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Clinical Navigators and a Hotline: The Systems Approach to Thoracic Surgery in the Community

Robert Zeldin
Robert Zeldin

Rob Zeldin has developed a remarkable network of partner institutions as he builds up the thoracic surgery division at Toronto East General Hospital (TEGH). Working with Carmine Simone and Simon Iu, he is developing a Level 1 Thoracic Surgery Centre at TEGH with affiliations at Sunnybrook, North York General, and the Royal Victoria Hospital (RVH) in Barrie. As the Section Chair for Thoracic Surgery at the Ontario Medical Association, Rob has been able to participate actively in the regionalization of the specialty throughout the province.

There is some active rearrangement going on as the LIHN (Local Integrated Health Network) boundaries don't match the referral patterns. Rob and his partners won the contract for the North Simcoe Muskoka LIHN centered around Barrie. They conduct one thoracic clinic per week in Barrie and admit the patients to Toronto East General for their procedures. Under the direction of the TEGH Thoracic Surgeons, a nurse practitioner interviews, examines and orders appropriate tests on patients who present to the Barrie site. The TEGH surgeons rotate through the weekly clinics at Barrie, Sunnybrook and their own hospital. In-patients and Emergency Room consults at Sunnybrook are covered by residents on the Acute Care Service. The trauma surgeons cover thoracic trauma very efficiently.

There is seamless computer access to the records within the thoracic service including its partner institutions. The Ministry of Health and Cancer Care Ontario are enthused by the partnership model that Rob and his colleagues have developed and hope it can be duplicated for other high intensity surgical services such as hepatobiliary surgery. The anesthesia department currently rotates its PGY5 residents to Toronto East General for experience in basic thoracic anesthesia. The thoracic unit has one senior and two junior general surgery residents assigned. The unit performs one day endoscopy and 4-5 major cases per week, 20 esophagectomies per year, and a large number of video-assisted thoracic procedures. All of the surgeons perform minimum access lobectomies. The collegiality of the practice is a source of great satisfaction, and the experience of the general surgery residents on the thoracic service serves as a focus for recruiting residents into thoracic training.

Carmine Simone serves as Director of the Intensive Care Unit in addition to his thoracic surgery responsibilities. He has a great five person unit, all part of the University of Toronto critical care training program. The unit consistently ranks as one the most popular rotations for junior general surgery residents and critical care fellows and has won awards.

Carmine Simone
Carmine Simone

The thoracic surgery unit has won accolades for its "Time to Treat" lung cancer program. It became evident that the waiting time from first suspicion of lung cancer to a treatment decision was as long as three months. Wait number one began in the general practitioners' office and generally included X-rays, CT scans, endoscopy and other studies. Wait number 2 came from the time of the decision to treat until the patient got to the operating room. The thoracic surgeons set up a hotline with clear instructions to referring doctors, guaranteeing that their patients would be seen within three business days. The access program included respirologists as well as surgeons, and clear guidelines were provided. For example, cough led to a referral to a respirologist, hemoptysis is referred to a surgeon. The wait time dropped from three months to less than one month for a complete work up and start of treatment. A key component of the program is the training role of the Clinical Navigators, Larissa Maxwell in Toronto and Candy Carnahan in Barrie. A 430 patient study on which this program is based was described by Dorothy Lo and Rob Zeldin in the November 2007 Journal of Thoracic Oncology(1). The success of this program has led to a province-wide guideline to be published in the fall of 2010 by Cancer Care Ontario. It will assist referring primary care physicians in triaging suspected lung cancer patients to the appropriate specialist.

(1) Lo, Dorothy S. MD ; Zeldin, Robert A. MD; Skrastins, Roland MD; Fraser, Ian M. MD; Newman, Harold MD; Monavvari, Alan MD; Ung, Yee C. MD; Joseph, Harry MBA; Downton, Teresa; Maxwell, Larissa; Meharchand, Jacinta MD. Time to Treat: A System Redesign Focusing on Decreasing the Time from Suspicion of Lung Cancer to Diagnosis. Journal of Thoracic Oncology. 2007; 2 (11): 1001-1006


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