LABORATORIES www.hospitalhealthcare.com Digital networking across North Wales The use of technology has overcome significant challenges in the modernisation of pathology services across North Wales, particularly in respect of geographical constraints and population base Muhammad Aslam MBBS FRCPATH support sub-specialist care provision while Clinical Lead Histopathology maintaining acceptable access times for David Fletcher PhD FIBMS C.Sci the majority of patients. Directorate General Manager For Pathology services across North Betsi Cadwaladr University Health Board, Wales, a single managed service was created Bangor, UK to replace the three individual hospital- based departments. With the relatively low requirement for direct patient access to he Betsi Cadwaladr University laboratory-based Pathology services, the Health Board (BCUHB) is the opportunity existed to re-provide these Tlargest single health organisation services in a more specialist, concentrated in Wales, and is responsible for providing form. During the period 2010–2015, community, hospital and mental health several business cases were approved services, and overseeing primary and implemented, to support this vision, health care services for a population of providing new/refurbished premises, around 680,000 people in North Wales, specialist laboratory equipment and IT together with providing some services technologies to improved both quality and to residents of North Powys and parts of performance of essential investigations Cheshire and Shropshire. The services and tests. are provided from three acute hospitals: Ysbyty Gwynedd (YG) in Bangor; Glan Cellular pathology in North Wales Clwyd Hospital near Rhyl (YGC); and For Cellular Pathology services, the Wrexham Maelor Hospital (YMW), along outcome of this major reconfiguration with a network of community hospitals, was a merge of the three small cellular health centres, clinics, mental health Location of BCUHB Acute Hospitals in pathology departments into one single units and community team bases. We North Wales managed central laboratory based in employ approximately 16,000 staff, and Glan Clwyd Hospital site near Rhyl; also coordinate the work of 191 general commissioning area units as a single a new, purpose-built laboratory and practitioner (GP) practices, and National provider. The reconfiguration provided accommodation for up to 12 medical staff Health Service (NHS) services provided great opportunity for closer working and their secretarial teams. The service by dentists, opticians and pharmacists together by multiple organisations in the operates principally from the Glan Clwyd across the region. BCUHB was established north of Wales to provide best possible site, with currently sample reception, on 1 October 2009 as a part of the Welsh and specialist care for our patients. The mortuary, and minimal consultant/ Government One Wales reform programme greatest constraint, similar to any mixed secretarial accommodation and facilities for the NHS in Wales, bringing together urban/rural population, is geographical remaining at the Ysbyty Wrexham/Ysbyty three acute and several community – presenting confounding issues in Gwynedd sites. The new single Cellular hospitals, along with six primary care respect of having adequate critical mass to Pathology service annually processes: HHE 2016 | 000 LABORATORIES www.hospitalhealthcare.com laboratory workload. In addition, there is a critical medical consultant workforce shortage within Cellular Pathology across the UK, and this is also currently the case across North Wales, exacerbated in part due to retirements and the relocation of services; this had resulted in extreme imbalance in the capacity and the workload. To maintain services’ reliance on locum agencies and outside providers was the only short-term option but that increased lab work further in terms of tracking and relying heavily on logistics, increasing the risk for specimen losses and damage in transportation. The number and location of MDTs also result in significant movement and tracking of slides. To develop specialist reporting and internal/external case review further increases transportation and associated risks and increase in additional gain in lab workload. • 44,000 histopathology requests coverslipper (Dako Coverstainer) was Digital pathology • 5000 non-cervical cytology requests installed in 2015 to ensure consistent, To manage these issues and to run the • 50,000 cervical cytology requests. high-quality slide preparations Department on Lean principles, the need However, the provision of clinical • The immunohistochemistry service to move towards digital pathology was services for patients remains locally is fully automated, using two Roche paramount. A digital pathology solution based at each hospital, and with over Benchmark XT analysers, including was expected to contribute across a 25 multidisciplinary team meetings all breast marker work and third number of applications. The solution scheduled each week. To fully modernise Benchmark ultra would help in the MDT reviews, similar to a the services provided and handle the • Video-conferencing facilities system PACS radiology-like solution, whereby the workload and geographical challenges, it installation in a separate room to consultant could review the case in their was envisaged at earliest stage to rely on provide global North Wales link for office digitally and present on the screen. modern digital technologies (in addition the multidisciplinary team (MDT) Across site frozen could be performed to consolidation alone) as follows: • Video-conferencing facilities system without a consultant needing to be • A new Laboratory Information in a large seminar room, which is present at the site. Outsourcing of work Management System (LIMS; currently used as managerial cross site could be completed without transporting Intersystems Trakcare Lab) has meetings, candidate interviews and slides, removing issues with tracking. been installed as part of an all-Wales teaching purposes Internal review on individual cases by Pathology implementation • Q-pulse, a laboratory quality assurance colleagues in the trust or elsewhere in • New digital dictation system ensures software installation, is carried out the country could be carried out quickly full end-to-end IT connectivity is (a new application for accreditation and without significant secretarial and achieved across the BCUHB Cellular under UKAS standards for the entire laboratory input. It was also considered Pathology Service with minimal need Cellular Pathology service will be that outsourcing some of the MDT would for staff to move between sites made in 2016). be possible, without additional pressure • Macroscopic digital photography Consolidation of Cellular Pathology on the lab staff. Digital pathology also system and digital faxitron for breast services to a single location provides provides a great potential contribution specimens are under process to be significant benefits in respect of critical towards teaching and training, as North installed and linked with digital mass, for example, efficiency and sub- Wales, serving a population of more than microimages and LIMS specialisation. However, the distance 600,000, provides exposure to plenty of • Blocks and slides barcoding and digital between acute hospital sites (35 miles), varied pathology which could be used labelling system installed the need for transporting slides for MDT across the country for training purposes. • Provision of barcode reader to the meetings/specialist review, and necessary The vision of the organisation to see consultants who can scan individual slide tracking issues would add significant beyond the traditional solutions and look slide and request form to report time to result turnaround times and into future has helped cellular pathology • A new automated H&E stainer/ also create a significant increase in to challenge the three centuries old HHE 2016 | 000 LABORATORIES www.hospitalhealthcare.com www.hospitalhealthcare.com of digital pathology is an ongoing process with the largest challenge seen in IT support. The target is to acquire all the data, identify any discrepancies, and make the results available by the end of 2016. Following this, there will be a transition to more and more reliance on digital reporting rather than microscopes. Before starting the verification process, 3 x 20 teaching cases were produced from a random collection of reported anonymous cases, and the glass slides and digitally scanned images were made available to review, in order to set individual consultant thresholds. Additional teaching sets for large resection cases are in process. The verification study is led by the all-Wales project, and involves a team of consultants, scientists, IT personals and managers. • The system produces high resolution images, which will be manipulated method of microscopic reports, to be • In April 2015, following a robust through bespoke software (Aperio replaced or supported by digital high procurement exercise, Leica eSlide Manager), and will be definition screen reviews and reporting. Biosystems’ Aperio Digital Pathology integrated with the LIMS. In 2013, the Welsh Government made system was installed; including a high- • Office-based video conferencing capital available though a competitive capacity automated slide scanner, facilities form part of each consultant ‘Health Technology Fund’ to introduce three smaller semi-automated workstation, allowing a broader new technologies into clinical service