Lean in Healthcare Wireless Sensor Networks RFID in Hospitals Molecular Diagnostics

Issue 11 2006 £5.95 €8.00 $8.95 www.asianhhm.com

An accreditation is a
way to distinguish
a hospital.

Anne Rooney
Executive Director
International Services
Joint Commission International (JCI)

World-class
Accreditations
via
Published by

In association with

Informa tion Technology | Surgical Speciality | Cardiology | Oncology | Facilities & Operations
Circle 01
 Contents

Healthcare Management
Bariatric Surgery 22
Medical Tourism 10
Preparing for the challenge The minimal
Bhaskar P Shah, Director, Asian Heart Institute,
India
access approach

INTRODUCTION
Minimal access surgery

World-class via has come as a boon

for bariatric surgery.

Accreditations Pradeep K Chowbey, Chairman, Minimal Access and

Bariatric Surgery Centre, Sir Ganga Ram Hospital,
India

7 Diagnostics
Human Genome and 29
the Molecular Diagnostics Market
Chee Gee See, Biomarker and Genetics Programme Manager,
Roche Products Limited and
Chris Chamberlain, Global Head, Medical Genetics,
Roche Products Limited,h
UK

Technology, Equipment & Devices

Medical Gloves 36
Going powder free
Mónica Sagardoy, Brand Support Manager - Professional -
Asia Pacific, Ansell Healthcare,
Medical tourism has played a catalytic role in Australia
making the Asian hospitals strive for
world-class quality standards. IPR in Medical Equipment 40
China’s rise
Allen Yeo, Principal Consultant, Thomson Scientific,
Akhil Tandulwadikar and Rajeshwer Chigullapalli Singapore
Healthcare Editorial Team
Patient Monitoring 43
Non-invasive is the way
Gido M Karges, Director Marketing & Sales, SenTec AG,
Surgical Speciality Switzerland

Minimally Invasive Surgery 18 Facilities & Operations

Emerging trends
Davide Lomanto, Director, Minimally Invasive Surgical Centre (MISC), Infection Control 46
National University Hospital, The role of nonwoven textiles
Singapore Catherine Lennon, Communications Director, EDANA Group,
Belgium
Minimally Invasive Surgery 25
Rise of the robotic systems
Makoto Hashizume, Director, Center for Integration of Advanced Cardiology
Medicine and Innovative Technology, Kyushu University Hospital,
Japan
15 Cardiac Surgery
New techniques
Oncology
The focus of new techniques
Cancer 27 has been on making cardiac
surgery safe, minimally
Early detection strategies invasive and cost-effective.
Ronald B. Herberman, Director,
University of Pittsburgh Cancer Institute and Ramakanta Panda, Vice Chairman,
Anna Lokshin, Assistant Professor of Medicine, Asian Heart Institute,
University of Pittsburgh, India
USA

w w w.asianhhm.com 
 Asian Hospital & Healthcare Management ISSUE-11 2006 Circle 02
 CONTENTs

Interview
13 Lean in Issue 11 2006
Healthcare
Lean focuses on the entire Chief Editor Rajeshwer Chigullapalli
healthcare process itself Healthcare Editorial Team Grace Jones
whereas traditionally Akhil Tandulwadikar
healthcare has focused Prasanthi Potluri
on separately scheduled
Copy Editors Srinivas G Roopi
individual activities.
Sreenivasa Rao Dasari
Daniel T Jones, Founding Chairman, Art Director M A Hannan
Lean Enterprise Academy,
UK Design Narsingoji Raju
Project Coordinators Sunny Roger
Yuvraj Sahni
Anaesthesiology
Project Associates Stella Powell
Anaesthesia N Sweta
The 21st century challenge 50 Srikanth Katragadda
Anneke E E Meursing, President,
World Federation of Societies of Anaesthesiologists, Circulation Manager S V Nageswara Rao
UK Circulation Executives Gagan Kumar Vallabhaneni
Kevin Smith
Kranti Kalidindi
Information Technology
Managing Director Vijay Chintamaneni
Telesurgery in Asia 56 Director Sales & Marketing Ashok Ganguly
Are we there yet?
Adam Chee, Industry Analyst, Healthcare (Asia Pacific), Marketing Manager Ahmed Tariq
Frost & Sullivan,
Singapore Asian Hospital & Healthcare Management is published by
SPG Media Limited in association with Frost & Sullivan
Medical Errors
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Asia’s Challenge to the Medical Manufacturers 58
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Medical Care www.asianhhm.com | www.frost.com | www.spgmedia.com |

Wireless sensor
networks
New opportunities now exist where
medical systems can be developed
which offer preventative care and
focus on delivering this directly to the
person at home.
60
Diana Hodgins, Managing Director,
European Technology for Business (ETB) Ltd.
And Project Co-ordinator Healthy Aims,
UK
ISBN no. 1 85938 676 8
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 Asian Hospital & Healthcare Management ISSUE-11 2006 Circle 03

Asia’s tryst with accreditations
“Is it not also true that no physician, in so far as he is a physician, considers or enjoins what is for the
physician’s interest, but that all seek the good of their patients? For we have agreed that a physician strictly
so called, is a ruler of bodies, and not a maker of money, have we not?”
P
lato, surely was advising physicians not to be mere
money makers. Enter international accreditations,
Asian hospitals now have an opportunity to make
money as well as put the patient’s interest as first and fore-
most. The National Heart Centre, Singapore on achieving
the Joint Commission International (JCI) accreditation
proudly proclaimed “We have learnt to look at healthcare
from the patients’ point of view.” And here lies the core
benefit of accreditation process.
Asia’s tryst with accreditations began with the
arrival of the medical tourist from the west. What began
as a trickle, is all set to turn into a flood, with the Asian
market predicted to reach US$ 4 billion by 2012. While
underinsured and uninsured patients began to drive the
market, soaring employee healthcare costs compelled
the MNCs to join the bandwagon. A few multinational
companies have begun sending their employees to Asian
hospitals for treatment and also pass on a part of the huge
savings in cost to them as well.
Global accreditations appear to hold the key to tap
this emerging lucrative market. JCI, the leading interna-
tional accreditation body, regarded as the gold standard,
which has already accredited 30 Asian hospitals, is gearing
up to strengthen its presence in Asia by setting up its first
Asia Pacific office in Singapore. While the share of revenue
lost by the US hospitals on account of the rise of Asia’s
medical tourism still remains negligible, it is just a begin-
ning. TIME magazine predicts that the trend will eventu-
ally turn the heat on the US hospitals. Reports TIME “It’s
(medical tourism) one that could put greater competitive
pressure on US hospitals as some of their most lucrative
patients are siphoned off. Elective surgeries are key money
makers for hospitals, and even a small drop-off can cut
deep into their profits.”
Foreword
- Plato
While the accreditation drive began with the objec-
tive of attracting the attention of foreign medical tourists,
they are bound to lay a platform for the hospitals in the
Asian region to catch-up with the best global practices.
There is a sense of deja vu. It has happened before in the
region, with mainstream outsourcing – in IT and ITES
sectors. Having to satisfy the exacting demands of global
customers made these companies build the capabilities to
become world-class.
Accreditations are organization-wide efforts and re-
quire commitment of the organization’s leaders. The ac-
credited hospitals vouchsafe the ability of standards to
deliver results. They tend to reduce the risk of medical
errors significantly, inculcate a culture of patient safety
and lead to overall quality improvement. However, for
a vast majority of medium to smaller size hospitals in
the region, affordability of international accreditations
remains an issue. The local governments could come up
with their models of independent domestic accreditation
agencies along the lines of international ones, customizing
the frameworks to suit the size of hospitals. The global
accreditation bodies could also come up with variants of
accreditations to suit the smaller hospitals.
The cover story, World-class via Accreditations,
presents the scenario of accreditations in Asia. This issue
also presents insightful articles covering Surgical Specialty,
Cardiology, Diagnostics, medical equipment etc.
Rajeshwer Chigullapalli
Chief Editor
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 Circle 04

Circle 05
 Asian Hospital & Healthcare Management ISSUE-11 2006
Healthcare Management
World-class via
Accreditations
T
he fact that medical tourism in Asia
is happening, is no longer news.
But prediction of its huge growth
potential certainly is. Abacus International,
a UK-based healthcare consultancy be-
lieves that the lure of low-cost, high quality
healthcare in Asia will attract more than 1.3
million tourists a year to the key locations
– Thailand, Singapore, India, South Korea
and Malaysia. The medical tourism market
is expected to be worth US$ 4 billion by
2012.
Rising healthcare costs in the US have
forced the un-insured and under-insured
patients to look at cheaper healthcare alter-
natives outside the US. But while high costs
have been an important driver, the factor
that has actually pushed the patients to un-
dertake the long journey is that the hospitals
in Asia have made an effort to match the
quality standards that exist in the US and
other western countries. They did so by
striving to achieve the global accreditations
like Joint Commission International (JCI).
“An accreditation is a way to distinguish a
hospital,” says Anne Rooney, Executive Di-
rector of International Services at JCI.
However, the importance of interna-
tional accreditations to Asian hospitals goes
far beyond just attracting foreign tourists.
Better quality of healthcare and higher
standards of patient safety help the hospitals
to give the best treatment to a patient – irre-
spective of nationality - in the least possible
time and with minimal wastage and lesser
medical errors. While for the patients this
means better treatment, for hospitals it is
reduced wastage and
lower costs
in the
Medical tourism has played a catalytic role in
making the Asian hospitals strive for world-class
quality standards.
Akhil Tandulwadikar and Rajeshwer Chigullapalli
long run. With accreditations, quality no
longer remains the job of a few but it gets
woven into the fabric of function involv-
ing all processes and people to pursue the
same goal.
Accreditations -
Reshaping Asian healthcare
Healthcare in Asia has emerged as a major
focus area, with many nations recovering
from the Asian Crisis as also the increasing
prosperity China and India have begun to
experience as a result of their policy reforms.
There is a greater need to revamp the health-
care systems for better quality of healthcare.
Attempts are on to benchmark with the best
globally. India established the National As-
sociation Board for Hospitals and Health
Service Providers (NABH) for accreditation
of hospitals in the country recently. Absence
of such standards always put the patients at
risk. A survey by the World Health Organi-
zation (WHO) found the incidence of hos-
pital-acquired infections to be highest in the
Southeast Asian region at 10%, only mar-
ginally behind the Eastern Mediterranean
region at 11.8%, which topped the list.
But there has been a gradual increase
in the awareness regarding the importance
of quality, thanks mainly to the increasing
role of private players in the sector, espe-
cially in countries like India and China,
where private sector hospitals have aggres-
sively pursued accreditation. Medical tour-
ism has played a catalytic role in making the
Asian hospitals strive for world-class quality
standards. Despite accreditations being a
voluntary process, the competition to
I NTR O D U CT I O N
Healthcare Editorial Team
attract foreign tourists has been driving hos-
pitals towards them. This of course is good
news for domestic patients as well since they
will be able to access the best healthcare
without having to travel a lot.
Among the various international ac-
creditations available, the one awarded by
JCI, the international arm of the US-based
accreditation body Joint Commission on
Accreditation for Healthcare Organisations
(JCAHO), has become very popular. High
standards, wide scope and rigorous process
of evaluation have made JCI accreditation
a ‘gold standard’ in hospital accreditation.
Already, as many as 30 Asian hospitals have
got themselves accredited. And this number
is only going up. While Singapore leads the
Asian pack with 11 accredited hospitals, In-
dia, so far has 5 accredited hospitals with a
few others preparing for it.
The other option that could soon
be available for hospitals is the NIA-
HO-ISO certification developed by the
TUVHS America. This program combines
two independent sets of standards — ISO
9001 Quality Management standards and
Hospital Conditions and Participation
Chapters in JCI accreditation
• Access to and continuity of care
• Patient and family rights
• Assessment of patient
• Care of patient
• Patient and family education
• Prevention and control of infection
• Staff qualification and education
• Governance, leadership and direction
• Facility management and safety
• Management of information
• Quality improvement and patient safety
w w w.asianhhm.com 
 I NTR O D U CT I O N
ObtainJCIStandards
manual and begin JCI Accreditation
preparing for JCI survey occurs
Accreditation
12-24 6-9 4-6
Months Prior Months Prior Months Prior
to Survey to Survey to Survey
Receive and
complete JCI Survey
Contract & Travel
Instuction Form
Source: JCI
standards set by the Medicare program in
the US. This new system has a wider scope
than ISO 9001:2000 certification, which
focuses largely on the administrative proc-
esses. However, it is yet to receive the final
approval from the Centers for Medicare and
Medicaid Services (CMS) of the US. Only
then it will be able to accredit hospitals in-
ternationally.
The accreditation process
For any hospital, the accreditation proc-
ess represents bringing about a significant
change in the way it functions. A compre-
hensive accreditation, such as that of JCI,
needs to be implemented organization-wide,
with the involvement of all the employees
who take part in the patient’s journey from
admission to discharge. In JCI, there are
565 standards divided into 197 core stand-
ards that must be met to achieve accredi-
tation and 368 other standards that lead
organisations to best practice levels. These
standards are further divided into 1033
measurable parameters, which focus on as-
pects such as patient safety, patient rights,
facilities, and physicians’ credentials besides
policies and procedures of the organisation.
To get accredited a hospital will have to fully
meet most of these parameters and the re-
maining ones at least partially. Singapore’s
National Health Centre (NHC), which got
accredited in November 2005, met 1013 of
the 1033 parameters successfully. The JCI
accreditation is valid for 3 years and has to
be renewed on a regular basis.
The accreditation process typically lasts
for about 2 years and involves two surveys
by a team of consultants from JCI who
 Asian Hospital & Healthcare Management ISSUE-11 2006
The accreditation timeline
Submit application ReceiveAccreditation
for survey to JCI, Decision and Official
andschedulesurvey Survey Findings
dates with JCI Report from JCI
2 Within 2
Continuous
6-9 Months
MonthsPrior Survey Months After PriortoTriennial quality
to Survey Dates Survey Due Date improvement
journey
Submit revised JCI Survey Team
application and Leader contacts
your organization to
schedule triennial
JCI Accreditation determine survey
resurvey agenda
also educate the hospital staff about various patient experience.” Further, as processes
standards and their implementation. Here, get streamlined and designed around the
the role of the top management becomes patient needs, there is also a better chance
very crucial since it is their commitment for the hospital to provide evidence-based
that in turn influences the commitment medicine to their patients.
of the whole organization. “It takes strong Implementing the exacting standards of
commitment from the top management” accreditation is usually a tough task to begin
says Rooney and adds that the point-of-care with. With so many standards to deal with,
staff, nursing staff, physicians and other there is a need for meticulous planning and
employees of the hospitals too play a crucial thorough implementation, which involves
role, as they have to adapt to a whole new active participation of all the employees. As
way of functioning. the process aims to influence the function-
The benefits are multi-fold. Both the ing of the organisation itself, change man-
healthcare provider and customer stand to agement – the process of generating a buy-
gain if an organization complies with the in by all, attains utmost importance prior
standards. The benefits that ensue accredi- to implementation. “Organizations that do
tations include better care for the patients, this well really get to see a huge difference in
a customer-centric approach, improved the way they manage their hospitals”, claims
branding as a result of increased confidence Rooney.
within the community, high employee mo-
rale and continuous monitoring
of standards. Over a period of
time the hospital would experi- Implementation Requirements
ence cost reductions as efficien-
cy go up and more is achieved • Standardise processes
through less effort. Medical • Clearly communicate new policies to the employees
errors that cost hospitals thou- • Improve documentation
sands of dollars every year could • Improve facilities to increase patient safety
be reduced as well. The final • ExpandthescopeoftheQualityManagementCommittee
• PlananddocumentContinuousMedicalEducation(CME)
beneficiaries would be the pa-
for all staff
tients since the new processes
• Implementnewandstrictercredentialingandprivileging
would be designed to meet their
criteria for medical staff
requirements and they have ac-
• Streamline the monitoring of clinical outcomes
cess to the best treatment. Says
• Change the maintenance records of medical equipment
Rooney, “It’s interesting to note
according to the standards
that some organizations have • Improve communication with the patient
reduced medication errors by • Practice strict control over patient information
almost 75% to 80%. That ob-
viously translates into a better
 Healthcare Management
Affordability
While the benefits of international accredi-
tation are quite attractive, the fact is that ac-
creditations such as JCI’s could be very ex-
pensive for a majority of medium-to-smaller
hospitals in the region. A JCI accredita-
tion would cost a hospital approximately
US$ 100,000 and this does not include the
expenses incurred for upgrading its facilities.
The Apollo Indraprastha Hospital in New
Delhi, India – first hospital in India to get
the JCI accreditation – spent close to Rs. 30
crore (US$ 600,000 approximately) to up-
grade its facilities. Medium-sized hospitals
may not have such financial muscle!
While this being the limitation, ac-
creditations also give rise to another pos-
sibility – national level accreditations with
standards designed on the lines of interna-
tional accreditations and customized to the
needs of the local hospitals. In this scenario,
the cost tends to come down significantly.
The NABH could perform this very func-
tion helping smaller hospitals improve qual-
ity of healthcare and patient safety without
having to spend huge amounts of money.
Circle 06
While this may or
may not result in
them being able
to attract interna-
tional patients, it
would certainly
help in improving
Full interview is available on www.asianhhm.com
the quality of care
in the hospitals.
The future
With an opportunity worth US$ 4 billion
around, competition for medical tourists
is bound to heat up and more hospitals are
likely to queue up for international accredi-
tations.
Accreditation organisations would have
to work closely with the governments of
various Asian countries to make this hap-
pen lest the world-class healthcare facilities
would be confined only to a small portion
of the population. As more hospitals start
acquiring accreditations, domestic patients
too would prefer to opt the accredited
hospitals for treatment. This scenario will
eventually push a general move towards
I NTR O D U CT I O N
"It is not just “we’ll get ready for getting the ac-
creditation” and then getting back to business
as usual. It is really about transforming an or-
ganization and its processes."
-- Anne Rooney, Executive Director
International Services, JCI
improvement in quality of care. The peer-
pressure is two-fold – those who can afford
accreditations start drawing blueprint for
the same whereas those who cannot start
learning about how to improve the status
quo. This sort of a trend is already evident.
“A recently held five-day practicum at Sin-
gapore was fully booked about six weeks
in advance! This shows that there is a very
strong interest in education about quality
standards in Asia,” points Rooney.
To be successful, the hospitals that are
gearing up to acquire accreditations, would
do well to remember what Phillip Crosby,
initiator of the Zero Defect concept said, “It
(quality) has to be the fabric of the organisa-
tion, not part of the fabric.”
w w w.asianhhm.com 
 H e a l t h c a r e M ANAGE M ENT

Medical Tourism
Preparing for the challenge
Medical tourism offers great potential for Asian hospitals, but they need to be thoroughly
prepared in order to make best use of the opportunity.

for hospitals in various Asian countries to
Bhaskar P. Shah promote medical tourism. So we now need
Interventional & Consultant Cardiologist to look into meting the challenges of medi-
and Director cal tourism.
Asian Heart Institute
A low cost, robust and high value
India
proposition would be to offer highly cost
competitive medical treatment with world-
class, cutting edge technology, by world-
class medical specialists in accredited hos-
ultrasound) costs GBP 350. A comparable
check up in India is available for US$ 84 at
the Mumbai-based Asian Heart Institute.
The mortality rate of coronary bypass
patients at Asian Heart Institute, Mumbai
and Escorts, Delhi is 0.8%. According to a
2002 study by the New York State Health
Dept., in 1999 the New York-Presbyterian
Hospital had a death rate of 2.35% for

M
edical tourism, where patients
travel abroad in search of
world-class medical treatment,
is growing rapidly and gaining popularity
in countries like Thailand, Singapore, Ma-
laysia, India and South Africa. Since time
immemorial medical tourism has been pre-
vailing across the world right from the Neo-
lithic and Bronze Age to Jet age (Table 1).
The global medical tourism market
was pegged at a little over US$ 40 billion
in 2000 and is growing at over 20% p.a. If
these figures were to be projected forward
it would be a US$ 100 billion opportu-
nity today. Considering such lucrative po-
tential, a former Indian Finance Minister
called for India to become a “Global Health
Destination”.
Overburdened healthcare infrastruc-
ture and high costs in the west are the key
drivers for the boom in medical tourism.
The healthcare infrastructure in Europe
and the United States is under severe pres-
sure. In Britain, the National Health Serv-
ice (NHS) has a long wait list of patients
for surgery. In US the healthcare crisis has
different dimensions — it has 50 million
uninsured citizens while the insured have
to pay dearly for healthcare facilities. To
add to this the stringent visa regulations
imposed by US and European countries
after 9/11 episode has led to a growing
number of foreign patients from Middle
East to visit Asian countries for treatment.
All these factors have opened up avenues
pitals with world-class infrastructure and the same procedure. It is noteworthy that
facilities. former US President Bill Clinton recently
Cost of comparable treatment in Asia underwent bypass surgery at the same hos-
is on an average one-eighth to one-fourth pital. In India, the overall success rate of
to those in western countries. A cardiac cardiac bypasses is 98.7% as opposed to
procedure which costs anywhere between 97.5% in the US.
US$ 40000 to US$ 60000 in the US, Hospital accreditations done by JCI,
US$ 30000 in Singapore and US$ 12000 ISO, OSHA etc — the seal of quality, pa-
to 15000 in Thailand costs only between tient safety, quality care, updated technol-
US$ 3000 to 6000 in India. The associ- ogy and organized systems — are a kind
ated costs of the surgery are also low. Not of assurance that people look for in any
only are skilled Indian surgeons available health institution with the two most im-
for a lower cost, they are less susceptible portant parameters being patient care and
to costly litigation. The cost of malprac- patient safety.
tice insurance in New York is around Hospitals should concentrate on uni-
US$ 100000 while in India it costs only form price range for various medical treat-
US$ 4000. These factors reduce the overall ments across various hospitals across the
cost of treatment. country and make it public (to establish
Diagnostic tests in India are also com- transparency) in order to facilitate the en-
paratively inexpensive. A Magnetic Reso- try of foreign patients seeking treatment
nance Imaging (MRI) scan costs US$ 60 with us.
in India compared
to US$ 700 in New Table-1: Evolution of Medical Tourism
York. The country
also has the potential Neolithic & Bronze Age Mineral & Hot Spring visits
to emerge as a hub
for preventive health Middle Ages Thermal Springs
screening. At a pri- 16th century “Fountain of Youth”
vate clinic in Lon-
don a routine health 17th/18th century Spa
check-up (includ- 19th century Sea & Mountain Air
ing blood-test, elec- (TB sanitarium)
tro-cardiogram test,
20th century “Health Farms” or “Fat Farms”
chest X-rays, lung
tests and abdominal

10 Asian Hospital & Healthcare Management ISSUE-11 2006

Circle 07 w w w . a s i a n h h m . c o m 11
 H e a l t h c a r e M ANAGE M ENT
An institute seeking foreign
patients has to ensure:
• Low cost and reasonable medical
treatment
• World-class treatment with cutting-
edge technology and top medical
professionals
• An accreditation which
1. is patient focused
2. is result oriented
3. covers international and
domestic patient centres
• Apowerfulmarketingdepartmentwith
aggressive promotion
Facilities in hospitals seeking foreign
patients need to be market driven i.e. at-
tractive to patients, must deliver results
and must be competitive. To attract foreign
patients the hospital must have willingness
and ability to build 5 star facilities, (Table
2), acquire state-of-the-art medical equip-
ment and technology and the ability to at-
tract medical professionals at the top of their
respective fields. Full accountability to:
a. Shareholders who are expecting results
b. Patients who have high expectations
c. Top medical professionals who have
joined the hospital, ensures delivery of
proper results
Competitive imperatives would mean
superior and excellent clinical outcomes
to gain commanding market share and
customer service focus to achieve patient
satisfaction and customer delight.
Each hospital should have a dedicated
international patient centre which could
match up to a 5 star hotel lounge. This
centre provides foreign language services,
transportation co-ordination including
airport pick-up ground and air ambulance
services, internet, fax and modem lines in
patients rooms, long term lodging arrange-
ments for patients families, VIP concierge
services for shopping, dining, sight-seeing,
visa assistance and special events.
Strict medical staff governance is the
hallmark of a good medical institute. This
governance needs to include proper cre-
dentialing of medical faculty, professional
ethics, regular mortality and morbidity re-
view, regular internal and external medical
audits, continuing medical education pro-
grammes, professional training and clinical
research.
A well-developed marketing depart-
12 Asian Hospital & Healthcare Management ISSUE-11 2006
ment in the hospital is a necessity for in-
tense marketing and publicity of medical
facilities. The west is more likely than not
largely ignorant about hospitals in Asia and
there is therefore a huge psychological hur-
dle. The promotional effort can be accom-
plished with a focus on specific countries
through a well-organized word-of-mouth
and media campaign (print or electronic)
or referral network involving tie-ups with
foreign governments, insurance companies
and overseas doctors. However tie-ups with
travel agents based abroad helps in better
exposure and marketing. Road shows and
exhibitions in targeted countries are good
means for marketing.
Strategic tie-ups and alliances in the
industry are now assuming greater impor-
tance. For instance Manipal Hospital has
a tie-up with the governments of Tanzania
and Mauritius. Further, agreements with
foreign travel insurance providers give the
hospitals a significant international expo-
sure. Tie-ups with foreign insurance com-
panies assures hassle-free cash-less benefits.
As hospitals upgrade their services to global
benchmarks, the country’s medical care
is increasingly gaining acceptance among
international insurers, for instance, US-
based private healthcare insurers Blue cross
and Blue Shield and British health insurer
BUPA now insure clients being treated at a
number of private hospitals in India.
Bringing healthcare providers/hospitals
with facilitator-tour operator together will
help to develop suitable healthcare cum
travel packages. Tour operators are playing
a role greater than just arranging a patient’s
tour itinerary, with their services covering
everything from pre-treatment counselling
to post-treatment care. The healthcare tour-
ism packages typically include identifying
the appropriate hospital for required treat-
ment, appointment with doctors, travel
arrangements, accommodation, logistics
and facilities for those accompanying the
patients and maintaining post-treatment as-
sistance via e-mail.
There is a greater need for public-private
partnerships as this will enable developing
health infrastructure and policy, through
sharing of technology, physical and human
resources, and information. Part of the rev-
enue generated through globalisation of this
sector can be channelled towards the overall
development of the healthcare system.
There is also a need for taking a holistic
approach towards healthcare and delivery.
For example, wellness tourism which is
meant for rejuvenation of the body and
mind involving services such as Herbal
therapy, Naturopathy, Yoga, Aroma ther-
apy, Reiki and Music therapy require no
advanced medical expertise, and are highly
sought after by many tourists coming in
for treatment.
Setting up of an International As-
sistance Centre in a foreign country with
the following goals is also necessary: The
centre must be able to create awareness
about medical tourism facilities among
local populace. It must provide detailed
information about facilities, procedures,
and competencies and costs. It should
have facilities for preliminary diagnostics
and expert opinion through tele-medicine
technologies. It should be able to manage
complete travel & stay plan and co-ordi-
nate appointments. It should give post-
treatment patient management. Above all,
it should build trust and confidence in the
clientele.
Table-2: Service with style
Someaddedamenitiesthatarebeingoffered
as a part of the bouquet of healthcare
services in large hospitals include:
• 24 hour pharmacy that serves both
patients and others
• Spacious waiting areas
• In-house cafeteria, sometimes
outsourced to reputed restaurant chains
• Coffee vending machines
• Internet access
• Prayer room
• Florist, gift and book shops
• Valet parking with ample car park space
• ATM machines and banking counters
• Travel desk and translators
• In-hospital accommodation
And last, but not the least, understand-
ing of the different cultural backgrounds
of medical tourists is of paramount im-
portance because the topic of healthcare is
very personal and means different things to
different cultures. Non-verbal communi-
cation, which is influenced by culture, is
also an important part of diagnosis. Fur-
ther, a good cultural understanding can
help in speedy patient recovery.
 H e a l t h c a r e M ANAGE M ENT

Interview
Lean in
Healthcare
The difference between lean and the
previous methods is that lean focuses
on the entire healthcare process itself
whereas traditionally healthcare has
focused on separately scheduled
individual activities.

Daniel T Jones
Founding Chairman
Lean Enterprise Academy
UK

What benefits does lean bring to the
healthcare organizations vis-à-vis the
older models of functioning?
The benefits of lean for healthcare organi-
zations are that firstly, the quality of the
outcomes in terms of mistakes and errors
improves. The second is that the amount of
time taken through the whole process sig-
nificantly improves as a result the number
of patients that can be put through the
process increases i.e. the productivity or
throughput of the process increases. While
the initial gains come in terms of improved
quality, reliability of the process and elimi-
nation of a lot of wastes associated with
the process. The medium term gains come
in the form of a significant increase in the
throughput of the process. It improves
Quality, Reliability and Productivity of a
process; and it does so while making work
easier for the medical staff by removing a
lot waste and improving the customer ex-
perience as well. So actually this is a win-
win opportunity for improving quality of
healthcare, delivery of healthcare and the
productivity of the staff. These gains are
realized by focusing on the entire sequence
of steps instead of individual activities.
The medical process is very much
geared to the event where the patient and
the doctor actually sit together, whereas if
you look at the actual sequence of events,
there is a tremendous amount of unneces-
sary activity that goes on because of lots of
delays, repeat tests and events not occur-
ring in the right sequence. So lean really
focuses on the patient’s journey on the one
hand and the medical process that goes to
make the journey possible.
So lean reduces the time taken by the
patient to go through the process of
treatment…
Time taken by the patient as well as the
provider to deal with the patient. So there
are two parallel processes going on: one is
the patient itself and the other is the ac-
tivities that have to happen in terms of
the scheduling, maintaining the records,
conducting the tests and so on. These are
streamlined better by implementation of
lean. The difference between lean and the
previous methods is that lean focuses on
the entire healthcare process itself whereas
traditionally healthcare has focused on sep-
arately scheduled individual activities.
Do the benefits outweigh the costs?
Almost certainly, yes. The costs are initially
an involvement of staff in coming together
to look at and analyse the current process
and improve it. So there is an investment
in time of the staff in actually looking to-
gether at the whole process and then go-
ing through several redesign activities.
However, the experience is that this is very
quickly paid back by the improvements in
the performance of the system. Initial gains
can come within a few weeks of implemen-
tation but the real gains come in a period
of eighteen months to two years, largely in
terms of increased throughput with existing
resources which means that you don’t need
to invest in additional capacity, equipment
and people. And that’s the typical situation
being faced by healthcare organizations,
there’s more demand than they can keep
up with. So lean really helps save both in
terms of current costs and capital costs.
While this is in terms of costs, in terms of
staff morale, it has a very dramatic effect
because people suddenly feel engaged in
improving the way they work.
What steps does an organization need
to take in order to implement lean?
There are various ways organizations have
gone about implementing lean but any or-
ganization certainly needs to build a small
group of staff, a lean team so to say, who
first of all understand lean and then take
responsibility for leading activities to look
at individual processes. The team needs to

w w w . a s i a n h h m . c o m 13
 H e a l t h c a r e M ANAGE M ENT
involve the clinicians, nursing staff and the
management. Having done that, they need
to pick key processes that are in trouble and
begin to analyse them and engage the peo-
ple involved. The key here is to build some
kind of internal knowledge. Therefore,
though the implementation of lean begins
at the top level of the hierarchy it needs
to be quickly passed down to the bottom.
It's top down in the sense that the initia-
tive must be supported by the top manage-
ment but the actual implementation has
to involve the people right at the frontline
since they are the people who know exactly
what’s wrong with the current processes.
What kind of penetration has lean
achieved in the healthcare sector?
Lean has been taken up in the healthcare
sector only in the last two or three years.
In the US several hospitals got involved in
try-and-apply lean by hiring Toyota experts
and experimenting with how lean applies
to healthcare. In the UK, the
UK NHS modernization agency
began work on applying lean to
the accident and emergency de-
partment and cancer treatment
about three years ago. In Austral-
ia they started about two years
ago. So in those three countries
it has already begun and they
were initially really experiments
where different hospitals tried to
translate the idea into language
of healthcare from a language of manufac-
turing.
But in the last year, especially in Aus-
tralia and UK, the interest has suddenly
become huge and it has certainly now
become a big wave and we are getting in-
terest from several other countries as well
such as Germany, Holland, Denmark and
of course, Asian countries as well. The
best example in the Asia-Pacific region is
the Flinders Medical Centre in Adelaide.
They held the first redesigning healthcare
conference last march that attracted over
300 people from countries like Australia,
New Zealand and Singapore. So these
ideas are trickling everywhere in health-
care. However, it is fair to say that we are
still in the early stages of working out what
the full impact of lean on healthcare is. We
don’t yet have a possibility of pointing at
a hospital and saying “here is a truly lean
14 Asian Hospital & Healthcare Management ISSUE-11 2006
hospital.” I think we are still two or three
years away from that.
I started walking around hospitals
around six years ago because I thought this
would come. I thought I needed to under-
stand how the healthcare system works.
But it was too early. People were not really
focused on the customer and were worried
about quality rather than efficiency.
What challenges does the
implementation of lean bring?
Initially it probably doesn’t change the or-
ganization a great deal but gradually as you
start separating out the different flows of
the hospital and start seeing the hospital
as a collection of different flows — a short
stay flow, a long stay flow, an out-patients
flow rather than a series of departments,
what you begin to see is a change in the
orientation of the hospital, where the de-
partments are increasingly supporting
different flows rather than just managing
The really exciting prospect in
the future is that we design systems
fundamentally from customer
backwards rather than trying to keep
a big hospital busy.
their own activities. And you begin to see
much better coordination and somebody
taking responsibility for coordinating each Theoretically yes. The knowledge of turn-
of these different flows across departments. ing around an existing hospital is quite a
Therefore, a process focus as well as an ac- struggle and it takes time but I don’t think
tivity focus begins to appear. In terms of
psychological change, this releases a tre-
mendous amount of energy. And if done
well it can actually change the psychologi- I think we are at the starting of a revolu-
cal atmosphere of the organization because
people feel less stress and pressure and
begin to achieve much greater results than
they actually thought possible.
How valid are the criticisms of lean,
like, it doesn’t consider the human
factor?
Actually, you can’t consider going lean
without taking the human factor into
consideration because lean depends upon
people in the process who are willingly co- trying to keep a big hospital busy.
operating to improve the process. If lean is
badly managed or is simply used as a tool
for pressurizing people it will go backwards
very quickly; people will stop collaborat-
ing. It’s very difficult to misuse lean as peo-
ple get to see what you are doing and they
will not be willing to cooperate. I know
that there have been lots of criticisms of
lean and look, not every lean implemen-
tation succeeds. Lean is quite hard and it
sometimes goes forward and sometimes
reaches a plateau, people leave, organiza-
tions change and you may have to go back-
wards again. In general, lean is a very posi-
tive step for an organization.
What are the limitations of lean with
respect to its application in healthcare?
I think we are still experimenting with
what lean is going to mean. I think lean in
the future is going to mean we will design
our healthcare processes very differently.
And quite possibly, some of the things we
do in the hospitals might well
be done down closer to the pa-
tients in what we call primary
care. Some of the more routine
activities can certainly be done
by nurses closer to patients but
we need smaller scale equipment
to help them do that while at the
moment people are building big-
ger and bigger and more expen-
sive machines.
Would it be easier for a new hospital to
implement lean than an older hospital?
it's necessary to start with a clean sheet.
Any other comments?
tion in healthcare in the way healthcare
is delivered and lean is an important trig-
ger in doing that. I think it will lead to all
sorts of new thoughts about how healthcare
is delivered in the future. And we need to
engage the pharmaceutical companies, the
medical equipment companies as well as the
hospitals and governments in thinking that
through. The really exciting prospect in the
future is that we design systems fundamen-
tally from customer backwards rather than

C
ardiac surgery has witnessed
major changes and rapid progress
in the last 50 years, since the time
of the development of cardiopulmonary
bypass (CPB) for clinical use in 1953.
Constantly the focus of the improvement
in the techniques and technologies has been
on making cardiac surgery safe, minimally
invasive and cost-effective. Major advances
have occurred in the fields of off-pump
surgery, video assisted surgery, surgical
treatment for heart failure, robotic surgery
and artificial hearts and prostheses.
Off-pump coronary artery bypass
graft surgery (opcab)
In off-pump coronary artery bypass graft,
as the name itself indicates, surgery is
done without putting the patient on a
heart-lung machine. For nearly 25 years,
the standard technique of conventional
Cardiac Surgery
New Techniques
The focus of new techniques has been on
making cardiac surgery safe, minimally invasive
and cost-effective.
Ramakanta Panda
Vice Chairman
Asian Heart Institute
India
CABG was to perform it on cardiopulmo-
nary bypass (CPB), i.e. the patient is put
on a heart-lung machine.
Cardiopulmonary bypass is an un-
physiological state involv-
ing alterations in the flow
properties of the blood, al-
teration in thermal regula-
tion, protein denaturation,
and exposure of blood to
unnatural, non-endothe-
lial surfaces triggering vari-
ous enzyme cascades such
as complement, kinins,
coagulation systems and
fibrinolytic systems.
There is a great disturbance of the
homeostasis leading to various organ dys-
functions, thus accounting for the post-
operative morbidity. Also the cost of the
operation is high especially in the devel-
oping countries because of the cost of the
import of various materials required for
the conventional CABG on CPB. Hence,
in a constant endeavour to make surgery
safer for the patients and the attempts to
do away with CPB, innovative surgeons
with the help and support of the enter-
prising industries strived together to deal
with the dual concerns of risks and cost
of conventional CABG. This culminated
in the development of Off-Pump CABG
(OPCAB).
C a r dio l o g y
Off-Pump CABG is minimally inva-
sive as compared to surgery on the heart-
lung machine. This method eliminates the
use of CPB thus avoiding an unphysiolog-
ical state and permits surgery on multiple
arteries within the heart by mechanically
stabilising it. The potential benefits in-
clude shorter hospital stay, less bleeding,
less chance of infection, less risk of irregu-
lar heart beats (arrhythmia), less trauma,
shorter recovery time, and greater cost
effectiveness. This procedure was initially
created to avoid brain injuries attributed
to the pump.
Off-pump CABG is performed with
the help of various mechanical stabilisers.
They immobilize a small area around the
coronary artery for the surgeon to oper-
ate while the heart continues to function.
The various commercial stabilisers that are
available are the Medtronic Octopus de-
vice, Guidant suction device, etc.
Off-Pump CABG is further undergo-
ing various modifications of techniques as
a result of which many different terminolo-
gies and abbreviations are in use. However,
the two main principles of OPCAB, mini-
mally invasive and mechanical stabilisation
of the heart, remain unchanged.
w w w . a s i a n h h m . c o m 15
 C a r dio l o g y
Minimally invasive coronary artery bypass
graft surgery (MICAS)
This refers to all techniques of CABG
wherein there is no use of CPB. It also in-
cludes operations involving lesser incisions
than a standard full median sternotomy.
Minimally invasive direct coronary artery
bypass graft surgery (MIDCAB)
MIDCAB or ‘limited access coronary ar-
tery bypass’ is usually limited to patients
with lesions in one or two coronary arter-
ies, mainly the Left Anterior Descending
Artery (LAD) and the Right Coronary Ar-
tery (RCA). In contrast with conventional
CABG, this procedure is done through a
smaller incision on the sides of the patients
chest in the fourth left intercostal space
and entering the pericardium through the
bed of the excised cartilage. This approach
avoids making long incisions, splitting
of the sternum (breast bone) and subse-
quently the development of instability of
the sternum and infection of the bone and
cartilages and also the development of ugly
scars (keloid), which is more prone in this
location and in dark skinned people.
Lower end sternal split coronary artery
bypass graft surgery (LESS)
In this procedure the bypass is done by
cutting only half of the breast bone. This is
done when there is blockage in one or two
coronary arteries. The advantages include
fast recovery of patient and quick return to
work within 10-14 days.
Thoracotomy Off-pump coronary artery
bypass surgery (TOPCAB)
In this procedure a left Antero-Lateral tho-
racotomy approach is employed.
Asian Heart Institute has been a pio-
neer in LESS, TOPCAB, and OPCAB
procedures, which are being done over
the last three years with excellent results.
Also, Asian Heart Institute is one of the
few centers in the world where more than
ninety-nine percent of the CABGs are
done on beating heart (OPCAB).
Video-assisted port-access mitral
valve surgery
In this technique, the breast bone is not
opened. The patient is put on heart lung
machine by inserting pipes through the
neck and the thigh. The heart is stopped by
inserting the catheter retrogradely through
the femoral artery in the upper part of the
thigh up to the ascending aorta. The heart
16 Asian Hospital & Healthcare Management ISSUE-11 2006
is stopped by inflating the balloon inside
the aorta and giving potassium to tempo-
rarily stop the heart. The operation is done
through a small cut in the side of the chest.
Video assistance and shafted instruments
help the surgeon to perform the surgery
through small holes and fulfill the main
goals of minimally invasive cardiac surgery,
comfort, cosmesis, and fast rehabilitation.
Voice activated video camera gives excel-
lent view of the mitral valve. Port-access
mitral valve surgery is a very important
minimally invasive technique.
Surgical treatment of heart failure
Large number of heart patients develop
and die from heart failure. Till recently
most of these patients were managed
with medicines without any surgical help.
Recently lot of new surgical techniques
have evolved to help treat patients with
end stage heart failure.They include the
Surgical Ventricular Restoration (SVR),
Acorn procedure,Myosling, etc
Left ventricular reconstructive surgery
(dor procedure)
Left ventricle reconstructive surgery is a
procedure sometimes used to treat heart failure.
When a heart attack occurs in the left ventricle
(left lower pumping chamber of the heart), a
scar may form. The scared area can become thin
and bulge out with each beat. The bulging thin
area is called aneurysm. The aneurysm, along
with the other damaged myocardium makes the
heart to work harder to pump blood throughout
the body. Initially the heart is able to handle
the additional work, but over time the heart
becomes larger than normal and pumps less
effectively
Left ventricular reconstructive surgery
allows the removal of the scarred, dead area
of the heart tissue and/or the aneurysm and
return the left ventricle to a more normal
shape. The goal is to improve heart failure
and/or angina (chest pain) symptoms and
possibly improve the pumping ability of
the heart.
Other names of Left Ventricular
Reconstructive Surgery:
• Endoventricular circular patch plasty re-
pair
• Dor procedure (to credit Vincent Dor,
MD, who authored many articles on the
procedure he began performing in the
early 1980s)
• Surgical Ventricular Restoration (SVR)
• Left ventricular infarct exclusion sur-
gery
• Left ventricular aneurysmectomy recon-
struction
• Surgical anterior ventricular endocardial
restoration
Left ventricular reconstructive surgery
is a major open-heart surgery, requiring the
use of the heart-lung machine. The dam-
aged part of the heart is removed and it is
reconstructed with an artificial patch.
In addition to this procedure, coro-
nary artery bypass graft (CABG) surgery is
often performed to improve blood supply
to the heart muscle. Further, about half of
the patients undergoing the left ventricular
reconstructive surgery, mitral valve leaks
are also repaired.
Some patients may require a special
device called an automatic implantable
cardioverter-defibrillator (AICD) to treat
serious abnormal heart rhythm, which is
a very common postoperative problem in
this type of procedure. Under special cir-
cumstances, an EP study (electrophysiol-
ogy study) will have to be done to evaluate
the heart rhythm.
Cardiac wrap surgery
This procedure uses a technique that wraps the
heart in a mesh bag, helping to prevent further
enlargement and failure. A mesh wrap is pulled
over the base of the heart and is attached with
stitches. The goal is to prevent a weakened
heart from enlarging (dilating) and failing
further. Initial results are very encouraging and
it is hoped that in a few years these procedures
will be routinely offered to patients with heart
failure.

Enhanced External Counterpulsation (EECP)
This is a non invasive techniqe. Inflatable
pressure cuffs are placed on the calves,
thighs and buttocks. These cuffs are in-
flated and deflated in sync with the heart
beat. This increases the blood flow back to
the heart
Arificial Heart
Although the heart is conceptually a simple
organ (basically a muscle that functions as
a pump), it embodies complex subtelities
that defy straightforward emulation using
synthetic materials and power supplies.
The obvious benefit of a functional artifi-
cial heart would be to lower the need for
heart transplants.
The total artificial heart (TAH) was
first used in 1969 for a patient who was
waiting for heart transplantation. An ar-
tificial heart is a prosthetic device that is
implanted into the body to replace the
original biological heart. It is distinct from
a cardiac pump, which is an external device
used to provide the functions of both the
heart and the lungs. Thus, the cardiac pump
need not be connected to both blood cir-
cuits. Also, a cardiac pump is only suitable
for use not longer than a few hours, while
for the artificial heart the current record
is 17 months. Another problem is that an
artificial heart requires an external power
supply such as a battery pack worn on the
patient’s waist; which carries a significant
risk of introducing infection; no design
so far has been able to use the body’s own
natural biological energy. The first artificial
heart patented was ‘Jarvik-7’, now known
as Cardiowest C70 total artificial heart.
Robotic Cardiac Surgery
The next advance in heart surgery is the
robotic surgery which will revolution-
ise cardiothoracic procedures. Contrary
to the popular belief, the robot does not
do the surgery independently, rather the
robot works as the extended arm of the
surgeon. The surgeon sits on a computer
control panel near the patient and controls
the movement of various robotic arms. An
assistant makes small holes in the patients
chest wall through which the robotic arms
are inserted.
The surgeon grasps and moves the
highly sensitive instruments at the console
while viewing the patient’s heart, greatly
magnified on a screen. The robot precisely
matches the surgeon’s natural hand and
wrist movements, and translates them
into precise, real time movements to the
tiny instruments placed inside the patient
through small puncture incisions. The
procedure, for e.g., a mitral valve repair,
will require three small incisions between
the ribs, two for the insertion of inter-
changeable instruments and another for
a thin, cylindrical video camera, called an
endoscope.
There are many systems available, the
most popular being da Vinci™ system.The
da Vinci™ Surgical System provides the
surgeon with the intuitive control, range
of motion, fine tissue manipulation capa-
bility and 3-D visualization characteristic
of open heart surgery, while simultaneous-
ly allowing the surgeon to work through
small ports of a minimally invasive sur-
gery. The patients experience shorter inci-
C a r dio l o g y
sions, less pain and trauma and a quicker
recovery time.
Stem Cell Therapy
Stem cells have the ability to grow into
other types of cells and thus represent great
promise for treating a wide range of dis-
eases. While harvesting of embryonic (fe-
tal) stem cells is extremely controversial,
the cells used in the heart study came from
the patient’s own bone marrow. Injected
into the heart muscle, the stem cells de-
veloped into muscle and blood vessels in
the damaged areas, increasing the heart’s
pumping capability and blood flow. Using
the patient’s own stem cells also eliminates
the problem of rejection of donated cells
and organs.
Total arterial revascularisation
In this procedure, coronary artery bypass
graft surgery is done using all arterial
grafts. Vein grafts are very
rarely used. The various arte-
rial conduits are the Internal
Mammary Arteries, Radial
artery, Gastroepiploic artery,
and Inferior epigastric ar-
tery. The arterial grafts have
longer patency rates unlike
the vein grafts which start
degenerating after 8 to 10
years, thereby necessitating
the need for a second time
(re-do) CABG.
Asian Heart Institute
has been doing almost all to-
tal arterial revascularisation
with excellent patency rates.
Valve repair surgery
Prosthetic valves came as
a boon to patients with
valvular heart disease, but
with it came a new set of
prosthesis-related problems.
Awareness of these problems
has refocused attention on
developing techniques to
preserve the patients narive
valve. Surgeons developed
renewed interest in repara-
tive techniques to preserve
mitral valve and devised
methods to debride and re-
construct aortic valve.
w w w . a s i a n h h m . c o m 17
 Surgical Speciality
Minimally Invasive Surgery
Emerging trends
Technological innovations in the field of robotics, and telemedicine will drive
the future of minimally invasive surgery.
Davide Lomanto,
Department of Surgery, Yong Loo Lin
School of Medicine, National University
of Singapore
and
Director, Minimally Invasive Surgical
Centre (MISC), National Univesrity
Hospital, Singapore
T
he substantial developments in
surgery, over the last century with
the advent of antiseptic substance,
anaesthetic agents, antibiotics, surgical nu-
trition, and organ transplantation, did not
modify the basic tools of surgery and even
the surgical techniques remained basically
unchanged.
But in the last few decades, “invasive-
ness” has been the focus of surgical practice
gaining the momentum especially because
of the better outcome in terms of post-
operative pain, fewer complications and
quicker return to functional activity. The
change was initiated with the advent of the
laparoscopic surgery, and because of the
rapid acceptance and success of such op-
erations as laparoscopic cholecystectomy,
over the last two decades a revolution has
taken place in general surgery. Since then,
a variety of surgical operations in the entire
Image-1
18 Asian Hospital & Healthcare Management ISSUE-11 2006
surgical speciality have used endo/laparo-
scopic techniques.
The modern era of laparoscopic
surgery ushered in when a miniature video
camera was attached to the eyepiece of the
laparoscope, which allowed multiple ob-
servers to view an operative field from the
same vantage point. But the major push
happened when many large series were re-
ported in the literature highlighting main
advantages of the laparoscopic approach
over traditional “open” surgery (in terms
of reduced postoperative pain, shorter
hospital stays, periods of disability and
cost-effective for hospitals and patients).
The media quickly portrayed laparo-
scopic surgery, with its small incisions,
as a panacea, inventing different name
as “key-hole surgery”, “minimally inva-
sive”, “band-aid” or “Nintendo surgery”
(Image-1). Hence, the success among pa-
tients was great which helped in the growth
of minimal invasive surgery supported by
the development of new high-tech instru-
mentation and devices.
The evolution
During the initial years, laparoscopic
surgery was limited by a number of factors
such as: two-dimensional vision, the con-
trol of the surgical field by an assistant. The
laparoscopic port, restricted the freedom of
movement of the instruments which them-
selves were straight without ar-
ticulated movements like human
wrist. Moreover, the instruments
utilized, did not provide any tac-
tile or force feedback. Neverthe-
less, the number of operations
grew, surgeons became skilled
over the limitation imposed by
laparoscopy and along the years
this gap was almost recovered.
The new high-technology equip-
ment not only resulted in changes to Hos-
pital design — as OTs had to be redrawn
according to the new devices — but the
surgical training programmes also had to
be re-organized. Together with technologi-
cal development new approaches come-
out.
The size of ports used to access the
abdominal cavity decreased over time
from 10 mm to 2 mm. The 2-mm ports,
called “needlescopic” ports, have proven
to be feasible, safe, and effective when an
enlarged port is not required for extrac-
tion of a specimen. Benefits include less
postoperative pain and improved wound
cosmesis. The use of “hand-assisted” ports,
in which a hand is inserted into the peri-
toneum to assist the performance of the
surgical procedure, allows for tactile assess-
ment by the surgeon. This different surgi-
cal approach is particularly advantageous
when a larger incision is needed to remove
the surgical specimen like donor nephrec-
tomy, splenectomy or gastric surgery or for
cases that are too complex or take too long
to be managed with the total laparoscopic
technique. The application of the mini-
mally invasive procedure to more complex
surgeries will require new technology and
techniques. In general surgery, techniques
such as hand-assisted laparoscopy attempt
to bridge the gap between open and com-
pletely endoscopic procedures. Other pos-
sibilities include developing new ways to
perform conventional surgical tasks as a
way to adapt these procedures to an endo-
scopic or less invasive surgical approach.
Inanimate trainers (Image-2) or simu-
lators (Image-3) are being used as teaching
tools to improve surgeon performance, and
the use of self-retaining retractors has ena-
bled the surgeon to use fewer assistants in
the operating room. More recently, robot-
assisted surgery has emerged as a popular
Circle 08 w w w . a s i a n h h m . c o m 19
 Surgical Speciality
Image-2
Image-3
method. Robotic arms allow the surgeons
for finer control and remote presence and
provide a computerized interface between
the patient and the surgeon. The DaVinci
Robotic system (Intuitive Surgical, USA),
provides enhanced dexterity, motion scal-
ing, articulation, 3-dimensional vision and
the potential for telesurgery. However,
the number of surgical applications of ro-
bot-assisted surgery are increasing slowly,
mainly due to the high investment and
running costs of the devices even though
the initial benefits exist. But new applica-
tions must be developed as the full range
of robotic application is still to be imple-
mented. The initial concept of robotics
in surgery involved operating at a remote
site from the surgeon. The ability to trans-
pose surgical and technical expertise from
one site to a distant site (i.e.: proctorship,
20 Asian Hospital & Healthcare Management ISSUE-11 2006
assisting developing country or remote
area like) was thought to expand surgical
application. Although simple surgical pro-
cedures have been performed remotely,
there are some difficulties for an extensive
clinical use because of high costs, transmis-
sion delay and medical and legal issues.
The future
Application of telepresence surgery
in the foreseeable future will probably
be limited to telementoring rather than
to remote manipulation. Telementoring
will allow the surgeon to teach or proctor
performance of an advanced or new tech-
nique at a remote site using real-time
teleobservation and monitoring. New
broadcasting technologies such as high-
speed broadband telecasting - a technology
that allows the users to utilize non-com-
pressed audiovisual signals keeping high
quality, low delay (Image-4) that are now
in the early stages will soon be available
worldwide. However, a robotic develop-
ment in the area of software simulation
and virtual reality could be expected. Also
surgical operations and that need dexter-
ity enhancement and motion microscaling
will need robotic assistance.
Other possible roles for computer
and robotic assistance in surgery include
voice control over surgical manipulators
and information manipulators. At present,
technology exists to give the surgeon
voice control over virtually all operating
room equipment including electrocautery,
operating table position, laparoscopic
movement-control, lighting and telephone.
Future developments promise the overlay
of additional data to the operative field
including 3-dimensional magnetic reso-
nance imaging reconstructions and physi-
ologic data acquisition, especially for pre-
operative virtual simulation.
In conclusion, efforts are now fo-
cussed on those techniques that facilitate
more complex tasks by the minimally
invasive approach. Other aspects are the
clear role of audio-visual telementoring
in future training concepts and of telema-
nipulation/telesurgery. New technologi-
cal concepts promote the development of
hand-held mechanical manipulators used
in combination with mono-tasking com-
puterized robots like AESOP, resulting in
a significant cost reduction. Advancements
in microchip and wireless technology may
allow the development of microrobots for
completing surgical procedures and mag-
netically controlled implants that can be
navigated remotely.
Image-4
The technological innovations in sur-
gery are only beginning, the future will be
very attractive, the potential is enormous
and the path is minimal.
w w w . a s i a n h h m . c oCircle
m 2109
 Surgical Speciality
Bariatric Surgery
The minimal access
approach
Minimal access surgery has come
as a boon far bariatric surgery.
Pradeep K Chowbey
Chairman, Minimal access and Bariatric
surgery centre, Sir Ganga Ram Hospital
President, Obesity Surgery Society of
India (OSSI)
and
Secretary general, Asia Pacific Bariatric
Surgery Society (APBSS)
India
M
inimal access technology is a
giant leap forward in deliver-
ing surgical care to patients.
The underlying principle of minimizing
the trauma of surgical access met with such
wide spread acceptance that there was an
uncontrolled and unmonitored surge in its
practice and application. This resulted in
accidents, which nearly put this technique
to disrepute. However, increasing experi-
ence and dedication of surgeons firmly be-
lieving in the technology’s principle helped
minimal access surgery achieve the status it
enjoys today.
There is no surgical speciality (belying
obstetrics) where minimal access surgery
has not made inroads. One such surgical
speciality where minimal access surgery
has come as a boon is bariatric surgery.
Bariatric surgery deals with surgical man-
agement of patients suffering from an ex-
treme degree of obesity. An obesity which
has crossed the boundary of being a mere
cosmetic problem to a life threatening dis-
22 Asian Hospital & Healthcare Management ISSUE-11 2006
ease. This disease is termed as morbid obes-
ity and is defined as a patient with a BMI
(body mass index) of > 40 Kg/m2 (Asians
> 37.5 Kg/m2) or 35 Kg/m2 (Asians 32.5
Kg/m2) with significant associated obes-
ity related comorbidities. The disease has
developed stealthily and has been declared
the worst pandemic of the 21st century.
The world health organization in
conjunction with the Regional Office for
Western Pacific (WPRO), International
Association for the study of obesity and
the International Obesity task force have
formulated an extremely well researched
and crisp perspective of obesity in the Asia
Pacific region. Extensive recommendations
are detailed on medical management of
obesity. The perspective documented in
February 2000 makes a reference to the
role of bariatric surgery in the manage-
ment of obesity in the Asia Pacific region.
Bariatric surgery in fact is the only treat-
ment option which has reported effective,
consistent and sustained prophylaxis and
improvement of obesity related complica-
tions.
The two basic principles underly-
ing bariatric surgery are restriction and
malabsorption. These are at two extremes
of a spectrum with a combination prin-
ciple lying in between. Classification of
bariatric procedures based on restriction and
malabsorption is described in Figure-1.
The data on obesity from the Asia
pacific region brings to light certain dif-
ferences in behavior patterns of obese
individuals here as compared to that
LaparoscopicAdjustable
Gastric Banding
observed in the west.
1. The most glaring difference is the onset
of obesity related complications occur-
ring in this population at much lower
BMIs.
2. A higher percentage of body fat for a
given weight.
3. Predisposition to abdominal adiposity.
Accumulation of visceral fat occurs at
lower BMIs increasing risk of hyperten-
sion dyslipidemia, diabetes and meta-
bolic syndrome.
4. Predominantly large vegetarian popula-
tion e.g. India.
5. Lack of adequate data on childhood
obesity.
This makes extreme malabsorptive
procedures like Biliopancreatic Diversion
(BPD) unsuitable for this patient popu-
lation, Laparoscopic Adjustable Gastric
Banding (LAGB) and Laparoscopic Roux-
en-Y gastric bypass (RYGBP) are the two
most popular procedures practiced in In-
dia today.
Laparoscopic Adjustable Gastric
Banding (LAGB)
This is a purely restrictive procedure
in which an adjustable silicon band is
placed on the stomach just below the gas-
troesophageal junction to create a 15cc
pouch. The balloon lining the band is con-
nected by a hollow tube tunneled through
the abdominal wall to a small reservoir
known as access port which is placed sub-
cutaneously and fixed to the muscle sheath
 Surgical Speciality

in the epigastrium or left hypochondrium.
By injecting saline into this reservoir, the
balloon lining the band can be inflated
to narrow the passage between the gastric
pouch and remaining stomach. The proce-
dure of gastric banding works on a simple
principle of decreasing the intake capac-
ity of the patient and slowing the rate of
emptying the gastric pouch to prolong the
time interval between meals. As the entire
digestive tract is intact in this procedure,
digestion and absorption is normal. Suc-
cess therefore relies significantly on the
patients motivation level and adherence to
dietary guidelines. The weight loss in vari-
ous reported series ranges between 40-60%
EWL by end of five years.
Complications associated with LAGB
Laparoscopic Roux-en-Y Gastric
Bypass (LRYGBP)
The gastric bypass is considered the gold
standard in treating morbid obesity. The
procedure is performed both laparosocpi-
cally and by conventional open access.
The procedure involves division of the
stomach using staples to create a 15-20cc
gastric pouch. A 100-150 cm roux-en-y
jejunal loop is created using staples. The je-
junum is anastomosed to the gastric pouch
creating a 1.2 – 1.5 cm wide anastomosis.
This gastrojejunostomy may be performed
using a circular stapler / linear staples or
intra corporeal suturing.
The principle underlying gastric by-
pass has a combina-
tion of restriction Figure-1: CLASSIFICATION OF BARIATRIC PROCEDURES
gestive juices and food consumed decreases
absorption.
The weight loss varies from 50-70%
EWL at five years following surgery. Com-
plications of gastric bypass occur in 7-10%
of patients. Morbidity and mortality are
both higher as compared to LAGB. This
is directly related to the multiple anasto-
mosis required in performing the gastric
bypass. Complication include anastomotic
leak, haemorrhage, stricture, DVT, PE and
dumping syndrome. The latter occurs due
to concentrated food rapidly reaching the
small gut causing nausea, vomiting, pal-
pitation, dizziness and diarrhea. This un-
pleasant event usually results in the patient

include gastric perforation, access port and malabsorption.

Restrictive Procedures Combined Procedures Malabsorptive Procedures
infection, access port leak, outlet obstruc- The small size of the
tion, pouch dilatation, band slippage / gastric pouch re-
• Roux en Y gastric bypass (RYGBP)
erosion. The overall incidence of these stricts the intake, the • Long limb RYGBP
complications is 3-5%. A significant ad- narrow outlet delays
vantage of this procedure is its reversibility. the emptying and • Laparoscopic adjustable • Biliopancreticdiversion(BPD)
gastric band (LAGB) • Biliopancreaticdiversionwith
It is a simple and safe procedure which is delayed mixing of di- • Verticalbandedgastroplasty(VBG) duodenal switch (BPD-DS)
rapidly gaining popularity the world over.

Circle 10
w w w . a s i a n h h m . c o m 23
 Surgical Speciality
Gastric Bypass Roux-en-Y
abstaining from foods which may cause
this to happen.
Patients of morbid obesity have been
effectively treated by bariatric surgery and
life style management in the west for the
past 50 years. Open bariatric surgery on
these patients with a high surgical risk is
associated with significant perioperative
morbidity and a prolonged convalescence.
Technical difficulties include an incision
through an anterior abdominal wall, of
increased thickness working in a depth
with difficulty in accessing areas like the
oesophageal hiatus, bulky and heavy intra-
abdominal contents, abdominal wall clo-
24 Asian Hospital & Healthcare Management ISSUE-11 2006
sure, delayed ambulation due to surgical
incision with increased risk of DVT and
pulmonary embolism. All complications
related to an open incision such as wound
dehiscence, incisional hernias, hypertroph-
ic scars etc. An event such as post-operative
bleeding or bowel leak requiring re-explo-
ration have a very high incidence of mor-
bidity and mortality.
Introduction of minimal access surgery
has significantly shortened convalescence
and perioperative morbidity. The laparo-
scope is able to access and provide excellent
vision of nearly the entire abdominal cavi-
ty. Appropriate placement of trocars makes
handling of entire GI tract comfortable.
The puncture wounds made by the trocars
do not require a layered closure. The post
operative pain is significantly decreased
and majority of patients are ambulatory in
the post-operative period. This results in
rapid recovery of the patient.
Any surgeon performing bariatric
procedures must be well versed with diag-
nosis and management of complications of
these procedures. Surgeons should possess
Biliopancretic diversion
appropriate and adequate surgical expertise
and technical skill to perform the proce-
dure by laparoscopic and open approach.
Bariatric surgery in India is at an infan-
cy stage. Patients of morbid obesity require
to be managed by a multidisciplinary team
comprising the surgeon at the helm with
help from, physician, nutritionists, physi-
otherapists, psychologists and counselors.
Protocol based management provides for
safe surgery and yields the best results.
Bariatric surgery is slowly growing
popular in India. The technology of mini-
mal surgery has made this surgical option
for treating obesity more acceptable.
Circle 11

Minimally Invasive Surgery
Rise of the robotic systems
The reason why MIS has so explosively spread all over the world is that there is a
significant difference in postoperative quality of life of the patients with MIS vis-à-vis
open surgery.
Makoto Hashizume
Director
Center for Integration of Advanced
Medicine and Innovative Technology
Kyushu University Hospital
Japan
S
ince the widespread introduction of
minimally invasive surgery (MIS) in
the early 1990s, initially with laparo-
scopic cholecystectomy, extensive evidence
has demonstrated its advantages over open
surgery — faster recovery with less pain
and fewer complications. The reason why
MIS is so explosively popularized all over
the world is that there is a significant dif-
ference in postoperative quality of life of
the patients with MIS from that with open
surgery. The patients who underwent MIS
not only had less incision on the skin sur-
face or less postoperative pain, but also
could receive earlier recovery to normal
life or normal activity after MIS than after
conventional open surgery.
Although there are clear benefits, MIS
also has some disadvantages for the sur-
geons. Long instruments placed through
fixed entry points creating a fulcrum effect,
with the surgical field viewed on a 2-D
screen and with the camera under an assist-
ant’s control, create an unnatural environ-
ment where the surgeon loses orientation,
the eye-hand-target axis, and visual depth
perception. All these obstacles reduce the
surgeon’s normal dexterity and limit his
ability to deal with difficult situation. Sur-
geons are now put into a tough condition
since more strict and correct preoperative
evaluation of the patients, less complica-
tion rate or less operation mistakes are
mandatory. Because it is different from
open surgery, once complications occurred
it led to more invasive major operation, by
following a life-threatening incident. This
new phenomenon was due to MIS. It is
mainly because of the technical difficulties
in movement of instruments or limitation
of surgical field through the endoscope,
and no tactile sensation or force feedback
sensation. The surgeon has to perform
complex procedures such as intra-cor-
poreal ligature or suturing in the limited
condition. However, a systematic training
system has not yet been established for
MIS all over the world because MIS had
developed so quickly since early 1990s.
Computer-enhanced surgery
This technology has been proposed to over-
come some of the drawbacks of traditional
MIS. This technology includes master-
slave telemanipulator systems. The goals of
these surgical systems are to enhance ma-
nipulation capabilities and to increase the
performance precision. Robotic surgery is
what is called computer-aided surgery. It
provides secure and precise procedure that
the operator wants. The surgeon has con-
trol over the system’s functions by means of
a computer interface that creates an intui-
tive environment when he is sitting at the
console. The movement of the instruments
is controlled by motion-scale function,
elimination of tremor, remote master-slave
manipulator system. The self fail system
is supported by checking the total system
about 1200 times every second, or by quick
  Makoto Hashizume and Kouji Tsugawa: Robotic
surgery and cancer: the present state, problems and future
vision, Jpn J Clin Oncol 2004: 34 (5) 227- 237.
Surgical Speciality
retrieval of the instrument from the body
and it allows us to shift to conventional
surgery within 10 seconds. The operative
field is provided by a high resolution 3-
dimensional viewer. The camera has two
eyes composed of 3 CCD tips. However,
the present commercially available surgi-
cal robotic systems do not provide tactile
sensation or force feedback, nor give you
anything more than what the human eyes
can see and recognize through the camera.
The image-guided surgical robotic system
is the complete system with navigation and
simulation capabilities. It is expected to be
the breakthrough to overcome these tech-
nical difficulties.
Robotic systems still have great dif-
ficulty identifying objects on the basis of
visual appearance or feel and they handle
objects clumsily, so they are far from ready
to perform complex tasks such as surgery
on the soft tissues autonomously. We have
recently developed a software system to
overlay or superimpose the pre-operative
or intra-operative images on the real-time
intra-operative endoscopic view. It is re-
ally helpful for the operator to recognize
the vascular structure or the tumor loca-
tion by seeing the superimposed images
on the endosocpic monitor. When CT or
MRI is taken before surgery a few specific
points are marked on the skin surface as
reference points. The pre-operative and
intra-operative reference points as well as
endoscopy with marks are registered in a
3D space with an optical sensor. All these
points are matched on the images in a per-
sonal computer. Finally the pre-operative
images are superimposed on the real time
endoscopic image. The advantage of the
superimposition is that it might compen-
w w w . a s i a n h h m . c o m 25
 Surgical Speciality
sate for the lack of haptics by giving the thermal damage and other undesirable ef-
surgeons more accurate manipulative skills fects. However, MRI may be ideal modal-
with a highly reliable image. ity to target the lesion precisely. Our group
The merits of image-guided system are has recently developed an MRI-compat-
also to prevent the intra-operative compli- ible image-guided surgical robotic system.
cations or surgical mistakes and to navi- Through information processing, master-
slave robotic systems
can filter our physi-
ologic tremor and al-
In the future, it could be possible low finer movement
that controllers with artificial by motion scaling. The
intelligencewillallowrobotstothinkon real time information
their own or even program themselves, of the patient’s surgical
anatomy and function
thereby making them more self-reliant is now available dur-
and independent. ing surgery.
The medical in-
formation can be
gate the surgeons to an errorless, safer and used to improve surgical planning, intra-
more precise operation, resulting in higher operative decision-making, and real-time
quality of medical care to the patients. control of surgical instruments. The cur-
Image-acquisition systems can introduce rent study could visualise lymph nodes
compatibility issues, especially when us- around the GI-tract as well as nervous sys-
ing MRI. Although MRI yields excellent tem on the open MRI. This shows that for
soft-tissue images, its high magnetic fields lymph node removal in GI surgery and for
may generate forces, produce substantial preservation of the function of the organ.
26 Asian Hospital & Healthcare Management ISSUE-11 2006
Conclusion
The goal of surgery will be to change
the function rather than the structure
of the organ or disease. In this concept,
termed biosurgery by Randall Wolf, MD,
the purpose will be to change the biologi-
cal processes of the body through direct
modification of cellular, molecular, meta-
bolic, and perhaps even genetic processes.
Almost all robots are preprogrammed by
people and will only perform programmed
tasks. In the future, it could be possible that
controllers with artificial intelligence will
allow robots to think on their own or even
program themselves, thereby making them
more self-reliant and independent. Finally,
the robotic systems, coupled with sophis-
ticated decision-support systems, will be
able to monitor surgeon performance in
real time, and act as a mentor to suggest
alternative or alert the surgeon when there
is a deviation from normal behaviour.
 Richard M. Satava: Robotic surgery: from past to
future- a personal journey, Surg Clin N Am 83
(2003) 1491- 1500
Circle 12

Cancer
Early Detection Strategies
Using biomarkers representing proteins with different biological functions may
allow complementarity in cancer detection, resulting in increased sensitivity without
compromising specificity.
Ronald B. Herberman
Director
University of Pittsburgh Cancer Institute
Anna Lokshin
Assistant Professor of Medicine
University of Pittsburgh, and
Director
LUMINEX Core Facility
University of Pittsburgh Cancer Institute
USA
C
ancer is a significant health
problem in Asia and around the
world, being the leading cause of
mortality in Taiwan, Thailand, Singapore,
Korea, Hong Kong, and Japan. The disease
is becoming an increasingly important
health concern in countries such as Ma-
laysia and The Philippines as the impact
of communicable diseases decreases with
the widespread supply of clean water and
sanitation facilities. Cancer currently is the
third and fourth leading cause of death in
The Philippines and Malaysia, respectively.
For most cancers, detection of asympto-
matic early-stage disease, when the tumors
are still localized, is critical for effective
treatment and possibly full recovery. Un-
fortunately, most cancers are detected at
later stages, after they have invaded the sur-
rounding tissue or metastasized to distant
sites. Current screening methods include
imaging (e.g.mammography), endoscopy
(e.g.colonoscopy and sigmoidoscopy for
colon cancer), cytology ((e.g.Papanicolau
or Pap test for cervical cancer), and blood
test (e.g.PSA test for prostate cancer). Of
all currently used screening methods, the
Pap test developed for cervical cancer is
the most effective, resulting in a dramatic
decrease of mortality from this cancer.
Other routine screening methods, mam-
mography for breast cancer, serum prostate
specific antigen (PSA) testing for prostate
cancer, and fecal occult blood testing and
colonoscopy for colon cancer, have also
reduced mortality through early detection
although to a lesser extent. Unfortunately,
none of these tests possesses high sensitiv-
ity (probability that someone with cancer
will have a positive test) for early disease
or specificity (probability that someone
without cancer will have a negative test).
As a result, only about 50% of breast can-
cers, 56% of prostate cancers, and 35% of
colorectal cancers are diagnosed at the early
stages, and these cancers remain the three
leading causes of cancer death, respectively,
after lung cancer . In another example, over
80% of the two deadliest cancers, ovarian
and pancreatic, are diagnosed at late stages,
where the chances of survival are dismal,
due to asymptomatic nature of these can-
cers at early stages.
Biomarkers - Improving cancer
detection
Most detection methods in use to date
identify fully developed cancer, not the
pre-malignant or early lesions amenable to
resection and cure. For example, imaging
methods, such as mammography or trans-
vaginal ultrasound, visualize tumors at >1
cm diameter, fecal occult blood is the result
of invasive tumour. On the other hand,
Pap test and endoscopy (colonoscopy, sig-
moidoscopy, and others) are sometimes
able to detect pre-cancerous lesions. An-
other problem is that in many organs, for
example, prostate or colon, pre-neoplastic
lesions are much more common than ag-
gressive cancers, and only 10% or less de-
oncology
velop into a malignant tumour. Therefore,
the development of a screening modality
that (i) will have high sensitivity for early
disease, and (ii) would diagnose cancers at
very early, possibly pre-clinical stages, and
(iii) would be capable of discrimination of
aggressive cancers vs. benign or non-ag-
gressive tumors, is strongly desired.
Blood-based tests may be good candi-
dates as early cancer screening tools, since:
(i) blood collection is simple and minimally
invasive; (ii) tumour biomarkers may come
not only from the tumour but from other
organs and tissues and may represent the
systemic response to tumour growth. As
such, these proteins may be secreted into
the bloodstream at the very early stages of
tumourigenesis, when tumour itself is un-
detectable by conventional imaging meth-
ods. Presently, very few blood biomarkers
have proven useful for diagnosing primary
cancer. Only three biomarkers, including
serum PSA for prostate cancer, and bladder
tumour antigen (BTA) and nuclear matrix
protein-22 as diagnostic markers for blad-
der cancer are currently approved by FDA
and are sensitive enough for screening and
early detection in selected populations.
Despite the success of PSA in detecting
early stage prostate cancer, its use to screen
patients for prostate cancer remains con-
troversial due to overdiagnosis. Three other
serum markers have been approved by the
FDA for cancer diagnosis: alpha-fetopro-
tein (AFP) for hepatocellular carcinoma
and testicular cancer, catecholamines for
neuroblastoma, and immunoglobulins for
multiple myeloma. Because the assays for
these proteins are neither sensitive nor spe-
cific enough for use as the sole screening
method for early cancer detection, all are
used as an adjunct to other direct detec-
w w w . a s i a n h h m . c o m 27
 oncology
tion and diagnostic methods. The identi-
fication of a new class of cancer associated
serum proteins, and the validation of sen-
sitive and specific predictive assays, would
expand the current clinical capabilities for
early cancer detection and diagnosis and
further reduce cancer mortality.
The intensive search for new biomark-
ers that would allow overcoming the hur-
dles of early cancer detection is currently
under way. Recent advances in biomarker
development using gene arrays in addi-
tion to proteomic technologies, including
two-dimensional electrophoresis and mass
spectrometry, have facilitated the discovery
of several new biomarkers. Recently, the
FDA has approved a small number of new
urine-based biomarkers, including bladder
tumour antigen (BTA) and nuclear matrix
protein-22 as diagnostic markers for blad-
der cancer (7, 8). Three serum biomarkers
of ovarian cancer, apolipoprotein A1, trun-
cated form of transthyretin, and a cleavage
fragment of inter-alpha-trypsin inhibitor
heavy chain H4, were identified using
mass spectrometry approach.
After new promising biomarkers are
discovered, they must be validated for their
ability to discriminate patients with cancer
from healthy individuals. No single bi-
omarker is likely to have 100% sensitivity
and specificity for a specific cancer. Instead,
combinations (panels) of several biomark-
ers seem to be a promising alternative for
the use in clinical laboratories. There are
several benefits of using combinations of
multiple biomarkers. First, since each can-
cer is represented by several histologies, and
even each histologic type is heterogeneous,
several biomarkers may help to recognize
all cancer subtypes. As mentioned earlier,
multiple biomarkers should represent not
only proteins secreted directly by tumour
but also proteins representing systemic
host response to tumour growth. These lat-
ter biomarkers will depend less on tumour
size and may be measurable early in the tu-
mour development. Finally, using biomar-
kers representing proteins with different
biological functions may allow for comple-
mentarity in cancer detection, resulting in
increased sensitivity without compromis-
ing specificity. Usefulness of combining
three serum biomarkers along with CA125
for increased sensitivity and specificity in
ovarian cancer was demonstrated in three
28 Asian Hospital & Healthcare Management ISSUE-11 2006
publications. Two biomarker combina-
tions, CA 125, CA 72-4, CA 15-3, and
M-CSF (13), and CA 125, apolipoprotein
A1, truncated form of transthyretin, and
a cleavage fragment of inter-alpha-trypsin
inhibitor heavy chain H4 (13) substantially
improved test accuracy over CA 125 alone,
with a sensitivity of 70-73% at a specifi-
city of 97-98%. A panel of 4 biomarkers,
leptin, prolactin, IGF-II, and osteopontin,
reportedly exhibited a sensitivity of 95% at
a specificity of 95% (14).
At the University of Pittsburgh Can-
cer Institute, we have developed highly
sensitive and specific biomarker panels for
early diagnosis of a variety of cancers, with
preliminary results appearing very promis-
ing for ovarian (sensitivity 90%/specificity
98%), pancreatic (sensitivity 96%/spe-
cificity 98%), and endometrial (sensitiv-
ity 98%/specificity 98%) cancers. These
assays are able, in addition to distinguish-
ing cancer cases from healthy controls, to
also discriminate malignant from benign
tumors, thus increasing the specificity of
assays. Importantly, each panel was able
to identify a specific cancer but not other
cancers. Furthermore, work is in progress
for developing an assay for breast cancer in
premenopausal women that substantially
surpasses the results of mammographic
screening. These assays will be further
validated in retrospective trials in which
large populations of healthy individuals
were screened yearly and blood samples
were obtained from them over the course
of over 10 years. Among the individuals
who were diagnosed with cancers, blood
samples preceding the diagnosis are now
available to determine the interval prior to
diagnosis when biomarker panels indicate
the presence of cancer. Subsequent pro-
spective clinical trials will determine the
effect of early detection on mortality from
these cancers.
Conclusion
Serum-based panels of multiple biomar-
kers hold a great promise for better and
more efficient early diagnosis of cancers.
Such tests are not only more convenient
and less expensive, but also may demon-
strate superior sensitivity and specificity
in comparison to conventional screening
methods. Blood-based assays may detect
cancer at very early, potentially pre-clini-
cal stages when the probability of efficient
therapy and complete cure is the highest.
Development of such assays for early de-
tection may shift cancer therapy towards
the development of new strategies aimed
at treatment of very early or pre-cancerous
lesions.
Full references are available on
www.asianhhm.com/magazine/
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Edited by: Fred R. Hirsch
Year of Publication: 2005
Pages: 416
Description:
IASLC Textbook of Prevention and Early
Detection of Lung Cancer examines the
variousmethodsandinterventionsusedin
screening lung cancer.
Fundamentals of
Cancer Prevention
Edited by: David S Alberts, Lisa M Hess
Year of Publication: 2005
Pages: 397
Description:
An authoritative work that provides a
detailed review of the current status of
practiceandresearchincancerprevention
and control an essential reference guide
and tool for primary care physicians, the
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asacollaborativeworkbythefacultyofthe
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Human Genome and the Molecular
Diagnostics Market
Molecular technologies will drive the expansion in market size and the range of
applications in the molecular diagnostics market.
Chee Gee See
Biomarker and Genetics Programme
Manager
Roche Products Limited
Chris Chamberlain
Global Head
Medical Genetics
Roche Products Limited
UK
T
he unravelling of the main bulk
of the human genome in 2000
led to a feverish explosion of ideas
of how genetic information could be used
to improve the identification and man-
agement of human disease and enhance
human health through improved thera-
peutics. Target-based drug discovery im-
mediately received a shot in the arm for
more molecular-based approaches. In part,
these ideas re-evaluated the massive costs
involved in the drug discovery process and
streamlined the targeted strategies already
employed by pharmaceutical and bio-
technology development companies. The
agreed estimate of 26,000 to 30,000 genes
in the human genome has probably 3,000
to 5,000 gene targets which are potentially
amenable to pharmacological intervention,
the so-called druggable genome. However,
5 years after the initial euphoria, all phar-
macological-based disease intervention is
still restricted to a select group of around
500 targets. The challenge for the post-
genome era remains to break through this
select group and to capitalize on the poten-
tial of the druggable genome.
Coupled with empirical sequence data
on the human genome has been the recent
surge of basic biological information and
the advent of various genomics-enabling
Molecular
Img
(DNA)
platforms to test disease hypotheses. Tak-
en together, this continues to be a powerful
cocktail for new discoveries. Constantly
improving genomics technologies such as
RNAi have satisfactorily validated targets
that would have taken much longer (and
at greater cost) with traditional knock-out
transgenics, and sometimes with the added
bonus of detecting both on and off-target
effects.
A new approach
The search by pharmaceutical and biotech-
nology development companies for newer,
safer and more efficacious pharmacologi-
cal compounds has also led to a renewed
appraisal of the value of diagnostics. The
pressure to be first-to-market for safer,
more efficacious and cost-effective medi-
cines has meant that, increasingly more
companies are integrating diagnostics
across their pipelines in parallel to drug
development. It is clear that this approach
makes a significant difference. Arguably
di a g n os t i c s
the most notable historical milestone can
be traced back to the early nineties. In
1991, when Roche acquired patent rights
to the Polymerase Chain Reaction (PCR)
technology from the Cetus Corporation,
PCR was not positioned or envisaged for
diagnostic purposes.
With inspirational foresight, Roche
quickly developed and launched the PCR-
based Amplicor system as standard kits for
clinical diagnosis within a year. With a
strong licensing strategy for its newly ac-
quired PCR technology and a very careful-
ly engineered commercial emphasis, Roche
launched in 1992 the Amplicor system for
detecting pathogens of two sexually trans-
mitted diseases, Chlamydia trachomatis
and HIV. The matching of an appropri-
ate diagnostic tool to the critical need of
the clinical environment ensured that this
was a timely delivery that was readily ac-
cepted. Current refinement of the Roche
Amplicor system now not only detects
HIV presence but also provides ultra-sen-
sitive measurements of the viral load of in-
dividual patients ensuring that physicians
are able to clinically manage their patients’
personalized treatment regime. Roche has
therefore optimally utilized the combina-
tion of a clear diagnostic tool with its drug
portfolio, making a significant material
difference both to the patient and pharma-
ceutical company.
Another example of a pharmacodiag-
nostic partnership is the Aventis/ Pharman-
etics story. Aventis has had approval for
Lovenox, a low-molecular weight heparin
for treatment of dangerous blood clots in
the arms and legs, in the US and Cana-
dian markets since 1993. The decision by
Aventis to invest $5 million to tailor the
development and regulatory approval of
Pharmanetics’ Enox test for the point-of-
w w w . a s i a n h h m . c o m 29
 Circle 13

30 Asian Hospital & Healthcare Management ISSUE-11 2006


use of Lovenox created the potential to
double the $1 billion per annum sales of
Lovenox. Concurrently, following the ap-
proval for the Enox test in August 2002,
90% of Pharmanetics’ revenues in 2003
came from sales of the Enox test itself. The
commercial potential in such pharmaco
in vitro diagnostic partnership is therefore
huge. The Aventis/ Pharmanetics story is
a good example of how such partnerships
can generate huge opportunities, although
sadly the current relationship between the
two companies has fallen on hard times.
Within the in vitro diagnostics in-
dustry, molecular diagnostics is the fastest
growing segment. In little more than a
decade, the clinical market for molecular
diagnostic products has surged from $50
million to over $1 billion in the US, and
is anticipated to reach a global market of
$35 billion by 2015. These are astonishing
exponential figures and they are an indi-
cation of the profitability of the molecular
diagnostics market. Even more indicative
is the market belief that a major
portion of this will be attrib-
uted to advances in genetics,
genomics and proteomics. It
is therefore clear that molecu- pharmacogenetics will potentially provide
lar technologies will drive the rich pickings for the diagnostic market.
expansion in market size and
the range of applications in the
molecular diagnostic market.
Driven by the perceived commercial ben-
efits pharmaceutical companies are increas-
ingly interested in developing tests that can
be used to guide the eventual prescription
of their drugs. Take the case of Herceptin.
Herceptin is indicated for metastatic breast
cancer and in late May 2006 also gained
UK approval for early-stage breast cancer.
Herceptin treatment is seriously considered
only when a patient scores a +2 or greater
on the pre-requisite Her2/ neu protein
over-expression diagnostic test. The Her2/
neu diagnostic test is therefore a targeted
clinical test as it indicates to the physi-
cian as to who should be appropriately
considered for Herceptin. In this respect,
the Her2/ neu diagnostic test selectively
identifies a subgroup from breast cancer
patients who may benefit from Herceptin
and equally importantly, identifies those
patients for whom Herceptin will not be
useful. Herceptin is the epitome of per-
sonalized medicine in its fundamental ap-
proach. The commercial cost of segment-
ing the breast cancer market by following
this approach is more than offset by the
superior effectiveness of providing the ap-
propriate drug to the appropriate patient
and at the appropriate dosage – the dogma
of the safety and well-being of the patient
coming first.
Whilst Herceptin is a good example of
the use of a specific molecular diagnostic
test in combination with clinical utility,
relatively few companies are devoting their
resources to developing molecular technol-
ogies for use in the actual clinical setting. are that tools for pharmacogenetics will
The high costs in validating any such mo-
lecular diagnostic tests to the FDA and the
extended lag-time from initial introduc-
tion to eventual adoption by the clinical
community are key factors in discouraging
many companies from taking this plunge.
Instead, most of the developmental inter-
ests for such molecular diagnostic tests lie of proteins from such case-control studies.
in the discovery and research arena, where
the FDA hurdle is considerably lower. In
Market indications are that tools for
the research environment free from regu-
latory constraints and associated costs,
both diagnostic and pharmaceutical-based
companies can actively exploit the rich
coal seam of the molecular diagnostic mar-
ket. This is the arena where sequence data
from the Human Genome and Proteome
Project is making an enormous impact. For
example, single nucleotide polymorphism
(SNP) data from both the Human Genome
project and the HapMap project has been
and continues to be exploited in the design
and construction of microarray chips used
for whole-genome association studies. Af-
fymetrix has been an astute leader in this
area and has produced GeneChip mapping
sets now extending to 500,000 SNPs. It is
envisaged that genetic association tools
such as these GeneChips will continue to
be major players in the next few years. As
long as there is a demand in discovery re-
search for the identification of key genes
involved in common disease etiology, this
di a g n os t i c s
is an area of the market where growth is
likely to continue. SNP information on
key genes involved in drug metabolism
or transport has also been exploited in the
design of microarray chips for pharmaco-
genetic studies. This is an area where phar-
maceutical companies in their quest for
safer, more efficacious and cost-effective
medicines require indicative answers as to
how subjects are metabolizing or excreting
their drugs or to discover if there may be
genetic reasons for pharmacokinetic out-
lier effects. Again, the market indications
potentially provide rich pickings for the
diagnostic market.
Even more informative are expression
microarrays which are used to interrogate
and compare transcripts from case-con-
trol studies. Developments in proteomic
platforms now also allow the comparison
Taken together, these molecular diagnos-
tic tools allow pharmaceutical companies
to either generate or validate
biomarkers in their drug devel-
opment programs. The incisive
molecular diagnostic partner will
continue to seek out these specific
requirements to match the need.
The need to trim down the
massive costs involved in bringing
a drug successfully to market and
the high attrition rate in the drug develop-
ment pipeline are two reasons biotechnol-
ogy and pharmaceutical companies are in-
creasingly looking to molecular diagnostics
to provide early leads and guidance as to a
program’s likely fate. The incredible syn-
ergy that can be found in such pharmacodi-
agnostic partnership is likely to grow as we
clock up more mileage on the human ge-
nome data. Such a synergy is clearly exem-
plified by the Roche-Affymetrix partnership
in the design, execution and marketing of
the AmpliChip diagnostic kits. Making use
of Affymetrix’s expertise in microarrays and
Roche’s PCR technology, this is an ongoing
partnership that seeks to create diagnostic
tests both for research and clinical use. As
targeted medicine and personalized health-
care become more relevant topics for con-
sideration, these could be the low-hanging
fruit that molecular diagnostic companies
should keep a watchful eye on.
*Clinical data available upon request.
w w w . a s i a n h h m . c o m 31
 di a g n os t i c s
We have everything for your lab animals
Founded in 2004, MFD Diagnostics GmbH has reached
its goal to act as a one-stop service provider for laboratory
animals. With a team of competent veterinarians, biolo-
gists and technicians, we cover most requirements con-
cerning animal science.
Our state-of-the-art laboratories and the animal facil-
ity are equipped to meet S1 and SPF conditions respec-
tively. Our services include animal care, animal husbandry,
genotyping and extensive health monitoring according to
FELASA.
We take care of a variety of laboratory animals includ-
ing mice, rats, hamsters, rabbits and guinea pigs. All fields
of microbiology, parasitology, serology and pathology are
covered by our team of scientists and technicians. To
guard your most valuable animals we keep your inbred,
transgenic or knock-out lines in an autonomous SPF envi-
ronment and offer embryo cryopreservation for your pre-
cious mice.
If your transgenic / knock-out mouse needs to be eval-
uated before you start your experiments or applications,
we can analyze various parameters starting from serum
/ blood parameters over detailed histology (following the
RITA guidelines if desired) to behavioural analysis (SHIRPA
I and II).
If you need a specialized animal model for in-vivo ap-
plications, our expert scientists chose the right model, set
up a precise experiment and provide a significant report
– all under one-point supervision.
32 Asian Hospital & Healthcare Management ISSUE-11 2006
Here are a few of our range of in-vivo possibilities:
• Tumor models (xenografts / orthotope models)
• Toxicity (acute / subchronic / chronic)
• Reproductive / teratogenic
• Pharmaco-/toxicokinetics
To provide customers from pharmaceutical / biotech-
nological background with various animal models, our
scientists start the project with a competent evaluation of
our customers needs and demands, set up the appropri-
ate animal models and conduct all experiments in-house
or with our selected partners.
We have companies as well as academic institutions
with excellent skills and reputation as our partners. Natu-
rally all data collected for our customers are kept confi-
dential as we run our own archive for data gained under
regulations of good laboratory practice.
Laboratories and animal facilities at MFD Diagnostics
are fully equipped to conduct non-clinical in-vivo studies,
safety evaluations or LADME studies. To top off the en-
folding through specific portfolio, MFD offers customized
antibodies generated in mice and rats. If you are in search
of a tailor-made antibody assay, ELISA or immuno-fluo-
rescence based, we are the right source for you.
We set up your desired assay and evaluate and manu-
facture in-house. Experienced scientists discuss your
needs and visualize solutions for your antibody-based
assays.
For further details visit www.mfd-diagnostics.com
Advertorial
Circle 14
Circle 15

w w w . a s i a n h h m . c o m 33
 di a g n os t i c s
ZOLL Medical Corporation:
Working to Help Hospitals Advance the
Practice of Resuscitation
The Pervasiveness of Sudden
Cardiac Arrest
Estimates are that nearly 460,000
adults die each year in the US from
sudden cardiac arrest (SCA). At
least this many die outside the US
Survival rates are alarmingly low—only
6 percent—because care in the
form of CPR and defibrillation is not
administered quickly enough. Time is
the most important factor; with every
passing minute after SCA occurs, a
victim’s survival rate decreases by 10
percent. It is vital that victims requiring
defibrillation receive it as soon as possible.
And those who do not require immediate
defibrillation need quality CPR.
Recent 2005 American Heart Associa-
tion/European Resuscitation Council (AHA/
ERC) Guidelines emphasize performing ef-
fective, high-quality CPR. More specifically,
AHA/ERC Guidelines increased the recom-
mended compressions to 30 compressions for
every two rescue breaths. The Guidelines stress a
focus on CPR because of studies showing that “blood cir-
culation increases with each chest compression in a se-
ries and must be built back up after interruptions.”*
Updated Guidelines also discuss data that show the
critical role of early, high-quality CPR in increasing cardiac
arrest survival rates. Furthermore, there is data that also
show few victims of cardiac arrest receive CPR, and even
fewer receive high-quality CPR. Without immediate inter-
vention, an SCA victim has a very low chance of survival.
However, if CPR and defibrillation are provided within the
first three minutes after collapse, survival rates can reach
as high as 75 percent.
Even in the best of conditions, meeting Guidelines’
recommendations during a cardiac arrest event can be
challenging. While administering CPR, rescuers can be-
come fatigued and, in the urgency of the moment, do not
always perform CPR to the ideal depth—pressing 1½ to 2
inches on the chest—and at the ideal frequency—about
100 compressions per minute. Fatigue can also inhibit
frequent, uninterrupted delivery of continuous chest com-
pressions.
ZOLL Medical Corporation has developed prod-
34 Asian Hospital & Healthcare Management ISSUE-11 2006
ucts that are designed to help rescuers
improve resuscitation efforts. With its
global headquarters in the US and of-
fices worldwide, ZOLL has one focus:
improve and advance the practice of
resuscitation. ZOLL is a company de-
voted to developing life-saving resus-
citation devices and support solutions
so that lay rescuers and healthcare
professionals can improve patient
outcomes.
The company founder, Paul M.
Zoll, M.D., was a practising physician
throughout his life, with a reputation
for careful and dedicated atten-
tion to his patients. His ac-
complishments include the
first successful use of
external defibrillation to
regulate heart rhythms in
patients. This year marks the 50th an-
niversary or Paul Zoll’s first successful ex-
ternal defibrillation in a patient. His accomplish-
ments also include the ability to display the heart’s
cardiac electrical activity on an oscilloscopic screen. This
development eventually led to cardiac monitors and other
programs found in modern cardiac care units today.
Staffed with dedicated employees, many of whom
hold backgrounds in healthcare and emergency rescue,
ZOLL takes a deliberate and forward-thinking approach
to new product development, and carefully studies the
needs of the market, along with prevailing medical data
and research. From its beginning in 1983, ZOLL has had a
clear clinical understanding of the needs of rescuers and
their patients.
For example, in advance of the 2005 AHA/ERC Guide-
lines for resuscitation (both announced in November
2005), ZOLL understood the importance of circulation and
chest compressions to move oxygenated blood quickly
to an SCA victim’s heart and brain. In 2002, ZOLL was
the first manufacturer to provide real-time CPR feedback
technology, known as Real CPR Help™, in its automated
external defibrillators (AEDs). This technology provides
rescuers with real-time feedback on the rate, depth, and
effectiveness of administered chest compressions. This
much-needed information can help rescuers perform

more effective CPR. To date, ZOLL estimates more than
500,000 rescuers worldwide have access to ZOLL AEDs
with Real CPR Help that can assist them in performing
high-quality CPR.
The 2005 AHA/ERC Guidelines call for more chest
compressions to better revive SCA patients. The ZOLL
AED Plus™ and the ZOLL AED Pro® with Real CPR Help
capability, are helping rescuers enhance the effectiveness
of CPR by letting them see and hear in real time how well
they are performing the rate and depth of CPR chest com-
pressions.
Given the importance of early defibrillation, hospitals
have made an effort to place AEDs outside clinical areas
(i.e., lobbies, car parks, and cafeterias). The AED Plus, de-
signed for infrequent rescuers, is an example of just such
an AED. The AED Plus supports the complete rescue event
through instructional graphics on the front of the device.
The AED Plus can help coach a rescuer with step-by-step
CPR instructions and Real CPR Help. This coaching can
help a rescuer provide the best manual CPR possible.
Along with the AED Plus is ZOLL’s AED Pro for pro-
fessional rescuers. The AED Pro features ECG monitoring
with standard ECG electrodes, as well as AED capability
combined with manual defibrillation and controlled access
for professional users. The device’s unmatched rugged-
ness and durability have been proven, as it is the only AED
in the industry to pass a 1.5-meter drop test. The AED Pro
includes 2-button functionality and an intuitive interface.
Its high-resolution display provides operating information
for defibrillation and can also be used to monitor a non-
cardiac arrest patient’s ECG.
In addition to the AED Plus and the AED Pro with Real
CPR help, several of the top cardiac hospitals have cho-
sen the ZOLL M Series® based on several factors, includ-
ing better efficacy with a low energy biphasic waveform,
improved safety with hands-free defibrillation, and the op-
portunity to collect data.
Many of these hospitals have standardized on one
brand of defibrillators in an attempt to decrease the “call-
to-shock” time. This is the time when a cardiac arrest
event is called and when the first shock is administered.
Precious time is saved if the responders work with equip-
ment that has a uniform operating system. ZOLL is enter-
ing its third decade of supplying ALS defibrillators with
a uniform operating system. While many advances have
occurred in technology, one constant is that the operating
controls of all ZOLL ALS defibrillators made since 1983
remain consistent. Any operator trained on one ZOLL de-
fibrillator model can easily operate any other model. This
unique aspect of ZOLL defibrillators could have life-saving
benefits during a cardiac arrest event.
Successful defibrillation is determined by the aver-
age electrical current delivered to a patient. There are two
types of waveforms used to deliver electrical current to the
heart: monophasic and biphasic. Monophasic waveform
di a g n os t i c s
defibrillators deliver current that flows in one direction—
from one defibrillating pad to another. Biphasic waveform
defibrillators deliver current that flows in two directions—
from one electrode to another and then back again.
Since 2000, ZOLL defibrillators have been equipped
with its proprietary Rectilinear Biphasic™ waveform
(RBW), which is clinically proven—in more than 11,000
patients—to improve patient outcomes when compared
to conventional monophasic waveforms. ZOLL’s RBW is
an exclusive innovation that delivers more current than
other biphasic waveforms, improving efficacy while re-
ducing the risks associated with high energy. At 200J,
the ZOLL RBW delivers more current to high impedance
patients than any other biphasic device—even ones that
escalate to 360J.
M Series defibrillators also offer the possibility of col-
lecting all ECG data from the defibrillator after an event.
This information creates a more complete patient record.
More importantly, the data can be used to review cases
and discover opportunities for process improvement.
At the Forefront of Circulatory Support
Advancing CPR performance technology further is the
ZOLL AutoPulse® Non-invasive Cardiac Support Pump.
The AutoPulse is a revolutionary device that moves more
blood more consistently* than is possible with human
hands. As an adjunct to CPR efforts, the AutoPulse can
help medical professionals deliver consistent and continu-
ous compressions, and improved blood flow to the heart
and brain during SCA.
The automated, portable device is comprised of a
backboard and a simple LifeBand® that fastens across
the victim’s chest. The AutoPulse compresses the entire
chest in a unique, consistent “hands-free” manner. Addi-
tionally, it offers the benefit of freeing up rescuers to focus
on other life-saving interventions. EMS agencies and hos-
pitals worldwide are employing the AutoPulse as part of
their resuscitation protocols.
In addressing precisely what the new AHA/ERC Guide-
lines call for—namely faster, stronger and more chest com-
pressions—ZOLL believes that the AutoPulse can have a
major impact on resuscitation protocols and significantly
improve SCA survival rates globally.
A Forward-thinking Approach to Resuscita-
tion Technology
ZOLL has made numerous advances in its understand-
ing of defibrillation, pacing, circulation, fluid resuscitation,
and documentation technology. By encompassing mul-
tiple facets of resuscitation and working as a system to
help improve survival rates, ZOLL has helped customers
move resuscitation from science to evidence to practice.
As ZOLL works with its customers, the company contin-
ues to grow and provide products that improve life-saving
efforts anywhere sudden cardiac arrest strikes.
Advertorial
w w w . a s i a n h h m . c o m 35
 t e c h n o l o g y , EQ U I P M ENT & D EV I CE S
Medical Glove Manufacture
Going powder free
The amount of aero-allergens in areas where powdered gloves are worn can increase
5-10 fold when compared to those where only powder-free gloves are used.
Mónica Sagardoy
Brand Support Manager - Professional -
Asia Pacific, Ansell Healthcare
Australia
G
love manufacturing has changed
dramatically in the last 20 years
with the advent of powder free
gloves technology. This technology was
developed due to the issues arising with
the use of powder in gloves as well as the
changing needs of the end-users such as
the need for double gloving and intra-op-
erative donning.
Powder free gloves are seen by many
as a more expensive choice than powdered
gloves. However, this is not true when the
need for washing powdered gloves prior to
use is considered. The US Food and Drug
Administration made man-
datory for manufacturers
to place a warning label
on the glove packaging
to indicate the need
for washing off the
glove powder.
36 Asian Hospital & Healthcare Management ISSUE-11 2006
Unfortunately, studies have shown that
washing of powdered gloves prior to use is
inefficient in totally removing glove pow-
der and can lead to clumping of the pow-
der particles, creating even less absorbable
aggregates. It has also been reported that
the cost of washing powdered gloves can be
at least seven times higher than the cost of
using powder free gloves.
Unfortunately, some surgeons do not
wash powdered gloves prior to use, which
can lead to complications. Exposure to
starch powder from both surgical and ex-
amination gloves can cause a number of
undesirable reactions for both patients and
the healthcare workers, which vary from
well-known allergy symptoms and upper
respiratory-tract disorders to adhesions,
granulomas, pleuritis, myocarditis, irrita-
tion of the central nervous system or even
carcinoma or tuberculosis misdiagnosis.
These complications can lead to an
increase of the hospitalisation
time or even require extra
surgery.
A well documented
consequence of the
use of starch pow-
der in gloves is its
capacity to bind
with natural rubber
latex (NRL)
protein anti-
gens. These
allergen/pro-
tein coated
powder particles
can be aerosolised
when the gloves are
donned or removed, thus
contaminating the hospital
environment. Inhalation or in-
gestion of these powders can lead to
sensitisation and many diverse allergic
reactions to NRL (e.g. upper respiratory
tract symptoms or eye irritation). It is es-
timated that the use of powdered gloves
within a theatre will deposit in excess of
2kg of glove powder within the theatre en-
vironment per year. The amount of these
aero-allergens in areas where powdered
gloves are worn can increase 5-10 fold when
compared to those where only powder-free
gloves are used. However, glove powder
acts not only as a vehicle for NRL antigens
but can also be a vehicle for opportunistic
and pathogenic micro-organisms, which
increases the occupational risks to both
healthcare workers and patients.
Another common problem that can
arise from the use of starch glove powder
is the development of adhesions, which are
likely to occur after most surgical proce-
dures and granulomas. These effects have
been very well documented concerning the
peritoneal cavity, but they have also been
reported in almost every anatomical site
including the oral region. Despite glove
washing with saline, the glove powder can
enter the body during surgery, which may
trigger an inflammatory response by the
immune system, leading to the formation
of fibrous bands and post-operative adhe-
sions. Adhesions are the major cause of
post-operative intestinal obstruction (more
than 40 per cent of all causes with 60-70
per cent of cases involving the small bow-
el). Uterine and fallopian tube adhesions,
resulting from glove powder, are a signifi-
cant risk to female fertility, with papers
advising that powder free gloves should be
used even for routine vaginal examination.
Analysis of adhesions occurrence showed
that between 69-93%, were due to foreign
micro-bodies, which include starch pow-
der.
Researchers have also shown powdered
gloves to be a risk factor for post-opera-
tive wound infections. As with most for-
eign bodies, glove powder decreases the
inoculum of bacteria required to produce
abscesses, being reduced in this case by a
Circle 16 w w w . a s i a n h h m . c o m 37
 t e c h n o l o g y , EQ U I P M ENT & D EV I CE S
factor of at least 10 fold. In addition, pow-
der also delays wound healing and alters
the normal reparative process while at the
same time increasing the wound’s inflam-
matory response. Surgical Site Infections
(SSI) are the second most common cause
of hospital-associated infections, with
studies showing that compared to similar
risk patients undergoing the same sur-
gery, a patient who develops a SSI is twice
as likely to die, 5-6 times more likely to
require re-admission, and likely to stay
in the hospital twice as long. For major
orthopedic or cardiac surgery, the costs
of these complications may range from
US$ 30,000-US$ 50,000.
All these problems, together with the
lack of an efficient removal of the glove
powder by means of washing, prompted
the development and adoption of new
powder free technologies.
Chlorinated Powder Free Gloves
The first generation of powder free
gloves were the double-sided chlorin-
ated gloves, where both the inside and
outside surfaces are chlorinated. Un-
treated latex gloves (both NRL and syn-
thetic latex), are too tacky to be donned
without any further treatment, therefore
a surface treatment is required if the
powder, which acts as a lubricant is re-
moved. The first powder free gloves were
treated with a chlorine solution which
modifies the surface texture and reduces
the natural tackiness. However, over
chlorination can deteriorate the gloves
and can affect the grip properties dur-
ing use. As such the chlorination process
has to be optimised and controlled with
great care.
There are two main methods of chlo-
rination: “Batch Chlorination” and “Piece
by Piece Chlorination”. Batch chlorination
is more economical, however it will pro-
duce a product with more grip variability
as the chlorine contact with each of the
glove cannot be controlled as precisely. On
the other hand, piece by piece chlorination
is more precise as it ensures glove chlorine
contact equally on all the glove surface for
a predetermined amount of time, ensur-
ing a more reproducible result and less
variability amongst batches or even gloves
within a same batch.
38 Asian Hospital & Healthcare Management ISSUE-11 2006
Polymer Coating Powder Free
Gloves
Another alternative to powdered gloves is
a NRL glove having a synthetic polymer
lining on the internal surface of the glove.
The slippery surface of such a lining facili-
tates donning of the glove. Due to its low
coefficient of friction, the lining facilitates
donning with either damp or dry hands.
This is the technology used in the
Gammex Powder Free family of products,
which uses a hydrophobic/hydrophilic pol-
ymer lining in order to ensure improved
donning qualities and undergoes external
carousel chlorination to guarantee a con-
sistent grip.
Recent Advances in NRL
Manufacture
Manufacturers of NRL medical gloves have
also investigated and implemented manu-
facturing processes to reduce the NRL
protein allergen and chemical accelerators
content of their products.
Some manufacturers have developed
leaching/washing processes either on-line
or in the post processing of the gloves,
which reduce the NRL protein allergen
content of the gloves.
The on-line leaching process reduces
the protein allergen content considerably,
however, the leaching only occurs from
one side of the film. In order to ensure a
more complete reduction of the extract-
able proteins, Ansell uses a unique high
temperature post-washing process called
P.E.A.R.L (Protein and Endogenous Al-
lergen Reduction Leaching Process). This
process can eliminate more of the extract-
able proteins as both sides of the film are
exposed to the cleaning process. The hot
water also hydrates the rubber film and as
the film’s intersticial spaces are enlarged the
allergens are easily extracted. As a result,
the final film has a lower protein allergen
content than the film formed using other
processes such as ‘de-proteinised’ natural
rubber latex.
Ansell’s P.E.A.R.L. process not only
reduces the extractable proteins levels
but also decreases the chemical resi-
dues, another cause of contact dermati-
tis. This is an area where manufacturers
have focused their efforts not only to
develop processes aimed at decreasing
the overall content of accelerator resi-
dues, but also developing new process-
es aimed at eliminating the use of some
accelerators, such as thiurams, which is
the accelerator most frequently linked
to contact dermatitis. Ansell, not only
has discontinued the use of Thiurams in
its powder free range, but it has also de-
veloped alternative options for health-
care workers suffering from accelerators
sensitivity, such as the use of PV100, an
accelerator that becomes volatile gases
completely consumed during vulcani-
sation therefore minimising the risks
of contact dermatitis and the complete
elimination of accelerators in Ansell’s
DermaPrene Ultra, a neoprene latex
free glove.
Conclusion
Powder free gloves are a more cost effective
and safer alternative to powdered gloves.
Today’s manufacturing technology ensures
powder free options with similar comfort,
donnability, tactile properties and grip
than the powder equivalent but with the
advantage of less post-operative complica-
tion and allergy problems.
Full references are available on
www.asianhhm.com/magazine/
Circle 17 w w w . a s i a n h h m . c o m 39
 t e c h n o l o g y , EQ U I P M ENT & D EV I CE S
IPR in Medical Equipment
China’s rise
China is no longer copying Western medical devices, but is now benefiting from
government funding to create its own, next-generation, medical devices.
Allen Yeo
Principal Consultant
Global Sales Support
Thomson Scientific
Singapore
T
he East Asian surge in patenting
of medical device equipment be-
gan in Japan during their period
of economic crisis in the late 1990s. At
this time there was a US$ 200 billion gap
between demand and supply, and a need
for a £ 500 billion package of restructuring
measures from the Japanese government.
In tandem with such fiscal measures was
the perceived need for economic growth
through innovative technical and scientific
development, and the pursuit of Intellec-
tual Property Rights (IPR).
Japan as a leader in IPR and
medical device development
IPR have been pursued in Japan, followed
by the rest of East Asia, through the com-
mercialisation of universities, the trading
of existing IP portfolios, and IP judicial
reform.
Japan has a rapidly ageing and shrink-
ing population. It is estimated that by
2015 just over 25% of the population will
be over 65 years of age. The diseases of old
age and the need to involve the elderly in
society, coupled with an unprecedented
drive (that commenced roughly in 2000)
to promote IPR through patenting, has led
to an explosion in medical device techno-
logical capability in Japan.
40 Asian Hospital & Healthcare Management ISSUE-11 2006
Increased develop- Figure-1: Asian Electrical Medical Device Patenting
ment and use of nan-
otechnology is help-
ing drive this change:
for example scien-
tists in bioscience
centres in Kanagawa
and Osaka have in-
jected nano-cameras
into human blood
streams to help them
better understand
cardiovascular dis-
2000 2001 2002 2003 2004
ease.
Sleep Apnoea - an in- Source: Derwent World Patents Index, Thomson Scientific
creasingly common
disease in the elderly
- has given rise to the development of
masks to enable sufferers to breath and
sleep at night. Telemetric platforms in
the home are connected to medical cent-
ers where any deviation in the routine of
an elderly patient will alert the medical
staff.
A significant contribution to the ex-
tensive development of medical devices is
being made by the 26 Technical Licensing
Organisations based in Japanese universi-
ties, coupled with 34 new intra–university
IPR units that give every type of assist-
ance. In 2004, over 16,000 medical device
patents were filed in Japan (see figure 1),
with many more in the pipeline: the AIST
(National Institute of Advanced Industrial
Science and Technology) alone has ten
thousand potential ideas (including medi-
cal devices) at different stages of develop-
ment.
Olympus is currently the leading
applicant for medical devices patents in
Japan. (see table 1)
in ‘000s
18
Japan
16
14
12
Australia 10
8
6
China 4
Korea 2
0
China as the new emerging market
for developing medical devices
Japan has a clear lead in Asia in both de-
veloping and patenting medical devices.
A similar meteoric rise in medical device
development in China can be understood
only when you consider the economies of
scale involved in meeting the huge demand
within the country:
The Republic of China’s 1.3 billion pop-
ulation is served by 320,000 healthcare
institutions, 65,000 hospitals and 8 mil-
lion healthcare professionals.
China has 3000 medical device compa-
nies, and a medical device market val-
ued at approximately £5 billion-this is
growing by a staggering 15% per year.
China will spend £50 billion in the
course of the next five years on a major
transformation in the healthcare delivery
system that will create a huge demand
for medical devices.
China, like Japan, is prioritising medi-
cal manufacturing, and facilitating progress
Circle 18 w w w . a s i a n h h m . c o m 41
 t e c h n o l o g y , EQ U I P M ENT & D EV I CE S
Pillars supporting increased
development in China’s medical device
development
The conversion of specific Research
Institutes from government-owned to
commercially funded and privately-
owned entities
IncreasingR&Dexpenditure:forexample
the RMB 128.8 billion (£9.16 billion)
spend in 2002 was a 23.5% growth on
the previous year, and was 1.23% of
China’s GDP in 2002 (compared to 0.6%
in 1995)
Less government direction in Science
andTechnology planning, to promote a
more market oriented approach
Taxbenefitsforthedevelopmentofnew
productsbasedonR&Dinvestment,with
anachievementofrealgrowthoutofnew
products, including software
Education regarding IP, shown in the
increase of IPR university courses
Encouragement of overseas Chinese
graduates to contribute to homeland
developmentintechnologicalR&D.Many
overseas Chinese are skilled medical
researchers.
by commercialising research institutes and
university departments. One example is
the General Research Institute for Nonfer-
rous Metals (GRINM). It was founded in
1952, but transformed in 2000 to become
a self-sustaining large-scale high tech en-
terprise. To date, GRINM has six spin out
companies which are involved in materials
for medical use, and generate over £100
million a year.
Research with human tissue is still seen
as socially unacceptable in Japan because of
taboos relating to the use of human body
parts. In contrast China’s Shanghai Hospi-
tal, has recently secured funds for a tissue
engineering facility.
As in Japan, China is no longer simply
copying Western medical devices, but is
now benefiting from government funding
for nanotechnology, information technol-
ogy and advanced materials to create their
own, next-generation, medical devices.
Emerging areas of expertise in
China
As China’s medical device development
becomes increasingly commercialised and
R&D focused, the emphasis on IPR is in-
42 Asian Hospital & Healthcare Management ISSUE-11 2006
creasing in proportion. Emerging areas of
implantable medical devices are:
Orthopaedics
Orthodontics
Vascular (grafts and stents)
Pacemakers
Implantable cardioverter-defibrillators
Drug delivery
Cell and tissue engineering
Regenerative medicine has become a
primary focus of research, with innova-
tion and clinical application in numerous
centres across China. The Chinese intend
to build on their home-grown technology
by placing academic and clinical teams in
close proximity to purpose-built produc-
tion facilities. Although their level of basic
science is still not as advanced as Western
medicine, this combination is driving rap-
id development and commercialisation of
medical devices.
China’s patent legislation reforms are
intended to protect against infringement
of the value it anticipates adding to its
products, including medical devices. The
experience of Japan and Taiwan shows us
that once a country achieves a certain level
of development, interest in protecting their
own IPR means they are far more likely to
abide by laws that protects foreign compa-
nies’ innovations as well. So China’s IP re-
form should also help reduce infringement
by Chinese companies of Western goods.
Generally, China is catching up with
western capabilities in medical devices. In-
deed China is expected to take a lead posi-
tion in some of the newer, rapidly emerging
areas such as regenerative medicine and na-
notechnology. Although there are still ma-
jor infrastructure problems, for example in
relation to regulatory, reimbursement and
clinical innovation, the evidence suggests
that China is well advanced in embracing
the commercial and clinical potential of
these new medical technologies.
In 2005, Siemens and General Electric
were the top holders of published medical
devices patents in China – see table-1.
The ageing population in China
fuels demand
As China’s One Child Policy begins to have
an effect on subsequent generations, cou-
pled with decreasing fertility and decreas-
ing mortality, China will have to address
the social and economic problems associ-
ated with an increasingly elderly popula-
tion. The proportion of those aged over 65
will increase from 7% of the population in
2000, to about 14% in 2025 -and 20% in
2040. While the very old (those aged over
80) are expected to increase from about 8
million to about 50 million, there will be
a parallel decrease in the ratio of working
age people to support each elderly person
from 5:1 to 3:1. These issues will be further
compounded by the increase of western-
type chronic disorders such as diabetes and
obesity, plus the emergence of an AIDS
epidemic among the younger population
(which is already beginning in both rural
and urban areas of China).
Conclusion
IP is growing in importance in China,
whose participation in the World Trade
Organisation (WTO) is driving govern-
ment organisations to both protect their
Table-1: Top applicants for Electrical Medical
Devices patents in 2005
China Japan
Siemens Olympus
General Electric General Electric
Philips Philips
Toshiba Toshiba
Matsushita Canon
Canon Hitachi Medical
Omron Fuji Photo Film
Johnson & Johnson Siemens
Olympus Matsushita
Hitachi Medical Asahi Optical
Source: Derwent World Patents Index, Thomson Scientific, using
Derwent Patent Assignee Code rankings.
own IP and respect that of others. West-
ern organisations can now be less wary of
technological collaboration with China be-
cause of this change in position over IPR,
and engagement with government organi-
sations is one route to ensure continued
protection.
The number of published Chinese pat-
ents reached a peak in 2003 at just over ten
thousand, dipping slightly in 2004. Over
one third of these (see figure 1) were for
medical devices, illustrating the growing
importance of this technology. To main-
tain their current lead in medical device
technology, both Japan and the USA will
need to keep looking over their shoulder at
Chinese developments in this area.
 t e c h n o l o g y , EQ U I P M ENT & D EV I CE S

Ventilation Monitoring
Non-invasive is the way
Non-invasive methods to monitor ventilation are valid surrogates
for arterial blood gas analysis.

fusion can occur between blood and air at
Gido M. Karges
high rates. The purpose of ventilation is to
ensure the efficiency of the passive diffusion
Director
Marketing & Sales through the walls of the alveoli by maintain-
SenTec AG ing higher concentrations of oxygen and
Switzerland lower concentrations of carbon dioxide in
the alveolar gas than those prevailing in the
blood flowing in the alveolar capillaries. In
other words, ventilation enables the organ-
while over-oxygenation remains undetec-
ted due to the S-shape of the oxygen-hae-
moglobin-dissociation-curve. Arterial oxy-
gen partial pressures of above 60 mmHg
correlate with arterial oxygen saturation
readings above 90%. Further increases of
PaO2 cause the saturation readings to near
or equal 100%, but will not cause them to
exceed 100% even in the case of extreme

G
rowing use of non-invasive venti-
lation, growing numbers of pro-
cedures carried out under con-
scious sedation and growing awareness of
the adverse effects of sleep apnoea are only
three of various trends in modern medi-
cine that call for continuous monitoring of
ventilation, preferably continuous non-in-
vasive monitoring of ventilation.
A variety of methods to monitor ven-
tilation are available. For a better under-
standing of the advantages and limitations,
it might prove helpful to recall the link
between ventilation and the basic physical
phenomenon of passive diffusion, i.e. the
movement of molecules from a region of
high partial pressure to a region of low par-
tial pressure. This phenomenon is utilized
even by the most primitive forms of life in
order to ensure the necessary gas exchange
between the medium surrounding the or-
ganism and the internal metabolism. For
the multi-cellular human organism, howev-
er, diffusion through the body surface alone
is insufficient, especially in order to supply
adequate oxygen to and to eliminate carbon
dioxide from cells and tissues. Therefore the
respiratory system facilitates the passive dif-
fusion of these gases by providing a huge ad-
ditional respiratory surface, the walls of the
alveoli. Ventilation, which can be spontane-
ous (breathing) or artificial (e.g. mechanical
ventilation), describes the movement of air
between the environment and the alveoli
walls, where the gas exchange by passive dif-
ism to use the phenomenon of passive dif-
fusion to maintain physiologically normal
partial pressures of oxygen and carbon di-
oxide. The efficiency of ventilation can be
monitored well by assessing the resulting ar-
terial levels of oxygen and carbon dioxide.
Methods of monitoring ventilation:
Invasive
Analysis of arterial blood samples has been
the standard method to measure ventila-
tion parameters like arterial oxygen partial
pressure (PaO2), arterial oxygen saturation
(SaO2) and partial pressure of carbon diox-
ide (PaCO2). But sampling arterial blood
is invasive, carries the risk of infections,
involves big amounts of disposables and
provides only snapshot information. In the
case of intermittent arterial puncture, it is
also associated with pain and discomfort
for the patient.
Non-invasive
Pulse oximetry (SpO2), end-tidal capnog-
raphy (PetCO2) as well as transcutane-
ous oxygen partial pressure (PtcO2) and
transcutaneous carbon dioxide tension
(PtcCO2) measurement are used as non-
invasive approaches to either continuously oxygen partial pressures. This particular
estimate arterial levels of these parameters shape of the oxygen-haemoglobin-dissoci-
or determine trend changes. ation-curve is also the reason for one of the
Pulse oximetry major limitations of the method in terms
Pulse oximetry optically assesses the colour of ventilation monitoring: while supple-
of the blood, which changes with the oxy- mental oxygen is administered to the pa-
gen saturation (SpO2) of the haemoglobin. tient, the partial pressure of oxygen might
The method is used to detect hypoxia, be elevated above physiologically normal

w w w . a s i a n h h m . c o m 43
 t e c h n o l o g y , EQ U I P M ENT & D EV I CE S
levels. Then, in an event of hypo-ventila-
tion, the oxygen saturation readings pro-
vided by optical pulse oximetry will remain
above 90% until the partial pressure of oxy-
gen has dropped to less than approximately
60 mmHg. Clinical research shows that a
decline in SpO2 appears to be a reliable in-
dicator of ventilatory abnormalities during
room-air breathing, while the detection of
such abnormalities may be delayed or even
remain undetected in the presence of sup-
plemental oxygen. Under the administra-
tion of supplemental oxygen, the detection
of adverse physiological trends in ventila-
tion might be facilitated by additionally
monitoring arterial carbon dioxide partial
44 Asian Hospital & Healthcare Management ISSUE-11 2006
pressure, as the adverse physiological trend
may be reflected by changes in the PaCO2
despite the still adequate arterial oxygen
saturation displayed by an oximeter.
End-tidal capnometry
End-tidal capnometry measures PetCO2
in the exhaled gas during expiration. The
flow of the exhaled gas diminishes towards
the end of the expiration, and is inexist-
ent during inspiration, leading to the typi-
cal waveform recorded by
capnometers. Closest to
alveolar PCO2, and thus
to blood gas levels, is the
ultimate reading obtained
at the end of one expira-
tional tide, on the verge of
the next inspiration. This
end-tidal value, although
representing a mixture of
tracheal, bronchial and alveolar gas, can be
used to estimate arterial PCO2. The accu-
racy of this estimation seems to depend on
various criteria, of which dilution by room
air or supplemental oxygen and, in case of
nasal cannula, mouth breathing are un-
derstood to have major significance. The
error levels in terms of absolute PCO2-val-
ues estimated can infringe with medically
tolerable inaccuracy. Technical develop-
ment and improved algorithms constantly
reduce the inaccuracies, and a sufficient
accuracy of the trend in PCO2 changes in-
dicated by this type of measurement seems
to explain the widespread use of end tidal
capnometry.
Transcutaneous measurement
Transcutaneous measurement of blood
gas levels is possible because the above
mentioned gas diffusion through the
body surface, while not sufficient for our
multicellular organism, nevertheless takes
place. Under adequate perfusion and skin
conditions, the gas diffusion through the
skin is closely correlated with vascular gas
pressures. Transcutaneous gas pressure sen-
sors heat the measurement site to normally
41°C to 45°C to increase gas diffusion
speed. When the site is warmed, the sen-
sors collect the gas diffusing through the
skin. Within minutes a pressure equilib-
rium between the skin and the sensor is
Circle 19
t e c h n o l o g y , EQ U I P M ENT & D EV I CE S
established. From this moment on, a con-
tinuous and very accurate estimate of e.g.
the arterial PO2 and or PCO2 is provided
for by elaborate algorithms.
Recent microelectronic developments
have allowed the components of transcu-
taneous PCO2 and pulse oximetry sensors
to be integrated within one digital sensor.
Concomitant pulse oximetry and PtcCO2-
measurement is possible by applying one
single sensor to the earlobe. Sensing gases
in immediate proxim-
ity to the preferred
central circulation of
the cranium, the dig-
ital technology assures
fast and reliable meas-
urements. Validation
studies have shown excellent correlations
of transcutaneous measurements in com-
parison with arterial blood gas analysis for
both pulse oximetry and PtcCO2. The
single sensors are heated to warm up the
measurement site and thus to increase the
local blood flow. A good perfusion does
not only add to PtcCO2-measurement
accuracy but also improves the quality of
the SpO2 signal. Modern PtcCO2-sensors,
which only heat up to 42°C, can be kept
safely on one measurement site for periods
of up to eight hours. Digital sensors am-
plify, digitise and pre-analyse the measure-
ment signals directly at the measurement
site. Combined earlobe sensors were found
to detect changes in SpO2 5 to 37 seconds
faster than an analogue finger sensor, and
changes in PtcCO2 9 to 48 seconds faster
than a cutaneous sensor fixed to the up-
per arm. In centralised patients, a warmed
sensor applied to the earlobe might be less
affected by low signal conditions than pe-
ripheral sensors. PtcCO2-values can be in-
fluenced by factors such as hypoperfusion
at the site of measurement, shock, oedema,
skin thickness and vasoconstricting drugs.
The clinical applications of com-
bined pulse oximetry and transcutaneous
PCO2-measurement potentially include
all settings when ventilation needs to be
monitored, especially when supplemen-
tal oxygen is administered. A combined
non-invasive sensor for pulse oximetry and
PtcCO2, measuring all three parameters
continuously and in real-time, might en-
hance patient safety in a variety of clini-
cal situations. During medical and surgical
procedures, sedatives are very commonly
used and are often administered in the
absence of an anaesthetist. Following the
administration of sedative medication, res-
piratory depression can occur, potentially
requiring treatment with antidotes to the
sedative and eventually causing need for
assisted ventilation. PtcCO2 rises reflect-
ing hypoventilation have been reported
e.g. in patients undergoing various endo-
scopic procedures (thoracoscopy, bron-
choscopy, colonoscopy) under sedation
and administration of supplemental oxy-
gen. Measuring the trends of oxygenation
and carbon dioxide elimination might be
useful to monitor the success of extubation
and the adequacy of non invasive ventila-
tion. Diagnosis of suspected hyperven-
tilation can be evaluated by studying the
trend of PtcCo2. Recently, combined pulse
oximetry and PtcCo2 have been used along
with polysomnography studies to titrate
non-invasive positive pressure ventilation
during the night in patients with chronic
respiratory failure.
Conclusion
Non-invasive methods to monitor ventila-
tion are valid surrogates for arterial blood
gas analysis when SaO2 and PaCO2 are
to be assessed, and additionally provide
continuous information. The different
approaches have distinct limitations and
should therefore be chosen carefully. Com-
bined pulse oximetry and transcutaneous
monitoring of estimated arterial PCO2 can
provide the clinician with information on
respiratory status that can assist with de-
cisions to provide ventilation support. In
situations where supplemental oxygen is
administered to the patient, a combined
measurement might facilitate the detection
of ventilation abnormalities. Continuous
monitoring with a combined pulse oxime-
try and PtcCO2 sensor has the potential to
enhance patient safety in clinical settings
where, without limitation, the ventilation
of patients is impaired by overmedication
or sedation, by obstructive or neurological
causes, in patients with acute or chronic
pulmonary diseases or where patients re-
ceive assisted ventilation or oxygen sup-
plementation.
Full references are available on
www.asianhhm.com/magazine/
Circle 20
w w w . a s i a n h h m . c o m 45
 f a c i l i t i e s & o p e r a t io n s

Infection Control
The role of nonwoven textiles

Using the right surgical barrier and protective gowns, masks, head and footwear
are some of the key means to achieving optimal protection from infection.

decreased nosocomial infection. Surgical gowns

Catherine Lennon In surgical procedures, where the po-
Communications Director
tential of infection is high, risk can be
EDANA greatly minimised by adopting best prac-
Belgium tices in several critical areas ranging from
the environment, design and preparation
of the operating room to the pre-operative
preparation of personnel and the patient.
Surgical gowns are used to prevent direct
contact transfer of potentially infective
agents from the surgical team to the op-
erating wound and vice versa. Operating
gowns prevent dispersal of skin scales if
they are made of a suitable material and
used in combination with ultra clean air

E
pidemics and pandemics have
shaped our history and today they
continue to threaten us by caus-
ing death, suffering and fear, and in doing
so also place sudden intense demands on
national and international health systems
throughout the world. The last 25 years
have brought new diseases to the world, in-
cluding HIV Aids, SARS, Ebola and, more
recently, avian flu, which, with the globali-
sation of trade and travel, has increased
their rapid spread.
In addition to this, the incidence of
Healthcare Associated Infection (HCAI)
due to causes such as Methicillin Resistant
Staphylococcus Aureus (MRSA), while by
no means a new situation, has apparently
rocketed (perhaps due to increased aware-
ness ) in the past decade and is today hit-
ting the newspapers with headlines such as
‘Killer bugs’, ‘Menacing microbes’, ‘Thou-
sands of avoidable deaths’.
It is estimated that in the European
Union (EU) alone, HCAI affects one
out of every 10 patients, causing roughly
3 million infections, resulting in longer
convalescence periods, increased suffer-
ing, and some 50,000 deaths per year. It is
estimated that about one third of HCAIs,
of which roughly 30% are discovered after
discharge from the hospital, are prevent-
able by improvements in infection control.
Whereas infection is making the headlines,
infection prevention is not!
There are a number of areas, especially
in patient-care practices such as hand hy-
giene which, while not headline material,
have proven to significantly contribute to
Using the right surgical barrier and protec- systems. Fabrics with interstices greater
tive gowns, masks, head and footwear are than 80µm, such as traditional cotton, do
some of key means to achieving optimal little to prevent dispersal of skin scales.
protection from infection.
Increased protection for the
Nonwovens in the operating patient and surgical team
theatre Protection against dry or wet contact Non-
The majority of postoperative surgical woven single-use gowns and drapes
site infections are acquired at the offer a variety of properties that
time of operation when there is a provide a safe barrier against
possibility for microorganisms to bacteria, such as:
reach the open wound. Routes of • Repellency
infection are via contact (dry or • Self-adherent edges
wet) or air-borne. Transfer of bacte- • Aseptic folding
ria occurs mainly by the contact Protection against air-borne
route via staff’s hands or cloth- particles
ing. A healthy individual may By using nonwovens to
disperse thousands of skin reduce the amount of
particles per minute and lint produced in the
each particle can harbour an operating room, and
army of bacteria. The role of to block the passage
drapes and gowns is to mini- of skin particles, the
mise the spread of infective particle count is re-
agents to and from patients’ duced by 90%
operating wounds thereby Single-use = 100%
helping to prevent postopera- certainty
tive wound infections. The principal advan-
tage of nonwovens is
Patient drapes that they are used only
Patient drapes are used to once on one single pa-
provide a microbiologically tient, and incinerated af-
clean working area around ter use, thus avoiding the
the wound. If they enclose need for handling and
the wound tightly and are fixed the consequent poten-
to the skin, they also prevent tial for spreading
transfer of the patient’s own skin contaminants. As
flora into the wound. single-use fabrics
are new for each

46 Asian Hospital & Healthcare Management ISSUE-11 2006

Circle 21 w w w . a s i a n h h m . c o m 47
 f a c i l i t i e s & o p e r a t io n s
procedure, there is no need to worry about
the quality of the material. Because of
their single-use property the same level of
barrier effect performance is always guar-
anteed whereas it is possible that a multi-
patient reusable fabric may lose some level
of performance after reprocessing.
Custom-made for the operating theatre
By using a combination of different fab-
rics, materials and designs, single-use op-
erating room nonwovens are custom-made
for the O.R. staff by offering the following
characteristics:
• Procedure-specific design
• Optimum wearer comfort
• Strong yet light in weight
• Optimal fluid absorbency
• Exchange of air, body heat and moisture
Exceeding Stringent European
Standards
A recent Frost & Sullivan report (August
2004) shows that the market for disposable
surgical drapes and gowns in Europe has
seen steady growth in the recent past ow-
ing to the high standards of infection con-
trol enforced by the new European Union
Medical Devices Directive (MDD) and
EU standard EN 13795.
The need for preventing the transfer
of infection between patient and medical
staff has never been greater. The introduc-
tion of the three-part European standard
for surgical drapes, gowns and clean air
suits, used as medical devices, EN 13795,
has been put in place for the protection of
patients, clinical staff and equipment.
The norm, a globally recognised
guideline, is designed to establish uniform
standards for single-use and reusable sur-
gical drapes and gowns, in order to mini-
mise the spread of bacteria and other mi-
cro-organisms during invasive procedures,
thereby helping to prevent post-operative
wound infections.
After nearly 10 years of European
standardisation work, the final section,
Part 3 - relating to performance require-
ments - has been approved in April 2006
and will be published shortly. This work
was accomplished with the full support
of EDANA’s Medical Devices Commit-
tee, ‘MEDECO’, whose experts fully con-
tributed to and participated in the CEN
Working Group responsible for the devel-
opment of the norm.
48 Asian Hospital & Healthcare Management ISSUE-11 2006
The EU Standards emphasise the im-
portance of the barrier performance of the
materials used, insisting that: “The use of
surgical gowns with resistance to the pen-
etration of liquids can diminish the risk to
the operating staff from contact with infec-
tive agents carried in blood or other body
fluids.”
EN 13795 further outlines the need
for rigorous standards in terms of manu-
facture and processing throughout a prod-
What are nonwovens and what is
their contribution to healthcare?
Nonwovens are uniquely engineered
and versatile materials which are
extensivelyusedinthemedicalfieldand
inprotectionagainstbiologicalagents
in other sectors. For example, they can
be designed to deliver critical safety
properties, such as protection against
infections and diseases. With today’s
multi-drugresistantstrainsofbacteria
and virus, nonwovens can help in the
fightagainstcross-contaminationand
the spread of infection in a medical or
surgicalenvironment.Nonwovensare
also increasingly a major component
in the design of “smart” wound care
products, providing such functions as
the creation of a moist wound healing
environment, with controlled vapour
transmission,absorbencyandlowskin
adhesion.
Most recent nonwoven innovations
include the design of new scaffolds
for 3D biological tissue engineering,
implantable fabrics that can reinforce
natural tissues, and nanofibre
nonwoven filtration media offering
enhancedparticlecaptureproperties.
Newnonwovenmaterialswithimproved
finishesincludingliquidrepellentand
bacterial barrier properties are also
beingdevelopedforapplicationssuch
as surgical masks, gowns and drapes,
especiallyinviewofthehighdemands
of the new European Standards, EN
13795.
uct’s useful life, as well as for the testing
and re-validation of reusable materials.
Nonwoven fabrics have excellent liquid
resistance, tensile strength and hydropho-
bic/hydrophilic properties and are, there-
fore, highly suitable for surgical drapes and
gowns. On the other hand, the use of tra-
ditional multi-patient cotton and cotton-
polyester mixed textiles has gradually been
decreasing and once the Standard comes
into operation, they will no longer be on
the market as their low performance, will
not meet the stringent requirements of EN
13795. More information on EN 13795 is
available on www.medeco.edana.org.
Better economics for hospitals
Infection prevention must be seen in a ho-
listic way, so cost should not be the main
factor in making decisions regarding prod-
ucts to reduce the risk of infection. By
looking at the whole picture preventing
infection will ultimately save money.
Single-patient operating room non-
wovens contribute to reduced healthcare
spending. Not only is a patient signifi-
cantly less likely to acquire a nosocomial
infection, with all its associated medical
care and treatment costs, but when com-
pared to all the hidden costs of re-process-
ing, single-use nonwoven products quickly
prove to be a cost-effective solution.
The choice of materials, in both single-
patient-use and multi-patient-use drapes,
gowns and apparel, is wide-ranging. The
degree to which they resist penetration by
potentially infective material is a crucial
factor, and should be the major concern
when different material options are being
considered.
Conclusion
Despite growing infection rates in hos-
pitals, there are effective ways to combat
this alarming trend. New and innovative
applications of nonwovens are increasingly
being used by healthcare professionals as
they provide efficient and cost-effective
solutions in many critical applications. As
today’s surgical techniques become more
and more complicated and save lives in
way that could never have been imagined,
even a decade ago, it is imperative that this
technical progress is matched with a simi-
lar quantum leap forward with regards to
infection prevention.
Circle 22 w w w . a s i a n h h m . c o m 49
 ANAE S T H E S I O L O GY
Anaesthesia
The 21st century challenge
The challenge for the 21st century anaesthesia leaders will be to bridge the widening gap
in practice and education within the speciality whilst at the same time increasing its safety.
Anneke E E Meursing
President
World Federation of Societies of
Anaesthesiologists
UK
A
naesthesia and its practice has
developed enormously following
WW II, thanks to an explosive
growth of anaesthesia equipment and
tools, shorter acting drugs, electronics and
sophisticated monitoring equipment. An-
aesthesia education, training and licensing
has not grown at the same pace, certainly
not globally. In the last two decades, anaes-
thesia in the more affluent world has fur-
ther evolved into perioperative medicine,
the practice thereof is still emerging. The
challenge for the 21st century anaesthesia
leaders will be to bridge the widening gap
in practice and education within the spe-
ciality whilst at the same time increasing
its safety.
The first Harvard Medical Practice
study demonstrated a substantial loss of re-
sources (taxpayers money) by medical neg-
ligence and errors whilst awareness about
this seemed low or absent amongst prac-
tising professionals. To Err is Human em-
phasised that safety and quality of care of
the patient should be underpinned by im-
proving standards and incorporating safety
in training, education and maintenance of
registration. The Joint Learning Initiative
not only revealed a worldwide physician
shortage but also discussed and advised on
how to overcome this obstacle.
The World Health Organisation made
patient safety a number one priority. The
awareness and emphasis on patient safety
50 Asian Hospital & Healthcare Management ISSUE-11 2006
and quality of care have focused atten-
tion on developing different approaches
to training (skills), education (knowledge)
and competencies (attitude) required for
the safe practice of medicine in general and
in anaesthesia specifically.
Since the successful public demonstra-
tion of anaesthesia (1846) in Boston, USA
and the comment made by the surgeon in
charge: “Gentlemen, this is no humbug”,
dentists, physicians and paramedical cadre
have mastered the technique to render pa-
tients unaware of the detrimental effects of
surgical or other, less invasive procedures.
Obstacles for anaesthesia to become a
physician practised only specialty
• Insufficient undergraduates to enter
medical school
• Insufficient number of qualifying
physicians
• No existing recognised anaesthesia
curriculum
• Brain drain to other more affluent
specialties or countries (greener grass)
• Insufficient remuneration as compared to
colleagues in other medical specialties
• Competition with higher professionally
trained non academic cadre
• Preference for physicians to remain in
the urban areas
The first administrations were mostly
done by physicians. Physicians adminis-
tered anaesthesia In the Anglo-Saxon in-
fluence sphere, some as specialists some as
general physicians whilst on the American
and European mainland, surgeons often
induced anaesthesia and then handed the
care over to an assistant supervising the
anaesthetic. Hence, the contemporary ad-
ministration of anaesthesia is practised by
a variety of trained individuals around the
world.
Surgeons, cardiologists and radiolo-
gists were able to develop new techniques
through the serendipity of inventive, crea-
tive and persistent anaesthesiologists to
adapt and adjust to new circumstances in
the best interest of the patient and in close
cooperation with technicians, pharmacists
and engineers. Non-physician anaesthetists
have mostly concentrated on care rather
than on the cure of the patient and always
required a formal prescription - in the wid-
est sense of the word - of the administra-
tion of anaesthesia by a physician.
The introduction of anaesthesia as a
physician practised only speciality world
wide has met with a number of obstacles
such as described in table-1. All of these
are the result of a global physician work-
force shortage but why is anaesthesia
more affected than other specialities such
as radiology or surgery? Radiologists can-
not function without adequate and well-
maintained equipment and assistance and
will therefore rarely flourish in the district
hospital. However, a radiographer can take
simple X rays that the district physician
can use in their practice. The same is true
for anaesthesia: with simple means basic
anaesthesia can be administered. It does
not require a specialist, a general physician
or an assistant thus trained can safely ad-
minister. However, this mode of practice
will not facilitate difficult cardiac surgery
or safe anaesthesia for a 63 year old cardiac
compromised patient with diabetes and
hypertension for a cholecystectomy. His-
tory in the more affluent world has shown
that a critical mass, a core of dedicated,
enthusiastic individuals is required to
further improve the quality of care in the
speciality establishing the speciality in its
full breadth. Moreover, advances in surgery
and its outcome are inextricably linked and
influenced by the quality of anaesthesia

care and cure. Additionally, populations
are ageing demanding regular orthopae-
dic, plastic, transplant or oncology surgery.
Moreover, younger physicians do not wish
to work the same number of hours com-
monly practised in the recent past by their
predecessors.
These factors have opened the floor to
develop and strengthen non-physician an-
aesthesia training and practice, filling the
void. Evidence-based planning, decision
making and re-assessing the process of re-
cruitment, training and re-registration of
anaesthesia providers are urgently required.
The scope of anaesthesia
Anaesthesia has become an integral part
of the practice of perioperative medicine.
Not only surgeons have come to realise
that good anaesthesia improves the surgical
outcome, psychiatrists prefer anaesthetists
to look after the vital functions of their pa-
tients during Electro Convulsive Therapy.
The list of physicians whose patients need
anaesthesia is too long for an individual
call out; just rest assured that all doctors
Circle 23
aim to keep their patients in optimal con-
dition whilst undergoing any procedure.
Perioperative medicine encompasses peri-
operative care from pre-operative assess-
ment until discharge from the hospital.
The different phases are:
• Pre-operative assessment and optimali-
sation of the patient before a procedure
can be carried out, be it surgical or inter-
ventional
• The administration of anaesthesia per se
(drugs, circuits, regional block and air-
way maintenance)
• The maintenance of physiologic bal-
ance and treating of imbalances during
induction, maintenance, emergence and
recovery from anaesthesia
• Maintenance or treatment of fluid (im)
balance, arrhythmia’s, or organ failure
• Oxygenation through a variety of methods
• Tardio-pulmonary and brain resuscita-
tion of patients of all ages
• Treatment of acute and chronic pain
inclusive of the obstetric and emergency
patients
• Trauma management on site and in
ANAE S T H E S I O L O GY
the emergency room with emphasis on
maintaining and improving vital func-
tions, resuscitation and emergency and
intensive care medicine.
As more and more medical practition-
ers require safe sedation and anaesthesia
for their patients, anaesthesiologists are in
much more demand and particularly more
outside the operating room. Quality of an-
aesthesia providers must not be sacrificed
on account of increased need.
How to cope with a growing
demand for the speciality
Several stake holders play a role in provid-
ing solution to this problem. Having ad-
equately trained professionals providing
anaesthesia is important to patients in the
first place. They would like to sustain their
surgery with minimal side effects followed
by a speedy recovery. Secondly, physicians
and other para-medical cadre aiming to
practice anaesthesia as a career need an
appropriate curriculum, qualification and
registration in order to practice safely.
Lastly, government is not only charged with
w w w . a s i a n h h m . c o m 51
 ANAE S T H E S I O L O GY

the control of training programmes but at
the same time committed to improve the
quality of care for patients nationwide at
all levels: rural, district and central.
A first step for all parties involved is
to agree on who may practice anaesthesia
under which conditions. An anaesthesi-
ologist is a physician further trained as a
medical specialist who masters all aspects
of cure and care at the conclusion of their
training. Certain aspects of perioperative
medicine can be delegated - in some parts
of the world - under clearly described con-
ditions and limitations to para-medical
trained personnel. These individuals func-
tion as the extended arm of the physician,
preferably an anaesthesiologist. Education
and skills training should be based on close
cooperation with physician anaesthesi-
ologists. Therefore, a national curriculum,
with set standards both of training and ex-
aminations must be agreed on. Following
ongoing assessment and maintenance of a
logbook, further enhances the high stand-
ards. In some countries, re-certification
and re-registration have already found a
place such as is commonplace in aviation.
Who should train the future
anaesthesia administrators
The medical background of the anaesthesi-
ologist is essential to comprehend the full
picture of disease, possibilities of treatment
and quality of long-term cure and care for
the patient. Anaesthesiologists must natu-
rally contribute to the education of the
non-physician anaesthetists. This is how-
ever not common practice in the world.
Some medically trained colleagues feel able
to teach or supervise the administration of
anaesthesia. Regarding this practice, let
it suffice to have a surgeon speak: Robert
Monod was a surgeon and the chairman
of the international congress preparing
the foundations of the World Federation
of Societies of Anaesthesiologists (WFSA):
“It is time anaesthesia freed itself from the
tutelage of surgery” were the words he said
at their opening ceremony in 1951. His
words became reality when WFSA saw its
inauguration on 9th of September 1955
adopting as their motto: to make avail-
able the highest standards of anaesthesia,
pain treatment, trauma management and
resuscitation. To make anaesthesiologists
responsible of delegating their responsibil-
ity and set the standards of those profes-
sionals, that seems to follow naturally.
Can workforce be compared to
equipment?
The previous WFSA president Dr TCK
Brown designed a table to function as
a guideline of tools and equipment re-
quired for different levels of anaesthesia
administration. To connect different lev-
els of trained professionals to each of the
equipment standards in the rows seems
logical. Basically, the WHO knows three
levels of medical care: the rural health
centre, the district hospital and the cen-
tral hospital. Teaching or academic hospi-
tals are mostly linked to universities and
thus to the Ministry of Education. These
organisations are primarily charged with
the education of healthcare profession-
als rather than providing healthcare in all
its forms such as the Ministry of Health.
It could be envisaged that such as avia-
tion has different education and licenses
for the different aircraft, anaesthesia could
acknowledge different levels of licensing

Anaesthetic Facility General Facilities EEquipment

Minimal
Basic draw over
Draw over, Oxygen,
Mechanical IPPV for simple
use
Plenum systems
Complying with national
minimum standards
Sophisticated international
minimum standards
Running water, electricity, oxygen, operating
room absent
Water, electricity (at times), operating room,
tilting table
Water, electricity (at all times and emergency
replacement), Oxygen in cylinder or through
concentrator. Autoclave
Piped gases, Nitrous oxide, Air, Oxygen
Air conditioned O.R. suite & air filters
Intravenous access, face masks and Guedel airways, spinal needles, boiler for
sterilizing, Laerdal self inflating bag, foot pump for suction
All of the above and draw over vaporizer, face and laryngeal masks, suction
catheters
All of the two above and O2 concentrator or cylinders laryngoscope &
endotracheal tubes, introducer, bougie, laryngeal masks, double cuff tourniquet
All of the above and anaesthetic machine with ventilator, breathing system,
paediatric arrangement, HME filter, Humidifier
All of the above and syringe pumps, warming and cooling devices. Systems for
pain treatment
Workstations

Translated into education in anaesthesia administration, the table would look as this:

Anaesthetic Facility General Facilities Training, background and assistance

Minimal ~ rural health centre Running water, electricity, oxygen, operating Anaesthetic clinical officer, assistant and/or nurse with unskilled assistance
room absent
Basic draw over ~ rural Water, electricity (at times), operating room , All of the above and (general) physician available to help with diagnosis and
health centre or < 100 beds tilting table treatment or referral decision. Locally trained assistance
hospital
District Hospital Water, electricity (at all times and emergency All of the above and physician anaesthesiologist available for consultation.
replacement),O2incylinderorfromconcentrator. Nationally or regionally trained assistance
Autoclave
Complying with national Air conditioned O.R. suite & air filters, Central All of the above and a critical mass of physician anaesthesiologists available
minimum standards ~ Sterilising Department to teach, assist, support, supervise and manage all anaesthesia locations or
Teaching Hospital emergency airway care required. Skilled assistance
Sophisticated minimum Top of the pops, both in cure, care, education and All of the above and specialised consultant anaesthesiologists for all areas of
standards ~ University research special interest Skilled and qualified assistance.
Hospital

52 Asian Hospital & Healthcare Management ISSUE-11 2006


related to a particular level of equipment
and whether one would be licensed to
operate this independently or under super-
vision.
Dilemma
What surfaces is the debate why patients
in some parts of the world should be satis-
fied with cure and care different from their
counterparts in the more affluent world? Is
it because they have no money to spend?
Or does prosperity bring different health
problems and solutions with it?
Manpower shortage in medicine has
set in all over the world regardless of the
speciality. The influx of more female physi-
cians desiring to work part-time in com-
bination with an increased workload cre-
ated less satisfying working conditions.
Moreover, it resulted in lower salaries
than expected or earned by their peers in
non-medical profession. This diminishing
workforce increases in addition to a grow-
ing, greying population in need. Addition-
ally, these patients desire more surgical
and interventional procedures demanding
Circle 24
quality and safety both in cure and care.
The dilemma: who and how to train in
anaesthesia to provide ongoing safe care
has evoked widespread interest around the
world amongst governments and profes-
sional organisations.
Future
If surgeons and other physicians demand-
ing quality anaesthetic support for their
patients were to accept the idea of the an-
aesthesia team and embrace perioperative
medicine as the field practised, then anaes-
thesiology could develop as the proverbial
umbrella under which all providers may
develop whilst physician anaesthesiologists
guarantee the quality and safety of care.
Time has come for anaesthesia administra-
tors to agree on the entry and exit criteria
for each level of qualification of anaesthe-
sia administrator, their licenses and limi-
tations and their respective nomenclature.
After all, the practices of many aspects of
medicine know and accept their respective
non-physician assistants such as the mid-
wife or the intensive care nurse.
ANAE S T H E S I O L O GY
Conclusion
Africa’s initiative of coping with a physi-
cian shortage by training non-physician
clinical officers may prove to be the front-
runner of a development needed in the
more affluent world. In the not-too-distant
future few countries in the world will be
able to afford fully trained and qualified
physician anaesthesiologists for all aspects
of perioperative medicine. Those in more
affluent countries would be wise to inves-
tigate whether the perioperative medicine
model with the anaesthesiologist in charge
delegating some of their tasks to non-phy-
sicians can be implemented in their cur-
rent practice. Anaesthesiologists should
supervise, guide and help set the standards
of practice. Anaesthesiologists have proven
to be the best team leaders in the past 160
years. There is no room to go back to the
days when surgeons supervised non-physi-
cian anaesthetists.
Full references are available on
www.asianhhm.com/magazine/
w w w . a s i a n h h m . c o m 53
 I N F O R M AT I O N TEC H N O L O GY

Medical Errors
RFID to the rescue

Against the background of medication errors and wrong treatments costing the health
system several million dollars every year, RFID can provide an important contribution to
improving the quality of treatment and increasing the safety of hospital routine.

Thomas Jell
Senior Principal Consultant
RFID Technology department
Siemens Business Services
Germany

I
n the Internal Medicine departments
of German hospitals, 29,000 patients
die each year as a result of being giv-
en the wrong medication, according to a
study by the Medical University of Hano-
ver. Health experts are hoping to remedy
this with the introduction of high-tech
radio-frequency identification, or RFID
for short.
Modern medicine combines a host of
complex processes. Medical and admin-
istrative services have to go hand in hand
and be well coordinated, and both highly
sensitive information and medical equip-
ment must be available round the clock.
Added to this is the central goal of con-
sistently increasing the quality of care and
customer orientation and looking after pa-
tients in the best possible way. In addition,
the pressure of higher economic efficiency
increases from day to day. In short: Mod-
ern medicine means managing more and
more tasks with fewer and fewer resources.
Against the background of medication
errors and wrong treatments costing the
health system several million dollars every
year, RFID (Radio Frequency Identifica-
tion) can provide an important contribu-
tion to improving the quality of treatment
and increasing the safety of hospital rou-
tine.
The non-contact radio technology is
made up of two components – a reader
RFIDallowsreliablepatientidentificationviaradioandsafeapportionmentofmedicationandbloodproducts.
Source: Siemens Business Services.
and a so-called transponder or tag – both
of which communicate via radio waves. Be-
tween the antenna of the tag and the reader
there is an electromagnetic energy field. If
the chip gets within range of the reader an-
tenna, it allows the reading or writing of
information. The data is either processed
on the spot or transmitted to a central
computer. Unlike barcodes, RFID tags can
reveal large quantities of data within a few
seconds over long distances and without a
direct line-of-sight.
In hospitals, the RFID chips are useful
in three key areas. Firstly, they can be used
to track objects like beds, wheelchairs and
operating instruments or medical items
such as Infusomats. The second applica-
tion area concerns the patients, in that their
treatment information can be accessed more
quickly using the tags. And the third field
is personalized medication, where RFID
ensures safe distribution of drugs.
RFID chips in use
The Klinikum Saarbrucken Hospital,
which is situated in the west of Germany
in Saarbrucken, is already trying out these
applications. Immediately before a drug
is administered, the nurse checks whether
the patient is getting the right medication
in the right dosage at the right time. This
is made possible by the non-contact radio
technology RFID. The principle behind it
is quite simple. At the heart of the system
is an intelligent chip, also called a trans-
ponder or tag, which is about half a square
millimeter in size and contains a number
similar to a barcode. The nurse uses a mo-
bile terminal such as an RFID-capable
PDA or tablet PC to read the number,

54 Asian Hospital & Healthcare Management ISSUE-11 2006


using it to call up information such as
the patient’s age, weight and size as well
as basic medical readings and lab results.
An expert program from RpDoc Solutions
checks the proposed medication and dos-
age. If there is any danger, it switches to
red and explains why. This artificial intel-
ligence can thus turn out to be a life saver,
for example with diseases such as renal
failure, where even minor discrepancies in
dosage can be fatal.
Proper medication and dosage is the
focus of the RFID pilot project launched
in Saarbrücken in April 2005, which also
involves Siemens Business Services, Intel
and Fujitsu Siemens Computers. With
over 695 beds, the hospital treats some
27,000 inpatients and 84,000 outpatients
every year. Since the beginning of this year,
units of stored blood for around 1,000 pa-
tients have also been fitted with RFID. On
arrival at the hospital, each blood bag is
given a tag with an appropriate code. This
code corresponds to an entry in a secure
database detailing the origin, purpose and
recipient. When the nurse takes the bag
containing the blood donation to the pa-
tient, she reads the chips on both the pack-
age and the patient’s RFID armband with
a PDA, and will only administer the blood
if the data matches. The patient receives
the correct transfusion in exactly the pre-
scribed quantity. The information is then
entered in the clinic’s process system and
the patient’s records.
Armbands transmit patient data
The modern radio technology is also mak-
ing its mark at New York’s biggest pub-
AttheKlinikumSaarbrückenHospital,some1,000patientscarrytheirmedical
history with them in a radio armband.
Source: Siemens Business Services
I N F O R M AT I O N TEC H N O L O GY
lic hospital in the Bronx, where patients
carry their medical history with them in
a radio-tagged armband. When they are
admitted to the Jacobi Medical Center as
in-patients, they are issued with a paper
armband with an integrated RFID chip, in
which are stored their name, date of admis-
sion and patient number. All other patient
data is kept in an electronic file on the cen-
tral database server. Using mobile devices,
the doctors can access all the medical data,
such as case history, diagnoses, lab reports,
allergy results or x-rays, via the patient
number and WLAN at any time. “This
immediately gets them up to speed on the
patient,” comments Daniel Morreale, CIO
at the Jacobi Medical Center.
The multi-award-winning solution
from Siemens has been in use since 2004.
Morreale praises the quality of the collabo-
rative partnership: “Siemens has delivered
a solution that not only satisfies our cur-
rent requirements but also gives us enough
scope to think further options through.
This partnership is of great value to us.”
With the aid of PDAs or tablet PCs,
hospital staff can update the patient data
during the actual treatment. Because they
save on paperwork, the doctors and nurses
have more time to attend to the individual
patients. The patients too are better in-
formed, thanks to RFID. Using special ter-
minals in the day room, they can consult
their armband to look up on screen many
of the questions that were not dealt with
during the ward round. On the screen pa-
tients will find information on their blood
pressure, about their ailments and appro-
priate therapies, as well as treatment times
or discharge dates.
Beds get radio IDs
too
But it’s not only the
medical history that
can be accessed more
quickly thanks to RFID:
A special sensor on the
patient’s chest measures
heart rate and sends the
results to an RFID clock,
which in turn transmits
the data to the doctor.
To allow the wearer’s lo-
cation to be pinpointed
to within two meters,
several antennae are distributed around
the hospital premises. Should the patient’s
condition take a sudden turn for the worse,
the medics can immediately head to their
location and take appropriate action.
RFID technology also offers poten-
tial for optimisation when it comes to the
management of hospital beds. RFID chips
attached to the beds automatically log in-
formation on their movement, which re-
lieves staff of routine tasks in housekeep-
ing, transport, repairs, accounting and
maintenance.
Dispelling doubts about data
protection
In view of the many positive factors that
speak in favour of RFID, it is not surpris-
ing that analysts see radio technology as a
billion-dollar market. Market researchers
at In-Stat anticipate a rise in the number
of tags produced from the current 1.3 bil-
lion to over 33 billion by 2010. However,
as a study carried out by Berlecon in July
2005 reveals, the health sector is still hesi-
tant about using RFID. This is mainly be-
cause of concerns about data protection.
However, it is unlikely that RFID will
turn its users into ‘transparent patients’.
After all, the data on the chips can only
be read within a range of a few meters at
most. Furthermore, the zones covered
by RFID chips can be securely protected
against unauthorised access. At the Klini-
kum Saarbrücken Hospital, this protection
is guaranteed by sophisticated encryption
technology.
There is no question of mass applica-
tion of radio technology as yet, partly due
to current chip prices, which are in the re-
gion of 20 cents. But new technologies, for
example from PolyIC, could soon deliver
the breakthrough. This company, which is
based in Erlangen, Germany, is working
on simply printing the radio chips – rather
than manufacturing them from expensive
silicon and copper. For this they are using
soluble high-tech synthetics, which can be
produced quickly and at low cost. So it will
be some time before RFID really catches
on in the hospital sector. In the light of
greater transparency in hospital procedures,
improved patient safety and constantly up-
to-date information, there is no doubt that
the RFID initiative is worthwhile for both
patients and hospitals.
w w w . a s i a n h h m . c o m 55
 I N F O R M AT I O N TEC H N O L O GY
Telesurgery in Asia
Are we there yet?
Telemedicine has traditionally been more popular with countries of huge
geographical distances where access to medical care for patients living in remote
areas is scarce. However, telemedicine has also proven itself to be viable in a
land-scarce place such as Singapore.
Adam Chee
Industry Analyst
Healthcare (Asia Pacific)
Frost & Sullivan
Singapore
T
elemedicine, which involves the
use of telecommunications tech-
nology to deliver healthcare serv-
ices to patients and providers at a distance,
is recognised by the World Health Or-
ganization (WHO) as a cost effective and
practical method for healthcare delivery. In
Telemedicine, there are two categories of
technologies, real-time and store-and-for-
ward.
Real-time (Synchronous)
In real-time telemedicine, patient’s medi-
cal data/information is transmitted as it
is being acquired (e.g. video conferencing
with attachment of medical equipment).
This allows an expert opinion to be sought
instantly.
Store-and-Forward
(Asynchronous)
In store-and-forward telemedicine, pa-
tient’s medical data/information are ac-
quired and stored locally before being for-
warded to an expert doctor at other centre
at a later time. This is usually implemented
for non-emergency use or in situations
where the doctor’s presence is not required
at the time of data transfer.
TeleMedicine in Singapore
Telemedicine has traditionally been more
popular with countries of huge geographi-
56 Asian Hospital & Healthcare Management ISSUE-11 2006
cal distances where access to medical care
for patients living in remote areas are
scarce, however, telemedicine has also
proven itself to be viable in a land-scarce
place such as Singapore.
The National Healthcare Group
(NHG), a major public healthcare pro-
vider in Singapore started a teleradiology
project in early 2006 where X-rays are sent
digitally to radiologists in India for report-
ing. The results were definitely cheaper and
the service was surely faster in comparison
to what the local resources can provide, in
return, the local hospitals are contemplat-
ing on tendering for similar X-ray reading
contracts proposed by hospitals in the US
and Canada.
Telesurgery, surgical procedures car-
ried out at a distance enabled by advances
in robotic and computer technology is an-
other sub-discipline of telemedicine that
may soon be available at healthcare facili-
ties in Singapore.
Robotics Surgery Systems
The da Vinci Surgical System, a robotic
surgery system from Intuitive Surgical is a
descendant of the 1980s US Department
of Defence project that was initiated to
create a robot that would allow surgeons
to operate on critically wounded soldiers
Present
Surgical Robotics
Video Conferencing Surgery
from a safe distance is already widely avail-
able in various public and private hospitals
for minimally invasive procedures.
Surgeons using the system perform the
operation through a console located a few
feet away from the patient where he/she
is provided with an immerse view of the
actual operating field in real-time three-di-
mension. The surgeon’s hand movements
at the console instrument are seamlessly
translated into corresponding micro-move-
ments of instruments positioned inside the
patient with high precision and accuracy.
Patients operated through the da Vinci
Surgical System usually experience less pain
and bleeding as also faster recovery as the
surgery is less intrusive compared to open
surgery. The overall surgical performance
is enhanced as the surgeon is positioned
comfortably throughout the operation to
reduce fatigue and tremor in the hands.
‘Live’ Surgery Video Conferencing
Apart from robotic surgery, the Minimally
Invasive Surgery Center of both the Glene-
agles Hospital and the National University
Hospital (NUH) also holds ‘live’ surgery
video conferencing with overseas health-
care facilities for teaching purposes and to
promote exchanges in the medical com-
munications among different countries.
Future
Telesurgery

Traditionally, transmission of medical
images and live-video conferencing over
the Internet has been plagued with costly
software, equipment, and bandwidth only
to produce low-quality images, audio, and
video. To overcome these problems, NUH
utilises the Digital Video Transfer System
technology (DVTS) to broadcast live sur-
With a worldwide shortage of medical
expertise and rapid advancement in
technology, it is only a matter of time
beforetelesurgerybecomesacommon
necessity for major healthcare facilities.
gery using high-speed bandwidth of at
least 30 Mbps per line to ensure high-qual-
ity digital video.
Taking it further, the Singapore Na-
tional Eye Centre (SNEC) hosted a live vit-
reoretinal surgery transmission from Japan
in February. The doctors under training
wore special 3D/three-dimesional viewing
glasses, which enables them to see exactly
what the operating surgeon sees through
the microscope in true 3-dimension as op-
posed to the conventional 2-dimensional
transmission. The improved visualisation
greatly enhances the doctor’s surgical train- initiative includes the implementation of
ing as they can now pick up knowledge
and techniques obtainable only through a
surgeon’s view through the microscope.
Telesurgery is not limited to robotic
surgery or providing training sessions over
the Internet. In September 2001, the Eu-
ropean Institute of Telesurgery in Stras-
bourg conducted a telesurgical operation
where doctors in the US performed a suc-
cessful gall bladder removal from a patient
in France by remotely operating a surgical
robot arm. Such a procedure indicates that
it is now possible for a surgeon to perform
an operation on a patient anywhere in the
world.
Telesurgery in Asia
(India, Malaysia and Thailand)
While Singapore enjoys a reputation of
being technologically advanced, it is not
the only country in Asia that is adopting
technology advancements in its quest to
provide quality patient care with afford-
able prices. Telemedicine has also found its of technology to improve healthcare. The
I N F O R M AT I O N TEC H N O L O GY
presence in countries like India, Malaysia
and Thailand.
Telemedicine in India
With its abundant supply of IT talent and
huge geographical surface, it is not surpris-
ing that Telemedicine has already been
widely adopted throughout India. The
Apollo Hospitals Group (the single largest
Telemedicine solu-
tion provider in In-
dia), is credited with
being the first to set
up a Rural Telemedi-
cine Centre in India.
Although the im-
plementation of Tele-
medicine in India
has been pioneered
by private hospitals,
things look to change as the Department
of Information Technology (of the Min-
istry of Communications & Information
Technology) had taken up the initiative
for defining the “Standards for Telemedi-
cine Systems” together with various other
organisations related to health and tech-
nology.
Telemedicine in Malaysia
In 1996, the Malaysia government em-
barked upon the Multimedia Super Cor-
ridor (MSC) initiative - a large-scale infra-
structure and services project. Part of this
Telemedicine to enhance the quality of
healthcare in both urban and rural areas.
To facilitate the implementation and
utilisation of telemedicine, the Malaysia
government implemented legal framework
with new cyberlaws such as Telemedicine
Act 1997 and Digital Signature Act 1997.
Selayang Hospital, a government hospital
in the state of Selangor became the first
paperless and filmless electronic hospital
in Malaysia in August 1999 and the latest
hospital to share the same/improved capa-
bilities is the Pandan Hospital in the state
of Johor.
Telemedicine in Thailand
Similar to India, the adoption of technol-
ogy in Thailand hospitals has so far been
driven by the private hospitals. Private hos-
pitals located in Bangkok (the capital city)
like Bumrungrad Hospital and Bangkok
Hospital Group (network of 15 private
hospitals) are famous for their utilisation
good news for public hospitals is that Thai-
land’s Ministry of Public Health has plans
in the pipeline to develop electronic health
information systems that will link the pub-
lic healthcare facilities across the country
to improve patient care and increase effi-
cient use of resources.
Conclusion
Effective deployment of telemedicine can
translate ultimately into patient benefits
as medical and technological resources can
be utilised to enhance patient care, while
reducing the cost. With telesurgery, the
need for patients to travel physically to
another healthcare facility can be reduced
since teams of top surgeons from around
the world could be assembled to perform
an operation or provide consultation or
obtain second opinions.
With a worldwide shortage of medical
expertise and rapid advancement in tech-
nology, it is only a matter of time before
telesurgery becomes a common necessity
for major healthcare facilities.
In the quest to establish itself as the re-
gional medical hub, medical centres across
Asia may soon find it necessary to start lev-
eraging on Surgical Networking Systems in
the bid to be number one.
BOOK Shelf
Human and
Organizational
Dynamics in e-Health
Edited by:
David C Bangert and Robert Doktor
Year of Publication: 2005
Pages: 342
Description:
Healthcareprofessionalsandgovernment
policyplannersbelievethattelemedicine
holds the promise of decreasing the
cost of healthcare services. Human and
Organizational Dynamics in e-Health is a
uniqueguidedesignedtohelphealthcare
professionals resolve organizational
resistance to telemedicine.
For more, visit Knowledge Bank section
of www.asianhhm.com
w w w . a s i a n h h m . c o m 57
 I N F O R M AT I O N TEC H N O L O GY

Asia's Challenge to
Medical manufacturers

The era of passive sales to local distributors is rapidly drawing to a close.

Take China for instance. As the fastest
Steve Stine growing healthcare market in the world,
Director the country’s State Drug Administration
Life Sciences (Medical)
(SDA) and the State Food & Drug Ad-
TNT
Singapore ministration (SFDA) have issued some 40
statutory regulations that monitor the im-
port, sale and usage of pharmaceutical and
medical products. Such regulations – in
China and elsewhere in Asia – are an at-
Oddly enough, it is the advent of eco-
nomic change in Asia that drives demand
for new medical treatments. With greater
prosperity come environmental pollu-
tion, over-population, dietary changes and
stress, all of which contribute to changing
disease patterns. In less than two decades,
chronic illnesses, such as cancer and heart
disease have overtaken infectious diseases,

M
edical products manufacturers tempt to stem the rise in public and private such as malaria and cholera, as the leading
take heed! There’s a quiet revo- healthcare spend, reduce misappropriation cause of death among Asians.
lution stirring throughout the of these products, and safeguard – wher- Initially, Asia’s healthcare systems were
Asian healthcare sector, and unless you are ever possible – those who seek out these caught off guard. In recent years, govern-
privy to these changes, the impact on your advanced and high-cost treatments. ments have made a flurry of investments
bottom-line could be severe.
“How can this be?” you ask. The re-
gion’s economies are on the rise. Out-of-
pocket spending by a more health-con-
scious middle class is propelling demand
for improved healthcare services. Innova-
tive prescription drugs and medical devices
hold promise of improving the lives of mil-
lions. With such market dynamics in play,
you might say it would be easy to take a
“business-as-usual” stance by pushing an
ever-increasing litany of products on local
distributors and logging sales, accordingly.
Unfortunately, this old-school reliance
on small and specialist distributors now
comes with a new batch of risk. On the
one hand, consumers are becoming in-
creasingly savvy about new medical prod-
ucts, treatments, and thousands of times a
day, are using the internet to “shop” for in-
formation on the latest developments and
treatments, and then demand them from
their physicians. On the other hand, gov-
ernments are getting smart. Stemming de-
mand won’t be easy. But curtailing supply is
possible. How? By exacting new guidelines
and regulations designed to lower the cost
of procuring advanced drugs and medical
technologies and insisting upon improved
efficacy and reliance of these products.

58 Asian Hospital & Healthcare Management ISSUE-11 2006


in new hospital technologies, surgical
procedures, and leading edge prescription
drugs, resulting in soaring annual health-
care spend. In an attempt to stem the he-
morrhaging of healthcare budgets, a new
wave of strict procurement and regulatory
changes are forcing suppliers to share the
burden.
Expired, defective, or inappropriately
handled reagents can mean the
difference between a correct and
incorrect diagnosis, and in some cases,
the life or death of a patient.
In short, the pressure is on. Consum-
ers, hospitals, physicians, and governments
are increasingly aligned against manufac-
turers of modern medical miracles, and the
era of passive sales to local distributors is
rapidly drawing to a close. The onus is now
on these global giants to both find ways to
lower the cost of sales to Asian buyers as
well as enhance the quality and efficacy of
their products.
One sound way to get started is to re-
think archaic supply-chains and distribu-
tion arrangements that traditionally have
kept manufacturers at arms length, and
left it up to distributors to manage the sale,
support, and delivery of medical products
to hospitals. There is ample evidence to
suggest that these traditional methods are
losing their vitality.
As a result, medical products manu-
facturers must search for the most cost-
effective, reliable answer. Take chemical
1. TNT, a specialist provider of life science logistics solu- of goods, and even when in-country dis-
tions, has seized the opportunity to modernise health-
care logistics supply-chains, offering manufacturers an
efficient, integrated supply-chain management with
end-to-end visibility. At TNT, we urge manufacturers
to consider a “direct ship” model where your existing
distributors manage hospital accounts, market new
products, invoice, and collect, but rely on a third-
party logistics provider, such as TNT, to coordinate
the physical distribution and inventory management.
TNT’s global network, leading edge IT platforms,
and professional workforce are best suited to ensure
your product’s integrity from point-of-manufacture to
point-of-use. Without the end-to-end visibility to your
product made possible by TNT’s integrated healthcare
supply-chain solutions, you may be in violation of a
growing litany of government regulations, and not
even know it, until it’s too late. For more on TNT’s life
science solutions in Asia see www.tntlifesciences.com
I N F O R M AT I O N TEC H N O L O GY
reagents as an example. The vast majority
of chronic diseases are revealed through
blood tests or other diagnostic methods,
and chemical reagents are the means by
which life-threatening diseases are tested.
Hospitals in the region (ex-Japan) pur-
chase an estimated US$ 30-40 million of
diagnostic reagents and instruments each
year. Expired, defec-
tive, or inappropri-
ately handled rea-
gents can mean the
difference between
a correct and incor-
rect diagnosis, and in
some cases, the life or
death of a patient.
So how are the
majority of these
critical, life-saving products handled to-
day when making their way from overseas
manufacturing centres to Asian hospitals?
Frankly, it varies.
In some markets with clear regula-
tions and careful monitoring, reagents are
delivered and, therefore, perform as in-
tended. But in developing markets, where
demand is outstripping government ability
to monitor procurement and use, there are
inevitable shortfalls in appropriate product
management, thus making the importance
of logistics all the more apparent.
For instance, maintaining reagents at 2-8
degrees Celsius is critical if the chemicals
are to perform their intended function.
Manufacturers typically take charge of
moving a product from a factory location
to an Asian port of entry, but after that, the
efficient handling of a product is anyone’s
guess. We know, for instance, that drugs,
devices and reagents can be held at Cus-
toms for days on end. On other occasions,
incorrect documentation can stall transfer
tributors do take ownership, controls on
product handling and expirations are un-
even at best, and dangerous at worse.
The good news is that new service so-
lutions and IT platforms are available to
track and safeguard your product from
point-to-point. RFID, or Radio Frequency
Identification, is one technology that is
proving both effective and cost-effective
(see sidebar).
Using RFID to Safeguard the
Integrity of Your Medical Products
In March this year, TNT Asia embarked
on a revolutionary new way to track and
monitor the distribution of chemical rea-
gents using RFID cold-chain technology.
As required by law in many countries
in the region, reagents must be maintained
at 2-8 degrees Celsius both in storage and
in transit in order to ensure that upon use,
these life-savings chemicals perform at
their optimal level.
Operating out of a medically-approved
Regional Distribution Center (RDC) in
Singapore, TNT has established a revolu-
tionary technique where battery-activated
passive RFID tags are carefully placed in
gel-packed and insulated boxes designed
specifically for chilled shipment of rea-
gents. The tags are activated at the RDC,
scanned again at the Singapore hub, and
programmed to “wake-up” and take a tem-
perature read every 30 minutes until reach-
ing its final warehouse destination at two
pilot locations: Shanghai and Bangkok.
By observing the performance of the
temperature-controlled boxes during the
2-3 day door-to-door transit period, we are
able to make adjustments to the packaging
by adding gel packs or layers of insulation.
The idea is to optimise the performance of
the packaging, while minimizing the cost
to our manufacturer customers.
One hundred shipments later, results
are promising. Not only is TNT able to
guarantee for the first time absolute tem-
perature integrity, but also we are doing our
part to raise awareness among distributors
and hospitals that have a vested interest in
ensuring reagents arrive at hospitals and
into labs in the best possible condition.
For TNT, RFID applications for
the Asia healthcare sector are unlimited.
What’s next? RFID readers strategically
placed in hospital storerooms in order to
allow remote inventory management and
auto-replenishment of surgical products.
These high-value products are typically
held on consignment by the world’s lead-
ing medical products manufacturers and
their distributors. With RFID at the hos-
pital level, gone are the days when patients
suffer because storerooms weren’t properly
replenished.
w w w . a s i a n h h m . c o m 59
 I N F O R M AT I O N TEC H N O L O GY
Medical Care
Wireless sensor networks
Wireless sensor networks are particularly relevant to preventative care offering patients the
potential to enjoy their home environment, minimise their time in hospital, improve their
quality of life and hopefully prolong their life expectancy.
Diana Hodgins
Managing Director
European Technology for Business Ltd
and
Project Co-ordinator
Healthy Aims
UK
T
he recent rapid advances in wire-
less communications, global digit-
al systems, microelectronics, nano
and micro-systems offer an ideal oppor-
tunity for major changes in medical care.
Organisations worldwide are now looking
to capitalise on these technology advance-
ments and move away from the conven-
tional medical approach where people visit
doctors and attend hospitals for treatment,
focusing mainly on treatment rather than
preventative care.
New opportunities now exist where
medical systems can be developed which
offer preventative care and focus on deliv-
ering this directly to the person at home.
An ultimate goal would be for people to
live their life with non invasive sensor sys-
tem monitoring critical parameters relevant
to their genetic make-up, lifestyle and any
medical condition they may have. Infor-
mation will be transmitted directly to the
health service provider for analysis and if a
change has occurred which requires an al-
teration to any drugs or possible treatment,
then the person is advised of this and the
necessary appointment made.
To complement this preventative care
monitoring will be advanced treatment.
This may, be in the way of intelligent im-
60 Asian Hospital & Healthcare Management ISSUE-11 2006
plants, minimally invasive surgery or drugs
designed specifically for individual’s own
genetic make-up.
Wireless sensor networks are particu-
larly relevant to preventative care, offer-
ing the potential for people to enjoy their
home environment rather than having to
live in care or nursing homes, minimise
their time in hospital, improve their qual-
ity of life and hopefully prolong their life
expectancy. Whilst we are still many years
away from the time when systems will be
made generally available, there are already
some pilot programmes developing. Once
the clinical efficacy of new medical systems
are demonstrated, these systems can be de-
veloped for general use.
Whilst this is likely to take up to 10
years to reach maturity and pass all the
necessary clinical trials, it is encouraging
that R&D programmes are pushing the
technology barriers and preparing the way
for many more medical systems in the fu-
ture.
Topics that push the boundaries of
technologies today are already in pilot clini-
cal trials. Example of this are included in
the Healthy Aims project1, an FP6 project
funded by the EC, to develop a range of
medical implants and diagnostic systems for
a range of applications. Examples that could
realistically reach pilot trials within the four
year project were chosen. These include:
Glaucoma sensor which can be
worn like a contact lens
Glaucoma is where the pressure in the
eye is so high that it damages the retina
and can ultimately cause blindness. This
new system monitors the change in cur-
vature of the eyeball which results from a
Image-1
build-up of pressure and this data can be
transmitted directly to the health advisor
(Image-1). An alarm will be triggered
when the pressure reaches an unacceptably
high level and the person would be called
in for treatment. Currently, the only means
of monitoring pressure is at the ophthal-
mologist where a spot pressure reading can
be taken. This proposed new system will
enable measurements to be taken over a
24 hour period and on a regular basis. It
is hoped that those people suffering with
glaucoma would all be provided with their
own wireless system and be regularly
monitored, ideally, preventing
blindness.
Intra-cranial pressure sensor
system
This pressure sensor system would
be permanently implanted and
pressure readings taken remotely on
a regular basis (Image-2). The data
would be transmitted to the health
provider and if the pressure exceeds
the alarm threshold, then the person
would be called in for immediate
treatment. The pressure sensor
needs to be stable for a lifetime
as once implanted it should
never be disturbed. Example
applications include hydro-
cephalus patients fitted with a
shunt to drain excess fluid from
Image-2

the brain cavity. If the shunt blocks then
the pressure can reach dangerously high
levels that can result in death.
Body worn inertial unit for human
motion detection
This example shows a person being moni-
tored whilst on the ‘BalanceMaster’2. This
machine has been designed specifically to
help people improve their balance. The
sensor system is used to ascertain how they
respond to treatment.
On-the-body sensor
systems can be used to
monitor a range of con-
ditions. For the elderly,
this could include mon-
itoring their balance and
ultimately determining
if they have fallen. They
can also be used to trig-
ger intelligent implants,
(for example, the upper
limb FES under devel-
opment in the Healthy
Image-3
Aims project).
Sphincter sensor
The human body has a number of sphinc-
ters which, if they fail, can cause embar-
rassment, discomfort or in extreme cases
death. For example the oesophagea sphinc-
ter is at the top of the stomach. If this par-
tially fails, then conditions like heartburn
can occur and if not treated this can ulti-
mately result in cancer of the oesophagus.
Using the sphincter sensor to monitor if
the sphincter has fully closed would enable
to correct treatment to be given to those
that require minimally invasive surgery.
This is just a selection of sensor sys-
tems that can be used to monitor differ-
ent aspects of a person’s health. There are
many more products under development
by clinical groups and medical device com-
panies both in the EU and worldwide. (For
example, a large niche market includes
people suffering with urinary incontinence
who are fitted with catheters). The Biomed
HTC3 in Bristol, UK, is guiding the de-
velopment of new diagnostic equipment
and medical devices to help improve the
quality of life and reduce hospital costs of
patients.
Intelligent implants that improve the
quality of life for people who have lost
I N F O R M AT I O N TEC H N O L O GY
specific functions are also being developed.
Some of these are within the Healthy Aims
project, namely:
• Retina implant to provide minimal sight
to blind people
• Cochlear implant to provide sound to
deaf people
• Functional stimulation to enable muscles
to be activated when the nervous system
has failed. Examples include upper limb
motion, bladder and bowel control.
The development of intelligent medi-
cal devices like those described above re-
quires the integration of a range of core
technologies. At the generic level, these are
equally applicable to a range of diagnostic
systems and intelligent implants that could
be envisaged within the next twenty years.
These include:
• Wireless communications, in and on the
body
• Mobile communications
• Power sources, implantable for in-the-
body applications
• Biomaterials, particularly for in-the-
body applications
• Nano and micro-systems and nano elec-
tronics, particularly to provide nerve
stimulation within the body
The 2 electrode designs shown in
images 4 and 5 utilise micro and nanote-
chnology, with both having features in the
order of microns, substrates down to 10
microns and electrode density constantly
Image-4
being driven down in order to improve the
performance of the implant. For example
the modulus electrode shown in figure 4 is
used to trigger the nerves in the inner co-
chlear stem to improve hearing whereas the
electrodes in image 5 are used to trigger the
ganglion cells at the back of the retina.
It needs to be recognised and under-
stood that whilst generic technology devel-
opment is an essential part of any early stage
R&D project, once the work progresses to
the detailed design and fabrication level
the work becomes product-specific. For ex-
ample, the electrodes in images 4 and 5 use
different substrate materials, the electrode
structure and topology is different as are
the interconnects to the electronics. Thus
generic technology development can only
be taken so far before specific design and
fabrication work is required.
The Healthy Aims project is an ex-
cellent example of how a selection of key
people across Europe can form together to
turn an academic road map for implants
and diagnostic equipment into reality. A
limited amount of core technology devel-
opment is included. However, the majority
of the work is focused on the integration
of technologies to produce new medical
products that are suitable for pilot clinical
trials.
In the future, in order to be able to
build upon the work already under way
in the medical sector and generate criti-
cal mass in the area of medical care strong
leadership from major medical organisa-
tions and national governments across
the EU and worldwide is required. Infra-
structures need to be put in place that can
handle data from a range of sensor systems,
medical implants and in the future drug
delivery systems. Formulating strategies
at the international level will stimulate
demand for new systems and encourage
innovations across the medical sector. For
this to be done effectively and efficiently,
road maps should be developed for both
the ‘Business systems’ and the ‘Products’.
Image-5
This approach is now being recognised
within the EU as necessary when address-
ing major challenges such as the ‘Future
healthcare in Europe’ and leading tech-
nologists and business groups are formu-
lating their own future strategies around
such models.
The questions yet to be answered
are based around how well the tech-
nologists, clinical experts, purchasing
groups and national bodies can work to-
gether to enable medical systems that are
technically feasible to be commercially
available within the next twenty years.
References:
1 Healthy Aims is a 26M€ EU funded project under the
IST FP6 programme. It has 27 partners from across
the EU, six of whom are SMEs. www.healthyaims.org
2 BalanceMaster is the trademark for the equipment
shown. www.balancemaster.co.uk
3 Biomed Health Technology Co-operative is an organi-
sation of patients and carers, health professionals,
industry and academia concerned with improving
continence management of elderly and disabled people.
www.biomedhtc.org.uk
w w w . a s i a n h h m . c o m 61
Product Showcase

COMPANION III
T he Companion III is an advanced Transcranial Doppler system that provides non-in-
vasive assessment of blood flow in the major arteries in the brain and throughout the
body, including evaluation of numerous neurologic vascular problems such as vasospasm,
and intra-cranial stenosis. The portability and light weight of the Companion III make it
extremely valuable in the ER, OR and bedside locations in the hospital, clinic or in everyday
office use.
The system has an integrated TFT and a convenient touch screen control panel. Data
acquisition is done easily via our latest version 3.7 of WinTCD software and NicVue patient
database. Data storage is a breeze with a sizeable hard drive and an integrated CDR/RW
drive. The Companion III offers you everything you could ask for in a portable TCD ma-
chine: probes ranging from 1.6 to 20MHz, color M-Mode display, pre-programmed diag-
nostic protocols or advanced monitoring and trending capabilities.

PIONEER TC8080

O ur Pioneer TCD system allows non-invasive assessment of the major arteries at the
base of the brain as well as most arteries throughout the body. Transcranial Doppler
applications include: detection of intra-cranial stenosis, detection and serial tracking of va-
sospasm, evaluation of Patent Foramen Ovale (PFI), intra-operative monitoring for changes
in blood flow or potential embolic events during cardiac and Carotid artery surgery. Stand
out features on the Pioneer include up to 4 simultaneous channels of Doppler, multi-depth
options, the original SoundTrakTM utility, power and color Doppler M-Mode and a choice
of quality 1.6, 2, 4, 8, 16 and 20MHz to suit practically every Doppler requirement.
The Pioneer operates on Windows XP using the latest version 3.7 of our proprietary
WinTCD software. Networking capabilities and our exclusive NicVue patient management
software allow communication with other VIASYS products for seamless data integration of
multiple systems and labs. The Pioneer is powerful and flexible yet remains user friendly.

VasoGuard II
V asoGuard II non-invasive vascular testing system delivers features you will not find
elsewhere: Transfer Function Index (TFI), QuickConnect arm for cuff attachment, up
to 10 channels of simultaneous Pulse Volume Recording (PVR) measurements and four-
channel PPG probes operating simultaneously. Our proprietary software makes the Va-
soGuard easy-to-use, combining intuitive commands with on-screen instructions and an
on-line manual. All requested calculations for Doppler spectral waveforms appear on the
screen at the touch of a button: rise time, maximum frequency, maximum velocity, pulsatil-
ity index and resistance index.
VasoGuard Autopick function allows the user to automatically select the moment when
the pulse returns in a pressure study making the test virtually effortless. VasoGuard offers
a variety of ways to store your data: a large hard drive and a built in CDR/RW drive. Net-
working capabilities, our exclusive NicVue patient management and Reader Station soft-
ware allow for seamless data integration into HIS and remote review.

Further information
Web: www.viasyshealthcare.com

62 Asian Hospital & Healthcare Management ISSUE-11 2006

ZOLL AutoPulse Non-invasive Cardiac Support Pump
References:

T he AutoPulse®—the only device of its kind—delivers the consistent, uninterrupted

chest compressions that new AHA/ERC Guidelines are calling for. It is an automated,
portable device with an easy-to-use, load-distributing LifeBand® that squeezes the entire
chest, improving blood flow to the heart and brain during cardiac arrest.1-3 Additionally, it
offers the benefit of freeing up rescuers to focus on other
life-saving interventions.
A recent independent study4 conducted in the United
States, using the AutoPulse, showed that survival rates of
cardiac arrest patients dramatically improved when treat-
ed with an automated CPR device, versus manual CPR,
prior to reaching the hospital. Data showed a survival-to-
hospital-discharge rate of 9.7 percent using automated
CPR, versus 2.9 percent using manual chest compres-
sions. There was also a 71 percent higher rate of return
of spontaneous circulation with the use of the AutoPulse
than with conventional CPR
1. Timerman S et al. Improved hemodynamic perform-
ance with a novel chest compression device during
treatment of in-hospital cardiac arrest. Resuscitation.
2004;61:273-280.
2. Halperin HR et al. Cardiopulmonary resuscitation
with a novel chest compression device during a porcine
model of cardiac arrest. Journal of the American Col-
lege of Cardiology. 2004;44(11):2214-2220.
3. Ikeno F et al. Augmentation of tissue perfusion by a
novel compression device increases neurologically intact
survival in a porcine model of prolonged cardiac arrest.
Resuscitation. 2006;68:109-118.
4. Ong MEH, Ornato JP, Edwards D, et al. Use of an
automated, load-distributing band chest compression
device for out-of-hospital cardiac arrest resuscitation.
JAMA. 2006;295:2629-2637.
Further information
Web: www.zoll.com

Eliminate blood toxins with MARS®

T he MARS® (Molecular Adsorbents Recirculating System) liver support therapy is a

therapy for treating various types of liver failure. This procedure may be required in
cases of acute liver failure, but also in cases of decompensation of a chronic liver disease.
In liver failure, blood detoxification carried out by the liver is severely compromised and
albumin-bound toxins accumulate. The MARS® therapy permits the extracorporeal removal
of these toxins via an albumin dialysate though a special membrane, thus eliminating them
from the blood.
The MARS® system combines the benefits of extracorporeal renal substitution thera-
pies with the possibility of removing albumin-bound substances: both water-soluble and
albumin-bound toxins of small and medium size can be removed from the blood selectively
and in a single step. To date about 5000 patients worldwide have undergone the MARS®
Therapy with over 120 publications and 130 MARS® centres.

Further information
Tel: +852 2576 2688 Website: www.gambro.com

Cefepime and Amikacin

C ombination of these two different antibiotics act synergistically to provide total solu-
tion against multi resistant bacteria like P.aeruginosa, S.aureus etc. The main advantag-
es of this combination: Wide range of bactericidal activity, better efficacy, safety, lesser dose,
least nephrotoxicity, minimization in development of resistance, reduction in hospitaliza-
tion time and cost. Our organization - VENUS REMEDIES is in grant of a patent for this
drug combination as a single compound which can be administered parentally. Our product
exists as a dry powder form which is reconstituted before injection with a suitable solvent,
after reconstitution it is sterile, colourless to light straw coloured with pH in range of 3.5
to 6. It is preferably twice a day product depending on the patient condition and severity
of infection, Average period of treatment is 9 to 10 days. It is provided in a sealed container
such as transparent glass vial capped with appropriate halogenated stopper and seal.

Further information
Web: www.venusremedies.com

w w w . a s i a n h h m . c o m 63
Products & Services
Company Page No. Company Page No. Company Page No.

Anaesthesiology Elekta Ltd 26 Synthes Asia Pacific IBC2

Gambro China 16 Faber Medi-Serve Sdn Bhd 49 Venus Remedies Ltd 02
Mediaid Inc 53 Gambro China 37 Viasys Healthcare Inc OBC3
Medima Ltd 19 Medima Ltd 19
Synthes Asia Pacific IBC2 MFD Diagnostics GmbH IFC1 Technology, Equipment & Devices
Unomedical Pty Ltd 51 Radicare (M) Sdn Bhd 47 Apel Co Ltd 45
Synthes Asia Pacific IBC2 APS Medical 21
Cardiology Unomedical Pty Ltd 51 Dometic S.à.rl 06
Eurosets s r l 39 Venus Remedies Ltd 02 Ekol Medikal 44
Gambro China 37 Elekta Ltd 26
Venus Remedies Ltd 02 Healthcare Management Eurosets s r l 39
Viasys Healthcare Inc OBC3 Banyan Hope Sdn Bhd 09 Gambro China 37
ZOLL Medical Corporation 04 Faber Medi-Serve Sdn Bhd 49 Lifecare Surgical Instruments 24
Messe Düsseldorf China Ltd 11 Mediaid Inc 53
Diagnostics Saeplast Asia Ltd 06 Medima Ltd 19
Gambro China 37 MFD Diagnostics GmbH IFC1
Lifecare Surgical Instruments 24 Oncology PhenixVision 32
MFD Diagnostics GmbH IFC1 Elekta Ltd 26 Qiagen Sdn Bhd 30
PhenixVision 32 Venus Remedies Ltd 02 Synthes Asia Pacific IBC2
Qiagen Sdn Bhd 30 Toha Plast Gmbh 41
Radpharm Scientific 33 Surgical Speciality Unomedical Pty Ltd 51
Synthes Asia Pacific IBC2 Akyol Medical Textile Co Ltd 23 Venus Remedies Ltd 02
Viasys Healthcare Inc OBC3 APS Medical 21 Viasys Healthcare Inc OBC3
Dometic S.à.rl 06 ZOLL Medical Corporation 04
Facilities & Operations Eurosets s r l 39
Akyol Medical Textile Co Ltd 23 Gambro China 37 Information Technology
APS Medical 21 Lifecare Surgical Instruments 24 Gambro China 37
Dometic S.à.rl 06 Medima Ltd 19 ZOLL Medical Corporation 04

Suppliers Guide
Company Page No. Company Page No. Company Page No.

Akyol Medical Textile Co Ltd 23 Gambro China 37 Radicare (M) Sdn Bhd 47
www.eurodrape.com www.gambro.com www.radicare.com.my
Apel Co Ltd 45 Lifecare Surgical Instruments 24 Radpharm Scientific 33
www.apel.co.jp www.lifecaresi.com www.radpharm.com.au
APS Medical 21 Mediaid Inc 53 Saeplast Asia Ltd 06
www.apsmedical.com.au www.mediaidinc.com www.saeplast.com
www.optosystems.com.sg
Banyan Hope Sdn Bhd 09 Synthes Asia Pacific IBC2
www.osteomed.com.my
www.banyanhope.com www.synthes.com
Medima Ltd 19
Dometic S.à.rl 06 Toha Plast GmbH 41
www.medima.com.pl
www.dometic.lu www.toha-med.de
Messe Düsseldorf China Ltd 11
Ekol Medikal 44 Unomedical Pty Ltd 51
www.hospimedica-asia.com
www.ekolmedikal.com www.unomedical.com
www.hospimedica-thailand.com
Elekta Ltd 26 Venus Remedies Ltd 02
MFD Diagnostics GmbH IFC1
www.elekta.com www.venusremedies.com
www.mfd-diagnostics.com
Eurosets s r l 39 Viasys Healthcare Inc OBC3
PhenixVision 32
www.eurosets.it www.viasyshealthcare.com
www.phenixvision.com
Faber Medi-Serve Sdn Bhd 49 ZOLL Medical Corporation 04
Qiagen Sdn Bhd 30
www.mediserve.com.my www.zoll.com
www.qiagen.com

To receive more information on products & services advertised in this issue, please fill up the "Info Request Form" provided
with the magazine and fax it, or fill it online at www.asianhhm.com by clicking "Request Client Info"link.

1. IFC: Inside Front Cover 2. IBC: Inside Back Cover 3. OBC: Outside Back cover

64 Asian Hospital & Healthcare Management ISSUE-11 2006

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