cardiology patients and scheduled exams, the SOMATOM Definition Edge was installed near the emergency room. The idea was to use it in the ER so that patients would not suffer scheduling disruptions when emergencies happened. The result has been a significant improvement in patient flow.
Locarno had seen the advantages of dual energy in Lugano and foresaw a mixed use: Emergencies and also programmed visits for – among other applications – gout, kidney stones, pulmonary embolisms, and cardiovascular pathologies. Patient satisfaction was a key reason for this acquisition. “The patient is our center of attention. So any new equipment we purchase must have a benefit for the patient,” explains Heinkel. “It was clear from the introduction of dual energy that it offered something more for the patient from a diagnostic point of view.”
Diagnostic applications for gout and kidney stones
Two of the most outstanding benefits are the dual energy postprocessing applications for gout and kidney stones, which can be applied in conjunction with TBDE technology. Gout is characterized by crystal deposits of urine acid. The TBDE technique is an important and popular problem-solving technique for the referring physician to directly visualize uric acid crystals that may indicate gout in and around the joints. The information from the TBDE CT scan will help clinicians to choose the optimal treatment for the patient.
The impact on kidney stone diagnosis is more dramatic. Ninety percent of kidney stones are composed of calcium oxalate, ten percent are uric acid; the prescribed therapy varies, depending on composition. Oxalate calls for breaking down the stones internally, acid calls for medicinal treatment. A TBDE scan enables a spectral analysis that identifies this chemical composition. “Clinically this is important,” says Heinkel. “Before TBDE, we had to wait for the stone to be expelled, then do a chemical analysis in the lab. For the patient this was very inconvenient; you had to try to catch the stone during urination. We used to do an X-ray, then ultrasound, then a CT scan. Now we start with the TBDE scan, and it is often the only exam needed. We can locate the stone precisely and see the damage it is causing.”
Another important application is to reduce artifacts when imaging patients with metal implant such as knee and hip arthroplasty and metal implants after surgical fracture correction. This is an interesting clinical application in continuously growing population. Dual energy minimizes interference from metal prosthetics, common in an older population. Older patients also have more need for vascular exams, and the elaboration of such data is reconstructed easily and precisely with the SOMATOM Definition Edge, according to Manara. The SOMATOM Definition Edge is also much faster than the previous CT scanner thanks to the fast pitch of 1.7. “We have gone from 17 seconds down to 7 seconds per scan,” reports Alberto Manara, the technician responsible for CT exams in Locarno.
Benefits of standardized protocols
The SOMATOM Definition Edge in Ticino has improved services for staff as well as patients. “Having the same machines allows us to be more cost efficient, and standardize procedures from one facility to another,” notes Del Grande. Like all Swiss hospitals, the facilities in Lugano and Locarno adhere to strict national rules regarding standardized medical protocols and low radiation doses, so acquisitions must facilitate adherence. Similar equipment facilitates the Swiss approach, because protocols can be more easily standardized. The same is true for training technicians. Staff can be more easily rotated among hospitals. Both Rezzonico and his colleague Matteo Merli, CAT scan technician, Ospedale Regionale di Lugano note that learning TBDE and the corresponding dual energy applications with the SOMATOM Definition Edge was easy because of Lugano’s experience with the SOMATOM Definition Flash. “We have always worked with Siemens equipment, so the same user interface, same applications and protocols speed up and facilitate the learning phase,” says Rezzonico.
Lower radiation doses than required by law
The Swiss passion for protocol is rivalled by their focus on dosage. Ticino hospitals maintain higher standards than the national minimums because they easily meet the minimum requirement. “What is important is to provide optimal images with low radiation doses,” notes Heinkel. After more than a year of working with the SOMATOM Definition Edge, he says that his department is using considerably less dose than with previous equipment. “This is significant for cancer patients who sometimes have to undergo several exams every year,” he points out. CT scans doubled over the last 10 years in Lugano, from 8,400 in 2006 to 17,000 in 2016. “Speed, improved workflows, new applications, reliable machines and the possibility to have the same CT technology in the radiology department helped dramatically to face efficiently and effectively the important increasing workload in the last years.” concludes Dr. Filippo Del Grande.
A winning combination
Swiss law requires competitive bidding for hospital equipment costing more than 200,000 Swiss francs (about 184,000 Euro). Price represents a certain part of the bid. The other factors are technical features, such as the power of the tube, the presence of dual energy, and the number of slices, as well as after-sales service, taking into consideration the experience, reliability, and availability of technicians in Ticino. Siemens shines in this category, as it has four technicians on call 24/7 and 365 days a year in the canton, one entirely dedicated to CT scanners. “We almost never have to call them but it is reassuring to know that we can,” says Filippo Del Grande, MD, Chief Radiologist at Ospedale Civico Regionale di Lugano in Ticino, Switzerland.
About the Author
Based in Italy, Claudia Flisi has written about the intersections of science and technology for the International New York Times and many other publications.