Hospital News November 2018 by Hospital News

Special: Annual MEDEC Supplement Inside: From the CEO’s Desk | Evidence Matters | Product Spotlight | Nursing Pulse | Long-Term Care

November 2018 Edition

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Contents November 2018 Edition

IN THIS ISSUE: MEDEC DEC

▲ Cover story: Physician Innovators

▲ 3D model helps in complex surgery

5 ▲ Virtual reality helps wound care patiends

COLUMNS

36 12

Editor’s Note ....................4 In brief .............................7 Evidence matters ...........16 Nursing pulse ................46 Long-Term Care .............50 From the CEO’s desk .....58 Ethics .............................60 Product S potlight ............62

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▲ Hallway medicine

▲ 3D printer creates new opportunities for patients

Drug checking expanded in Vancouver

Accounting for pain beyond opioids It’s time to change what we measure when funding healthcare

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Editor

Kristie Jones

editor@hospitalnews.com Advertising Representatives

Denise Hodgson

denise@hospitalnews.com

By Michael Wolfson he prestigious Canadian Academy of Health Sciences annual meeting in Vancouver focused on chronic pain, and of course, the current catastrophe of opioid deaths was discussed. But most of the discussion was broader: What are the biological mechanisms underlying chronic pain? What are the experiences of those suffering from chronic pain? How could Canada’s healthcare deal with chronic pain much more compassionately and effectively? Pain is a difficult topic for Canada’s healthcare sector. It can arise from many diseases, but not always. For example, arthritis in a joint can be visible on X-rays and not cause any pain; but it can also be so painful as to completely disable an individual. Pain is subjective so that sufferers can be dismissed as wimps or malingerers. Science is only just beginning to find biological markers that can provide “objective” evidence that someone is really suffering from pain. But there’s another problem: we don’t take pain into account when assessing where to invest health sector research and delivery dollars. There are well-known adages that “you get what you measure” and “you cannot manage what you don’t

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measure.” Canada’s health sector is unfortunately informed by misleading life expectancy and cause of death statistics. We pay much less attention to the kinds of health burdens borne while we are alive – like pain. But we can change that. Canada, as most countries, has a league table of the most important health problems in the population based on the disease written on death certificates. But only recently, with the advent of high-quality population health surveys, do we now have good data on what makes us feel lousy while we are alive. Cancer and heart disease are number one and two on the health problem league table because they are the most frequent causes of death. Chronic pain does not register on this league table because it is generally non-fatal. Pain is not a “disease” in the lexicon of the medical profession; it is more often considered only a symptom of some “real” disease. And it does not have an obvious bodily location like heart or lung. But what if we used another indicator: health-adjusted life expectancy or HALE? This is like the usual life expectancy measure, with one major difference. Continued on page 7

Publisher

Stefan Dreesen

stefan@hospitalnews.com Accounting Inquiries

accountingteam@mediaclassified.ca Circulation Inquiries

info@hospitalnews.com

ADVISORY BOARD Barb Mildon,

RN, PHD, CHE VP Professional Practice & Research & CNE, Ontario Shores Centre for Mental Health Sciences

Helen Reilly,

Publicist Health-Care Communications

Jane Adams,

President Brainstorm Communications & Creations

Bobbi Greenberg, Health care communications

Sarah Quadri Magnotta, Health care communications

Dr. Cory Ross, B.A., MS.C., DC, CSM (OXON), MBA, CHE Vice President, Academic George Brown College, Toronto, ON

Michael Wolfson is a member of the Centre for Health Law, Policy and Ethics at the University of Ottawa and a Contributor with EvidenceNetwork.ca based at the University of Winnipeg. He was a Canada Research Chair at the University of Ottawa. He is a former assistant chief statistician at Statistics Canada. ASSOCIATE PARTNERS:

UPCOMING DEADLINES DECEMBER 2018 ISSUE

JANUARY 2019 ISSUE

EDITORIAL: Nov 10 ADVERTISING: Display – Nov 24 | Careers – Nov 28

EDITORIAL: Dec 1 ADVERTISING: Display – Dec 14 | Careers – Dec 18

Monthly Focus: Year In Review/Future Of Healthcare/Accreditation/ Hospital Performance Indicators: Overview of advancements and trends in healthcare in 2018 and a look ahead at trends and advancements in health care for 2019. An examination of how hospitals are improving the quality of services through accreditation. Overview of health system performance based on hospitals performance indicators and successful initiatives hospitals have undertaken to measure and improve performance.

Monthly Focus: Professional Development/Continuing Medical Education (CME)/ Human Resources: Continuing Medical Education (CME) for health care professionals. Human resource programs implemented to manage stress in the workplace and attract and retain health care staff. Health and safety issues for health care professionals. Quality work environment initiatives and outcomes. + Professional Development Supplement

THANKS TO OUR ADVERTISERS Hospital News is provided at no cost in hospitals. When you visit our advertisers, please mention you saw their ads in Hospital News. 4 HOSPITAL NEWS NOVEMBER 2018

Hospital News is published for hospital health-care professionals, patients, visitors and students. It is available free of charge from distribution racks in hospitals in Ontario. Bulk subscriptions are available for hospitals outside Ontario. The statements, opinions and viewpoints made or expressed by the writers do not necessarily represent the opinions and views of Hospital News, or the publishers. Hospital News and Members of the Advisory Board assume no responsibility or liability for claims, statements, opinions or views, written or reported by its contributing writers, including product or service information that is advertised. Changes of address, notices, subscriptions orders and undeliverable address notifications. Subscription rate in Canada for single copies is $29.40 per year. Send enquiries to: subscriptions@ hospitalnews.com Canadian Publications mail sales product agreement number 42578518.

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3D-printed model helps in complex surgery to remove 50 tumours By Season Osborne he uterus fits in the palm of Dr. Sony Singh’s hand. The large pink lumps inside the clear, plastic 3D-printed model are fibroids, or tumours, and there are more than 50 of them. To ensure his patient could carry a child in the future, Dr. Singh had to do something that had never been done before. Maureen had suffered for years with abdominal pain. Over the past six years, she was told by five doctors that she had so many fibroids in her uterus, her only option was to have a hysterectomy – complete removal of her womb. She refused this option.

3D PRINTING IS REVOLUTIONIZING THE WAY WE LOOK AT ANATOMY. “I will die with my womb. Nobody will touch it,” says Maureen (who did not want her last name used). She was referred to the Shirley E. Greenberg Women’s Health Centre at The Ottawa Hospital, where she saw the Minimally Invasive Gynecology team of doctors and nurses. Dr. Singh, a surgeon and the Elaine Jolly Research Chair in Surgical Gynecology, told Maureen he could remove all the fibroids, and she would not need a hysterectomy. Dr. Teresa Flaxman, Research Associate at The Ottawa Hospital, said it was difficult to see tumours in the patient’s uterus on an MRI. So, she contacted the hospital’s 3D Printing Lab.

With the opening of the lab in February 2017, the hospital became the first in Canada to have an integrated medical 3D-printing program for pre-surgical planning and education. “3D printing is revolutionizing the way we look at anatomy,” says Orthopaedic Surgeon and Oncologist Dr. Joel Werier, who has used 3D-printed models of his patients’ hips and bones since the lab opened. “It adds another perspective to how we view tumours, how we plan our surgery techniques, and our ability to offer precision surgery.” Bones are relatively easy to create from CT scans and MRIs, notes Dr. Flaxman. However, soft tissues, such as uterine tissue, is harder to identify, and a model hadn’t been made of one before. Dr. Flaxman and other researchers from the Women’s Health Centre worked with the lab to create 3D images from an MRI of Maureen’s uterus. Then the lab printed a model that allowed them to see exactly where the fibroids and the lining of the uterus were located. Dr. Singh successfully removed the fibroids, sparing Maureen from having a hysterectomy. “This model helped to provide a good visual aspect,” says Dr. Singh. “To have a model in my hands during surgery was incredible.” Dr. Adnan Sheikh, Director of The Ottawa Hospital’s 3D Printing Program said that, since this recent success, the lab is working on other similar projects with the Minimally Invasive Gynecology team to offer other women alternatives to major H surgery in the future. ■

Season Osborne is the Publications Officer at The Ottawa Hospital Foundation. www.hospitalnews.com

Holding the 3D-printed model of Maureen’s uterus, Dr. Sony Singh examined the MRIs and 3D renderings – the images that appear on the operating room screens that doctors can move to get a 3D view of the surgical area.

Researcher Dr. Teresa Flaxman (left) and surgeon Dr. Sony Singh worked with the 3D Printing Lab to create a 3D model of the uterus.

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IN BRIEF

Opioids Continued from page 4 Instead of simply counting years as either alive = 1, and dead = 0, we count only years in full health = 1. Periods of life spent being mobility impaired or in chronic pain would count somewhere in between 0 and 1. In other words, for HALE, we count years in less than full health as positive, but not as highly as years in full health. There are well-accepted ways to derive the numerical values to be given to living with this or that health problem. If we do this, non-fatal health problems like chronic pain and mental illness rise dramatically in the health problem league table. For example, the burden of arthritis (musculo-skeletal diseases) among women becomes their number one health problem, ahead of breast cancer, lung cancer and heart disease. Instead of using diseases, we can also measure health problems defined in non-technical terms that everyone can understand: Can you see? Are you able to move around? Do you have problems remembering? Do you suffer from chronic pain? While this switch from biomedically defined diseases to more ordinary vernacular descriptions of health problems may seem innocuous, it actually has profound implications for health care. Doctors are generally trained to diagnose and treat diseases. With clinical specialization, this orientation has become ever more siloed. The cardiologist sees a patient in terms of their heart function, while a rheumatologist sees their joints. They may only see the patient’s pain secondarily. If we use HALE as our measure, and look at the impact of chronic pain from whatever source (or no obvious source at all), it is about four times as large as the two most common causes of death – heart disease and cancers. If we allow our analysis to be more sophisticated to look also at the impacts of risk factors like tobacco smoking and obesity, chronic pain is still many times larger in its impact. It’s time for our Health Ministers to start publishing and acting on the right indicators if they want to address the real experienced health H burdens of Canadians. ■ www.hospitalnews.com

Common arthritis medications

routinely prescribed to high-risk patients

early 10 per cent of patients considered to be high risk with existing heart or kidney conditions, who see their family doctor with a musculoskeletal disorder like back pain are prescribed common arthritis medication that could cause them harm or complications, according to a new study by researchers at the Institute for Clinical Evaluative Sciences (ICES) and Women’s College Hospital (WCH). Nonsteroidal anti-inflammatory drugs (NSAIDs) represent one of the most common classes of medications used worldwide, with an estimated usage of more than 30 million per day. NSAIDs are commonly prescribed and effective for the treatment of musculoskeletal pain and are commonly used for arthritis. NSAIDs are not recommended for people with heart failure, chronic kidney disease and high blood pressure. “International guidelines recommend against prescribing NSAIDs to patients with high blood pressure, heart

NSAIDS ARE NOT RECOMMENDED FOR PEOPLE WITH HEART FAILURE, CHRONIC KIDNEY DISEASE AND HIGH BLOOD PRESSURE. failure and chronic kidney disease but our findings show that these common medications are routinely prescribed with widespread provider-level variation,” says Dr. Sacha Bhatia, lead author on the study and ICES adjunct scientist. The study published in JAMA Internal Medicine, used administrative data housed at ICES, and included more than 2.4 million primary care visits for a musculoskeletal disorder involving nearly 815,000 patients aged 65 or older with a history of high blood pressure, heart failure and/or chronic kidney disease from 2012 to 2016.

The researchers found: • NSAIDs use was observed following 9.3 per cent of visits. • Prescription NSAID use ranged from 0.9 per cent to 69.2 per cent among more than 7,300 family doctors in Ontario. • A declining trend in prescription NSAIDs use over time, with an absolute reduction of 2.1 per cent during the study period. The researchers also found that short term NSAIDs use was not associated with higher risk of adverse outcomes at 30 days. “Considering present concerns regarding opioid use for non-cancer pain, the ability for physicians to prescribe NSAIDs to manage musculoskeletal pain in the short term could be an important clinical option in this patient population,” adds Bhatia. “Frequency and impact of prescription nonsteroidal antiinflammatory drug use among patients with hypertension, heart failure, or chronic kidney disease,” was published H in JAMA Internal Medicine. ■

New guideline provides comprehensive recommendations to manage heart disease he updated comprehensive C-CHANGE (Canadian Cardiovascular Harmonized National Guidelines Endeavour) guideline to manage cardiovascular disease will help primary care physicians across Canada provide better care for patients with, or who are at risk of, heart disease. The guideline, published in CMAJ (Canadian Medical Association Journal) updates the 2014 guideline, with 52 newly added or updated recommendations. “Patients often have multiple comorbidities, complicated by conditions such as stroke or myocardial infarction,” writes Dr. Sheldon Tobe, Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, with coauthors. “A disease-silo approach to care leads to the risk of fragmentation, overlooking treatable risk factors. C-CHANGE helps to promote pa-

tient care by bringing guidelines from multiple groups together, formatted so that members of the interprofessional team can collaborate to formulate a comprehensive treatment plan directed to patient priorities.” The guideline, developed by nine Canadian guideline groups, is based on the best available evidence and provides a single nationally recognized set of best practices for physicians to use across the country. New or updated recommendations include the following: • A new, lower threshold for treatment and blood pressure in highrisk patients with hypertension • Treatment of high-risk patients with dyslipidemia (high cholesterol) with statins to prevent cardiovascular disease (a risk-assessment should be performed in primary-care patients to avoid unnecessary pharmacologic treatment)

• Diabetes testing with a two-hour plasma glucose after a 75 g oral glucose tolerance test • Use of direct oral anticoagulants instead of warfarin for nonvalvular atrial fibrillation • Lifestyle changes, such as lower sodium intake, in people with hypertension and screening and advice on smoking cessation The guideline is aimed at primary-care providers treating adult patients who have, or are at risk of developing, cardiovascular diseases, such as hypertension, diabetes, high cholesterol, heart failure and stroke, as well as the risk factors for these conditions, including obesity, smoking and inactivity. “The goal of the C-CHANGE process is for all Canadian health care practitioners to have easy access to a comprehensive and usable set of harmonized guidelines,” write H the authors. ■ NOVEMBER 2018 HOSPITAL NEWS 7

NEWS

Earl Bakken 1924–2018

Celebrating Earl Bakken

Legendary Medtronic co-founder passes away in Hawaii edtronic co-founder Earl E. Bakken, a pioneer in medical technology whose inventions impacted the lives of millions of people around the world, passed away Sunday, October 21st in Hawaii. He was 94 years old. “All of us at Medtronic are saddened today by the news of Earl’s passing,” said Omar Ishrak, chairman and CEO of Medtronic. “Earl was a true pioneer in healthcare and his vision of using technology to help people still inspires us today. We are privileged to continue the work that he started over 60 years ago and we remain fully committed to all six tenets of the Mission that he crafted so many years ago.” Bakken turned a childhood fascination with electricity into Medtronic, the world’s largest medical device company. Along with brother-in-law Palmer J. Hermundslie, Bakken founded the company, which grew from a struggling operation in a Minneapolis garage to a multinational medical technology corporation. In the late 1950’s, Bakken developed the first external, wearable, battery-powered, transistorized heart

0 8 HOSPITAL NEWS NOVEMBER 2018

pacemaker, and commercialized the first implantable pacemaker in 1960. Medtronic grew rapidly from there; today its medical products and devices improve the lives of two people every second. And it all started because young Earl Bakken was fascinated by Frankenstein. In the early 1930’s, at age eight, Bakken and his friends regularly attended Saturday matinee movies at the Heights Theatre in Columbia Heights, Minn., not far from the present day operational headquarters of Medtronic. He remembered being captivated by actor Colin Clive’s portrayal of the mad scientist. “What intrigued me the most, as I sat through the movie again and again,” Bakken later recalled, “was the creative spark of Dr. Frankenstein’s electricity. Through the power of his wildly flashing laboratory apparatus, the doctor restored life to the un-living.” By age nine, Bakken’s fascination with electricity led to a phone system stretching across the street to a friend’s house. Later, among his many child-

hood inventions, he built a radio from a crystal set and a five-foot-tall robot that could blink and speak. At his confirmation in 1937, the minister told young Bakken to “use science to benefit humankind,” and that message resonated with him the rest of his life. “I recognized later that was my spiritual calling,” Bakken said in 2008. After serving as a radar instructor in World War II, Bakken earned a degree in electrical engineering at the University of Minnesota. In grad school, Bakken did parttime work repairing delicate lab equipment at Northwestern Hospital in Minneapolis. Demand for his services grew, and on April 29, 1949, Bakken and Hermundslie formed a business partnership and called their company Medtronic. The business struggled, but while servicing medical equipment, Bakken and Hermundslie built relationships with doctors at university hospitals in Minneapolis. There they met C. Walton Lillehei, a young staff surgeon who would later become famous for pioneering open-heart surgery. Follow-

ing a blackout in the Twin Cities that caused the death of an infant, Lillehei asked Bakken to come up with a solution. He responded by adapting a circuit described in Popular Electronics magazine to create the first external wearable, battery-powered pacemaker, replacing the large, alternating current-powered pacemakers that were in use at the time. They expanded services to other medical technology. Then in 1960, the first implantable pacemaker was implanted in a human patient. Bakken and Hermundslie reached a licensing agreement with the inventors, giving their small company exclusive manufacturing and marketing rights to the device, and Medtronic took off. Earl Hatten was employee number eight at the tiny company. “The thing I liked about Mr. Bakken, and the thing that I think helped Medtronic grow was that he had the ability to pick good people to do a job and then he got out of their way and let them do their job. A lot of CEOs can’t do that and the companies don’t grow,” Hatten said. www.hospitalnews.com

NEWS

Omar Ishrak and Earl Bakken

The garage where Medtronic began

Medtronic Operational Headquarters in Fridley, MN

Every Medtronic employee receives a medallion engraved with the Medtronic Mission

Through the decades that followed, Medtronic grew exponentially, refining its heart devices and expanding into other medical businesses such as diabetes treatment, brain surgery and spine therapy. The company now employs more than 86,000 people around the world. Bakken was at the helm for 40 years, retiring as Medtronic chairman in 1989. “We didn’t set out to be the world’s largest medical device company,” Bakken said. “We just wanted to make a lasting positive change in patients’ lives.” Bakken maintained close contact with the company throughout his retirement, and his legacy within Medtronic will forever be the Medtronic Mission. In 1960, Bakken wrote a mission statement for Medtronic that has remained intact, word for word, ever since. In part, it reads: “To contribute to human welfare by application of biomedical engineering in the research, design, manufacture and sale of instruments or appliances that alleviate pain, restore health and extend life.” “Earl always had a vision of healthcare of not being about devices, about drugs, but about restoring people to full health,” said former Medtronic CEO Bill George. “And so from the very start he was focused on not implanting a device, but enabling people to live a full active life and he delivered that point of view to all Medtronic employwww.hospitalnews.com

The Historic Heights Theatre in Columbia Heights in 2008

Former Medtronic CEO Bill George and Earl Bakken

Young Earl Bakken in the family basement

Earl at The Bakken Museum

ees through The Mission. Earl is one of the greatest visionaries in the history of medicine,” George said. In retirement, Bakken set out to fulfill that mission in new ways. In 1975, he founded The Bakken Museum, a nonprofit library, museum and education center in Minneapolis. The Bakken Museum is devoted to the history of electricity and magnetism and their uses in science and medicine. In 1994, Bakken built a home in Hawaii, where he became Chairman of the Board of Directors of the Five Mountain Medical Community as it developed the North Hawaii Community Hospital. He helped to establish Tutu’s House, a community resource center promoting careers, education, and effective health outcomes, and the Kohala Center, which concerns itself with scientific resources an education. Bakken was also involved in several other philanthropic ventures including the Na Kalai Waa Moku O Hawaii, Friends of the Future, and the Imiloa: Astronomy Center of Hawaii. A lifelong aspiration came true for Bakken in 2013, when Medtronic Philanthropy launched The Bakken Invitation to honor people who received medical devices, and who made an impact on the lives of others, through service and volunteerism. Bakken, who in his later years became a medical device

Earl Bakken working at the original Medtronic

Earl with Bakken Invitation recipients in 2013

Hunter Mauston poses with his external pacemaker

The Garage Gang Standing: Dale Blosberg, Norman Hagfors, Earl Hatten. Seated: John Bravis, Earl Bakken, Louis Leisch

Ron and Judy Brown with Earl Bakken

Earl with five-yearold pacemaker recipient Lyla Koch in 1984

patient, with a pacemaker, coronary stents and insulin pump, was fond of asking patients what they planned to do with their gift of “extra life.” Each year Bakken met with the honorees. “Their stories are a powerful reminder that we can all give back – no matter our current situation,” he said after meeting them in 2014. Every year in December, Medtronic employees gather to mark another Bakken inspiration – the employee holiday program. The company invites patients from all over the world to share their stories of how medical technology has improved their lives. Hundreds of employees fill the Medtronic conservatory for the event, while thousands of others listen or watch via Medtronic TV. Ron Brown, who received his first Medtronic pacemaker in 1972, was among the first patients to speak at the holiday program. Every year for 40 years, Bakken read Brown’s Christmas letter to the assembled employees. Brown and Bakken, patient and inventor, became friends. “The man has been an inspiration for so many young people,” Brown said in 2014. “I mean – to be around him is inspiring. You know that he’s constantly thinking and trying to solve problems and when he was developing the company, when he formed it, his thought of better health was always on his mind. And that inspiration for others to de-

velop that idea is as great as what he accomplished.” In his later years, Bakken was asked to reflect on his legacy. “When you put it all together and you see a person fully restored – physically mentally, spiritually – from what we have done. What better career could anyone think of?” H he said. Q Bakken was born to Florence and Osval Bakken on January 10, 1924, in Minneapolis, Minnesota. He is survived by his wife, Doris J. Bakken, sister Marjorie Andersen of Avon, IN, children Wendy Watson and husband Warren of New Brighton, MN, Jeff Bakken and wife, Linda Shaw of Orono, MN, Bradley Bakken and wife Mary of Orono, MN, Pamela Petersmeyer and husband Jeff of Prior Lake, MN, step-children Ramona West of Waikoloa, HI, and David Marshall and wife Linda of Rice, MN, eleven grandchildren, three stepgrandchildren, and eight stepgreat-grandchildren. Medtronic will host a program for employees to celebrate Bakken’s life and accomplishments. A date has not yet been set.

NOVEMBER 2018 HOSPITAL NEWS 0 9

NEWS

Pharmacogenomics Providing the right drug to the right patient at the right dose, at the right time By Catalina-Lopez Correa

AFFORDABILITY MAKES PRECISION HEALTH MORE ACCESSIBLE The ‘one-size-fits-all’ approach to healthcare is nearing an end ushering in the era of precision. The future of healthcare lies in harnessing the power of molecular approaches embodied in modern genomics. Today, sequencing the human genome costs around $1000 and it can be done in just a couple of days. It is predicted that advancements in the technology over the next few years will enable our genome to be sequenced in a matter of hours for $100 – a feat that was unimaginable just ten years ago. The lower cost and increased access to genome sequencing is already helping to improve diagnosis, treatment and disease management for patients touched by cancer, heart disease, autism, epilepsy, rare diseases and other debilitating diseases. Societal attitudes toward genomics in clinical care are also shifting. We are no longer asking ‘if’ genomics should be integrated with clinical care. Instead we are asking ‘when’ and ‘how’ genomics can be applied to benefit as many people as possible. When patients are matched with diagnosis and treatment specific to their individual disease or “omic” information, medical practice becomes much more precise. Individual patients are provided a greater chance of better health outcomes than if they were subjected to diagnoses and treatment strategies based on the generalized data collected through observation of patient populations.

WHEN PATIENTS ARE MATCHED WITH DIAGNOSIS AND TREATMENT SPECIFIC TO THEIR INDIVIDUAL DISEASE OR “OMIC” INFORMATION, MEDICAL PRACTICE BECOMES MUCH MORE PRECISE. PHARMACOGENOMICS IS A GAME CHANGER

either react or respond to treatment has become much more accessible.

We know that the use of medication in modern medicine has revolutionized healthcare and made a significant impact on patient longevity and quality of life. We know there can be individual variability in a patient’s response to drug treatment – the same treatment doesn’t always work in patients with similar conditions. And we also know that many medications can cause unintended side effects, known as adverse drug reactions (ADRs). What is now becoming much clearer is the role our genes and genetics play in predicting drug response. The discipline of pharmacogenomics uses an individual’s genetic profile to understand whether a person will benefit from a particular medication or suffer serious side effects. While science has yet to discover all there is to know about the workings of human DNA, some of the specific genes that determine a person’s response to drug therapy are well documented. Now that sequencing DNA is no longer cost-prohibitive, analyzing the genes that impact how a patient will

THE STAKES ARE HIGH In Canada, patients experience significant preventable ADRs, which account for approximately 1.6 million (12%) of emergency department visits, and 1.2 million (5%) of hospital admissions. Some studies even attribute up to 25 per cent of all hospital and emergency room admissions to medication-related illnesses according to the Canadian Institute for Health Information (CIHI). CIHI also reports that, people over the age of 65 are five times as likely to be hospitalized due to an adverse drug reaction. It is estimated that ADRs cost Canadians upwards of $14 billion annually, placing a significant burden on the healthcare system. Furthermore, these numbers don’t account for costly and inefficient prescribing for people who simply aren’t benefiting from a drug therapy. The lack of efficacy for a drug may not always lead to severe ADRs, but prescribing treatments for patients who will not benefit is a waste of limited healthcare dollars. A recent economic evaluation

indicated that ‘pharmacogenomics guided treatment can be a cost-effective and even a cost-saving strategy. Having genetic information readily available in the clinical health record is a realistic future prospect and would make more genetic tests economically worthwhile.’ Pharmacogenomics can also play an important role in pre-screening for efficacy of a patient’s response to a drug therapy where high cost drugs are the prescribed treatment. Considering the extremely high cost of some drug treatments (e.g. a 12-week therapy for Hepatitis C can cost as much as $68,000 US per patient), pre-screening can save millions of dollars by avoiding treatments that would have no benefit to the patient.

MOVING TOWARD CLINICAL APPLICATION The time seems right to move toward the adoption of pharmacogenomics as a standard of care. Toward this goal, Genome BC, in cooperation with BC’s Ministry of Health, is exploring opportunities to illustrate the effectiveness of pharmacogenomics within BC’s public healthcare system. This three-phase initiative seeks to advance the clinical implementation of pharmacogenomics in British Columbia. Phase I and II will outline the anticipated resources and infrastructure while developing a robust business case and a detailed study design. Phase Ill would initiate a project focused on evaluating the potential pharmacogenomics has to improve health outcomes for mental health patients in British Columbia and improve cost-effectiveness within the healthcare system. Pharmacogenomics clearly has a role to play in most disease areas. The expertise, infrastructure and economic analysis developed through this pharmacogenomics initiative should help to advance the broader clinical implementation of genomics in other areas of importance, such as oncology, rare diseases and infectious diseases. The potential for improving healthcare delivery in Canada is enormous, but more H importantly, patients will benefit. ■

Catalina-Lopez Correa is Chief Scientific Officer and Vice President, Sectors at Genome British Columbia. 10 HOSPITAL NEWS NOVEMBER 2018

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Virtual reality helps ease the pain for wound care patients By Blain Fairbairn n a Canadian first, patients undergoing wound care procedures at Calgary’s Rockyview General Hospital are now using a virtual-reality program to help ease pain and anxiety. Using one of two Samsung Gear headsets funded by an anonymous donor, wound care patients are transported to an immersive, three-dimensional environment that includes a virtual lakeside campground, a prehistoric landscape with dinosaurs and a tranquil ocean to swim with dolphins. Graydon Cuthbertson used the therapy three times after having multiple surgeries involving his calves. “It’s a godsend,” says the 47-year-old Calgary man. “Even with painkillers, the first time I had wound care after my surgery, the pain was excruciating. But with virtual reality, I got through the next treatment with flying colours. “I was focused on what I was seeing and hearing, and not thinking at all about how painful it might be. All of a sudden, one-and-a-half hours go by and it’s all over. It was awesome.” Virtual reality’s visual and auditory experience has been clinically proven to be effective in reducing pain and anxiety reported by patients. The team leading the initiative at the hospital was inspired to investigate the therapeutic benefits of virtual reality after reviewing studies on its effectiveness from a pilot program conducted by Cedars-Sinai Medical Center in Los Angeles. While virtual reality has been used in clinical settings around the world for a variety of therapeutic and relaxation purposes, Rockyview General Hospital is the first hospital in Canada to employ the technology for wound care patients.

Photo credit: Blain Fairbairn.

Physiotherapists Jaclyn Frank, left, and Jane Crosley, right, help patient Graydon Cuthbertson take his mind off a painful wound care procedure thanks to virtual reality.

VIRTUAL REALITY’S VISUAL AND AUDITORY EXPERIENCE HAS BEEN CLINICALLY PROVEN TO BE EFFECTIVE IN REDUCING PAIN AND ANXIETY REPORTED BY PATIENTS

During the research phase at the hospital, patients receiving wound care were asked to rate their level of discomfort and overall experience using surveys administered before and after virtual-reality therapy. Patient discomfort included ratings of pain, nausea and anxiety while measures of patient experience included feelings about future treatments and overall impression. The results were impressive: All patients who used virtual reality found it helpful. Patients reported a 75 per cent reduction in patient discomfort with a 31 per cent improvement in overall patient experience. Unlike conventional pain and anxiety-reduction therapies, such as painkillers or sedatives, no side effects were reported by patients who used virtual-reality therapy. While the program is not intended to replace

pharmaceutical interventions, it’s anticipated virtual reality can be widely used as a complementary therapy that may reduce dependency upon drugs to enhance patient care. “Rockyview’s virtual reality program illustrates how AHS employs innovative technology to improve patient care,” says Christopher Burnie, allied health manager at the hospital. “Technology has always played an important role in healthcare but this is particularly exciting in that we can make a really positive impact on a patient’s experience without having to invest in something costly or complex. Interestingly, we’ve also seen how the therapy benefits staff. When surveyed, wound care staff described lower levels of distress while they delivered treatment because they know their patients are much more comfortable.”

In addition to wound care patients, the virtual-reality program is also being tested on patients in the hospital’s intensive care and cardiac care units. Comprehensive criteria have been developed by the researchers and clinicians to ensure patients are suitable candidates for the therapy. Those who qualify can choose from 12 curated virtual reality experiences currently offered by the hospital. Rockyview recently announced a second donor has come forward with a gift to fund the purchase of two addition virtual-reality headsets and phones. This newest donor was inspired to give because, as a cancer patient, she can relate to living in pain and she wants to help ease discomfort for other patients if possible. Results from the virtual-reality study are being shared with other Alberta Health Services sites in the hopes the program may benefit patients across Alberta. Foothills Medical Centre’s burn unit is investigating the therapy for its patients and the program has received interest from the Royal Columbian Hospital H in New Westminster, B.C. ■

Blain Fairbairn is a Senior Communications Advisor at Alberta Health Services. 12 HOSPITAL NEWS NOVEMBER 2018

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Making patient and family voices central to care By Carla Wintersgill ave Fasano believes everyone has the responsibility to look out for those who can’t look out for themselves. That’s why most days he can be found at Runnymede Healthcare Centre, caring for his wife, Lori. That philosophy is also his motivation for taking on the challenge of co-chairing Runnymede’s Patient Family Advisory Council. Lori Fasano was 52 years old when she went into cardiac arrest in her Mississauga home. The resulting anoxic brain injury left her wheelchair bound. Communication is a challenge. While she can understand, she is unable to verbalize or express herself beyond limited movement. “Nothing’s been the same since,” Dave says. In his new role with Runnymede’s Patient Family Advisory Council, Dave is not just a voice for Lori, but an advocate for all patients at Runnymede. Runnymede’s new Patient Family Advisory Council is an unprecedented way for patients and families to influence care delivery and enhance the patient experience. The more formal meeting structure expands on the success of the long-running Patient Family Council. The Advisory Council will be made up of patients and family members who commit for a full year, with its leadership shared between a Runnymede staff member and a patient family member, who each serve as co-chairs. Lori and Dave met in a physiology course at the University of Manitoba. Their first date was November 19th 1979. Dave was 19 and Lori was just shy of her 19th birthday. They were married in 1983 and have two children, Scott and Alison. Lori studied pharmacy and steadily rose up the ranks to become a national leader in retail pharmacy. The family moved to Mississauga in 1997 and Lori managed Zellers’ slate of pharmacies. When Zellers was sold to Target, she moved into consulting.

Dave Fasano spends most days caring for his wife, who is a patient at Runnymede. He is co-chairing Runnymede’s Patient Family Advisory Council. Dave also worked in pharmaceutical consulting but when it became too much to juggle work and visits to the hospital, he opted for early retirement so he could better care for Lori. “It was not a decision,” he says about his choice to give up his career. “Lori was in the position where she needed someone to be her voice.”

14 HOSPITAL NEWS NOVEMBER 2018

“The idea behind the council is to effect what people see on a daily basis,” Dave says. “Through the change in structure, we’re able to better impact policy and procedure, and see changes that occur from input at the patient and family level.” By fostering longer-term relationships the new council provides partici-

pants with an opportunity to be a part of meaningful change and improve the quality and safety of healthcare services. Participants will be asked to share their stories, review information and educational materials and participate in short or long-term projects. “When the right people are involved, it can lead to a significant www.hospitalnews.com

NEWS change,” Dave says. “We are fortunate to be at Runnymede because of the quality of people who deliver care. But there are always opportunities to improve, and that is driven by involvement in the council.” Runnymede’s Patient and Family Advisory Council joins the hospital’s existing floor-based patient and family engagement committees as a forum for patients and families to actively engage in their healthcare by voicing their feedback. Through the Patient and Family Council and the patient and family engagement committee, participants can bring forward feeback on policies, education, resources, customer service, and safety. Patients and families have provided input on staff recruitment and their suggestions have paved the way for adopting technological solutions to their needs – Runnymede’s Vocera badges, which enable hands-free mobile communication, were implemented as a result of patients’ and family members’ expressed desire for enhanced staff communication. “Patients and families are part-

REAL-TIME DATA COLLECTION ENABLES RUNNYMEDE TO GATHER ONGOING FEEDBACK FROM PATIENTS AND FAMILIES ON AN HOURLY, DAILY OR WEEKLY BASIS SO THE HOSPITAL CAN CONSTANTLY ENHANCE THE PATIENT EXPERIENCE.

ners in their care at Runnymede,” says Sharleen Ahmed, vice president of strategy, quality and clinical programs. “The more avenues we can provide to hear from them and incorporate their thoughts and respond to their feedback, the more we can ultimately enhance the patient experience.” Patients’ and families’ voices are central to Runnymede’s patient storytelling initiative. Runnymede has adopted a video storytelling process as a means of improving quality through memorable staff education. Personal storytelling serves to make concepts real by putting patient faces and their

experiences to the standards of care. In its guide to using storytelling in healthcare improvement, The Health Foundation, a UK-based healthcare charity, notes that stories of real-life events are used because they are more memorable than data or lengthy manuals and speak strongly to frontline staff, who are often the most motivated by their individual interactions with patients. Facilitating instant family and patient feedback is another way Runnymede enhances patient care. Recently, Runnymede introduced real-time patient experience survey kiosks throughout the facility.

Real-time data collection enables Runnymede to gather ongoing feedback from patients and families on an hourly, daily or weekly basis so the hospital can constantly enhance the patient experience. It also offers the ability to measure patient satisfaction immediately and on an ongoing basis, as well as providing an opportunity for patients and visitors to provide feedback in a continuous, user friendly and accessible way. The system allows comments on service and care to be sent immediately to responsible departments so they can be addressed in a timely manner. While the survey responses are completely anonymous, patients and family members can choose to self-identify through a video testimonial feature on the survey. “We want to hear from patients and families and we want to respond to what they have to say,” Sharleen says. “Putting our patients and families first is what allows us to build on our excellent, patient-centred H care.” ■

Carla Wintersgill is a Communications Specialist at Runnymede Healthcare Centre.

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EVIDENCE MATTERS

Can artificial intelligence lead to better health? By Barbara Greenwood Dafour any of us already use artificial intelligence – or AI – in our daily lives. Voice-activated personal assistants answer our random questions, thermostats adjust to our home heating and cooling needs, and streaming media services give us personalized suggestions. While these forms of AI provide somewhat trivial benefits, AI could have a transformative effect on healthcare. AI involves the development of systems to perform tasks that normally require human intelligence, such as problem-solving, reasoning, and recognition. Rather than being explicitly programmed to perform a set of tasks, an AI system is programmed to learn from the data it receives and to perform tasks on its own according to what it has learned. This is also called “machine learning.” AI has the potential to improve patient care and the delivery of health services across a broad range of clinical specialties. The CADTH Horizon Scanning service recently looked at current and emerging uses of AI that have the potential to impact healthcare. CADTH is an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures to find out what the evidence says. Its Overview of Clinical Applications of Artificial Intelligence provides a synopsis of several AI innovations to watch. Clinical specialties that rely on the interpretation and analysis of images – primarily radiology, pathology, and dermatology – will likely be the first to experience large-scale change from AI. Studies suggest that AI may have the potential to interpret images as well as physicians can, and might also offer other advantages. Because it can process large amounts of data without lapses in memory, emotional response, or fatigue, AI could help prevent errors in image interpretation (which are es-

AI TOOLS ALSO HAVE THE POTENTIAL TO DIAGNOSE DISEASE EARLIER BECAUSE THEY CAN BECOME BETTER ABLE TO IDENTIFY SMALL VARIANCES NOT DISCERNIBLE BY THE HUMAN EYE. timated to occur three to five per cent of the time). AI tools also have the potential to diagnose disease earlier because they can become better able to identify small variances not discernible by the human eye. For example, AI has been shown to be able to identify certain characteristics of new lesions, such as border demarcation features, which are often subtle and difficult for a dermatologist to see. Similarly, AI could more efficiently track a patient’s response to treatment – for example, both detecting and recording changes in the size and density of tumours over time. AI

algorithms have also been developed that make predictions about disease progression and help determine the most effective treatment. Like voice-activated personal assistants, some AI applications use a combination of machine learning algorithms and natural language processing (which involves understanding and interpreting human language, either spoken or written) to simulate participant-clinician interactions. This is being explored as a way to deliver mental health initiatives. For example, when human moderators are not available, an online community for youth men-

tal health has used this type of AI to assess the sentiment and emotions of participants from their posts and recommend appropriate actions to them. Natural language processing systems can also be used to transfer a clinician’s written notes into electronic medical records and to interface with patients as an automated agent, responding to and asking questions. To reduce the risk of misdiagnosis, AI can be used to allow pathology images to be more easily shared with another lab for a second opinion. Similarly, AI can be used in telepathology so that physicians in rural and remote communities can more easily access and consult with specialized pathologists from a distance. There are also AI applications that can be downloaded to mobile devices so patients can scan their own bodies for skin moles — these applications identify moles that are suspicious and send images of them to a dermatologist for further analysis. Similar AI applications are also being used to diagnose acne, psoriasis, seborrheic dermatitis, and nail fungus. The ways that AI is being integrated into healthcare are many. The CADTH overview touches on several more applications of AI not covered in this article. But whether these technologies lead to better healthcare and better health outcomes will depend on how successfully AI can be implemented. The issue of how easily AI can be integrated into the existing healthcare system is often overshadowed by concerns around the privacy and use of personal information. Ensuring that personal data will be kept safe and secure and gaining the trust of the public is necessary if AI is to be successfully and widely adopted. If you’d like to learn more about CADTH or this horizon scan, visit www.cadth.ca. You can also follow us on Twitter @CADTH_ACMTS or speak to a CADTH Liaison Officer in H your region. ■

Barbara Greenwood Dafour is a knowledge mobilization officer at CADTH . 16 HOSPITAL NEWS NOVEMBER 2018

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NEWS

Sue Hickey with one of the bags lovingly created by the “bag ladies.”

The gift of the ‘Bag Ladies’ By Dahlia Reich ach assigned a specific task, 15 to 25 women sit in clusters at tables toiling all day long – well organized, perfectly choreographed and intensely focused. They cut, fold, serge, sew and snip, taking few breaks and churning out hundreds of brightly coloured garments designed and destined for a very specific – and special – customer. If not for the laughter and love, compassion and camaraderie in the room, there might be cause for concern. But it is the spirit of generosity that brings these women together, and their giving heart is stitched into every piece they create. They are known as the “Bag Ladies”

because they make fabric bags to hold the surgical drains and tubes required by breast cancer patients after surgery. The drains are inserted during surgery and remain for three to five days, sometimes as long as two weeks, post – operatively. The fabric bags, which can be worn on a belt, neatly contain the drainage containers and tubes making them easier and more comfortable for the patient to manage. The Bag Ladies are all members of the Canadian Embroiderers’ Guild, London, and the “sweatshop” is a cherished annual gathering that yields a vital supply of the bags for the Breast Care Program of St. Joseph’s

18 HOSPITAL NEWS NOVEMBER 2018

Health Care London. Every year, the Bag Ladies donate nearly 400 of the hand-crafted bags to the hospital. “The sisterhood of the Bag Ladies is amazing,” says Sue Hickey, long-time guild member and current organizer of the Bag Ladies outreach project. “It’s so rewarding. We feel we are making someone’s life easier and adding a woman’s touch, a dose of humanity and a splash of colour to the clinical and sterile hospital experience and recovery.” Breast Care Program staff and physicians see daily the difference the bags make for patients. “The kind generosity of the Canadian Embroiderers’ Guild offer a person-

al touch to our patients at a time when they may feel vulnerable and anxious,” says nurse practitioner Pat Baruth. “We are so appreciative of their contribution to our patient’s journey, which can be stressful at times.” Breast surgery can be very emotional, adds surgical oncologist Dr. Muriel Brackstone, Medical Director of St. Joseph’s Breast Care Program. “And having drains that hang out, get caught and constantly tug and hurt are an ongoing reminder that they are not the same as they once were. The bags are so convenient that patients rave about them to me, but I can see that it is more than the physical convenience of drain storage. www.hospitalnews.com

NEWS The fabric bags hold the surgical drains and tubes required by breast cancer patients, making them easier and more comfortable for the patients to manage.

BREAST CARE PROGRAM STAFF AND PHYSICIANS SEE DAILY THE DIFFERENCE THE BAGS MAKE FOR PATIENTS. It’s tangible evidence that other women who they have never met, care about them and wish them well in their recovery.” The Bag Ladies’ beginning dates back about two decades, when a guild member was diagnosed with breast cancer and underwent surgery. “She kept getting the tubes caught on door knobs, drawer handers and like projections,” says Sue. “She knew there had to be a better way – one that would be more comfortable and more aesthetically able to accommodate the paraphernalia. The first bag was conceived to suit the needs of this guild member, which received an enthusiastic response from the nurses and surgeon when they saw it.” Members of the guild set about mass producing the bags, which have

been modified over years as the drainage containers have changed. Relying on donations of unused fabric, the goal is to produce about 500 bags a year. While the majority of the bags are created during the annual, funfilled yet industrious sweatshop-style “Bag Ladies Day,” some guild members work on them at home all year long. Sue, who became a bag lady in 2013 and took over as lead bag lady in 2015, has some impressive credentials for the job. A fibre artist by training, she was a fashion designer in England and Ireland – even worked in the costume department of an opera company – and taught design at Fanshawe College before switching gears to become a law clerk, retiring in 2002. She runs a tight, sweatshop

ship with Bag Ladies Day carefully orchestrated to produce as many bags as possible. “The women come prepared to work hard but also to laugh and cheer our success,” says Sue, whose passion is also personal. Her mom was a breast cancer survivor who underwent a radical mastectomy nearly 40 years ago. The bag project, she says, “is one of the most rewarding things I have ever done.” At St. Joseph’s Hospital, every breast surgery patient with drains receives a bag lady bag, and each bag comes with a card clipped to the pocket with the group’s mission stated in a simple sentence: “Women supporting women, to rest, to heal, to become strong H again.” ■

Dahlia Reich works in Communication and Public Affairs at St. Joseph’s Health Care London. D

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Innovators Celebrating exceptional physician ingenuity in Canada all marks the time of year when Canada’s most entrepreneurial physicians are recognized and celebrated, all in the name of healthcare innovation. For the third year, Joule’s Innovation grant program shines a light on some of Canada’s most impressive innovations and those who dared to imagine them. The grants, which total $200,000 in flexible funding, are open to all the Canadian Medical Association’s 87,000 plus members. Along with early and later stage innovations, Joule’s grants support social innovations – initiatives that address a societal problem in a manner that improves the status quo, and for which the primary value created is to healthcare as a whole. This year, Joule widened the playing field by adding four new grants specifically aimed at medical students and residents.

Of 183 exceptional submissions, nine were chosen based on four weighted criteria: healthcare benefits, degree of disruption, relevance and scalability. The range of technology-driven solutions address a wide scope of issues ranging from gaps in quality of care and accuracy of diagnostics to clinician experience and training the next generation of physicians. Each of Joule’s nine 2018 grant recipients will use the grant funding to take their ventures to a new level and drive change in Canada and beyond.

CONAVI MEDICAL Improving tools, improving outcomes Open surgical procedures are becoming increasingly less common and are being replaced by minimally invasive techniques – however existing imaging modalities are often limited – in terms of visualization capabilities such as field of view, contrast and resolution, as well

20 HOSPITAL NEWS NOVEMBER 2018

as cost and deliverability to anatomic targets. To address these limitations, Dr. Brian Courtney and his team founded Conavi Medical, a medical device company that develops image guidance technologies for use in minimally invasive procedures. The company’s primary product offering is an intravascular imaging system, which combines catheter-based intravascular ultrasound (IVUS) and optical coherence tomography (OCT) onto a single catheter for use in coronary arteries. This system is the first technology to combine co-linear and co-registered IVUS and OCT, and the cost, image quality and catheter-size are comparable to standalone systems. Ultimately, Conavi’s goal is to be the world-leading provider of image guidance technologies for use in minimally invasive procedures so that they may be simpler, faster, safer and more costeffective.

CARETEAM A holistic approach to patient care Care fragmentation is a challenge in our current healthcare system. It is a headache for patients, families, providers and the whole care team, often resulting in poor outcomes. Dr. Alexandra T. Greenhill, physician turned tech entrepreneur, sought to address this gap by developing Careteam, a flexible communication tool focused on the patient and their support circle. An AI-enhanced digital health platform, Careteam enables patient-centered care collaboration and system navigation for patients, especially those with complex, chronic diseases. Working across different health conditions and contexts including hospital, clinic, community and home, the platform works to make sure everyone involved is on the same page – patients, families and health professionals. www.hospitalnews.com

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1. Dr. Brian Courtney, Conavi Medical 2. (l to r) The 16 Bit team: Dr. Mark Cicero and Dr. Alex Bilbily. 3. (l to r) The team from Careteam: Rob Attwell, cofounder COO Jordan Hiltunen, Dr. Alexandra T. Greenhill, cofounder CEO|CMO., Jeremy Smith, cofounder CCO, Shannon Skelley, Andy Theriault, Kris Goudie, Nick Baldwin. Missing from photo: Kevin Purcell, Ali Versi, Kevin Lysyk and Tolu Oloruntoba.

4. From left: The CODI Team; Jeffery Michael Harder, Dr. Donalk Burke, John Pawlovich and Dave Loewen. 5. Dr. Nada Gawad, My on Call Pager App. 6. The Lumina team: Robert Young, Tyler Lum, Jessica Ma, Eric Zhao, Purujeet Monga and Dr. David Agulnik.

7. Dr. David Benrimoh, Aifred Health. 8. The VitalEyes team: (l-r) Fonda Chau, Justine Sultan, Arielle Baldwin, Charles Choi, Laurenz Schmielau, Chris Yoon and Dr. David Agulnik. Missing from photo: Graden Deasey 9. Dr. Latif Murji, Stand Up for Health. As a whole, this collaborative platform reduces system costs and improves outcomes while increasing both patient and provider satisfaction – benefitting the quadruple aim.

CRITICAL OUTREACH & DIAGNOSTIC INTERVENTION (CODI) Better care in rural and remote areas Rural physicians are often faced with critical situations where they need additional support they simply can’t access. As a result, patients may get suboptimal care, rural physicians will get discouraged and exit the community, leaving many patients without a physician. To support rural physicians, Dr. Donald Burke and his team developed a service app called Critical Outreach & Diagnostic Intervention (CODI). CODI provides an on-dewww.hospitalnews.com

mand, virtual 24/7, immediate point of care service that connects rural physicians and intensivists in British Columbia. They can communicate via audio and video, even in areas of poor connectivity or reception. The CODI app aims to improve the confidence and skills of rural physicians to increase both their recruitment and retention – leading to better patient outcomes, fewer unnecessary hospital transfers and reduced healthcare costs.

AIFRED HEALTH Harnessing AI for better mental health treatment Depression is common, affecting over 300 million people worldwide. Despite the treatments available, clinicians often require multiple attempts before identifying an effective treatment for their individual patients.

Aifred Health, a company led by Dr. David Benrimoh, has developed a clinical decision aid as a response – harnessing the power of artificial intelligence (AI) to more accurately recommend optimal treatment for patients with depression. By training computer algorithms with evidence-based medical data to produce treatment decision aids, Aifred Health is supporting physicians to prescribe treatments more effectively. By way of precision medicine, Aifred Health aims to enhance the quality of mental healthcare services by improving patient flow and reducing patient recovery time, healthcare costs and clinician burnout.

MY ON CALL (MOC) PAGER APP A learning tool to support clinical excellence It’s estimated that 138,000 Canadians suffer adverse events due to

medical errors each year, of which approximately half involve errors in clinical decision-making. To address this challenge, resident physician Dr. Nada Gawad led the development of the My On Call (MOC) Pager App. As a real-time simulated pager program, it is designed to practice safe clinical decision-making. The MOC Pager App serves as a unique adjunct to clinical training and addresses the currently unmet need to practice and assess clinical decision-making across any discipline or stage of training. As the first and only simulated pager app, the MOC Pager App pushes the boundaries of technology in healthcare to support clinical excellence. Their ultimate goal is to improve patient safety. Continued on page 22

NOVEMBER 2018 HOSPITAL NEWS 21

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Celebrating exceptional physician ingenuity in Canada Continued from page 21

16 BIT Using data-driven intel for system efficiency Approximately one in eight women will be diagnosed with breast cancer in their lifetime. Mammograms are the current gold-standard for screening and are recommended on a biennial basis for women aged 50-74 in Canada. However, the majority of screening mammograms are normal or benign. Resident physician Dr. Alex Bilbily and his company, 16 Bit, undertook this challenge by developing the Intelligent Mammogram Triage System, capable of triaging screening mammograms with high negative predictive value. Through this initiative, should a mammogram be deemed normal or benign by the artificially intelligent system, a radiologist interpretation may no longer be required.

Such a system will decrease the cost associated with screening programs and the burden on radiologists, providing a means of creating widespread screening programs that are economically feasible.

STAND UP FOR HEALTH (SU4H) A learning simulation for the social determinants of health The common didactic approach to teaching can often leave learners with a superficial understanding of concepts such as the social determinants of health. Stand Up for Health (SU4H) is a not-for-profit organization – led by resident physician Dr. Latif Murji – that aims to use experiential learning to generate meaningful discussion and action surrounding the social determinants of health. Its cornerstone is an immersive simulation that places participants in

CNA introduces accreditation services With 110 years’ experience in providing credible continuing professional development (CPD) programs to nurses, the Canadian Nurses Association (CNA) is excited to now also offer accreditation services. This endeavour is part of CNA’s new direction to grow its programs, services and networks. Its aim is to support nurses so they can continue to make a real impact on the lives of Canadians. The CNA Accreditation Program helps nurses identify top-quality group-learning and self-assessment opportunities. It also gives external and partner organizations the opportunity to earn national recognition through CNA for their CPD programs, courses, conferences and activities. Eligible applications to the CNA Accreditation Program are carefully reviewed to ensure their learning and development objectives meet CNA’s accreditation standards. Applications that satisfy all the requirements will be assigned credit values based on the activity’s length, complexity and thoroughness. For a CPD activity to be eligible for accreditation, a nursing organization must have played a lead role in its development. To date, CNA has accredited e-learning modules on medical assistance in dying, suicide prevention and the Code of Ethics for Registered Nurses.

For information about the application process and fees, please contact accreditation@cna-aiic.ca

22 HOSPITAL NEWS NOVEMBER 2018

the role of Canadians living in poverty. Participants interact, make choices, and solve challenges within their given set of circumstances. The workshop concludes with a facilitated discussion on public policy and the challenges marginalized Canadians face. SU4H will redefine the field of medical education by shifting didactic teachings to an interactive, technology-based simulation for physicians and trainees, leading to a healthier and more equitable society.

LUMINA Reducing risk through efficiency Lumina, created by fourth year medical student Eric J. Zhao and his team, is an improved Toolkit for Central Line Access. The Lumina team – which consists of engineers, students, and physicians including Dr. David Agulnik – is driven by a shared belief in improving health outcomes for Canadians through evolutionary design. Its creation was catalyzed by the support of the medtech community in Vancouver and the University of British Columbia. The device combines the tools for needle insertion, flashback verification, and guidewire insertion into one compact, ergonomic tool. With Lumina, the user can advance the guidewire immediately after flashback. The team has also designed a simple modification to existing dilators – a slit running down the entire length of the dilator – that allows the dilator to be snapped onto the guidewire anywhere along its length. This decreases the travel distance and risk for compromise of sterility when working with long guidewires. Lumina is committed to finding simple solutions to tough problems. This tool will enable physicians to have more control in ER scenarios, helping them perform at their peak performance and provide excellence in health and patient care.

VITALEYES –Extending care to the waiting room VitalEyes was created by medical student Charles Choi and his team at Hatching Health, a weekend hackathon with students and professionals in technology and health care. Inspired by Dr. David Agulnik’s experiences in the Emergency Department at St. Paul’s Hospital, the team worked to develop a prototype. VitalEyes simultaneously measures heart rate, respiratory rate, and temperature of a single patient. The potential of their work has been recognized by the Faculty of Applied Sciences Award at Hatching Health. They also received the finalist award at RBC Get Seeded and were semi-finalists for Medical Device Development Centre’s Award for Excellence in Biomedical Engineering. Recently, their team has expanded, and they are exploring the use of video cameras, 24GHz frequency modulated continuous wave radars, and thermographic cameras to determine heart rate, respiratory rate, and temperature. Their system is designed to then alert healthcare professionals to attend to deteriorating patients whose vital signs have become abnormal. These are nine of the hundreds of physicians who are leading by example, forging the pathway to better health. Joule is proud to boost their efforts as they improve the healthcare landscape in Canada and internationally. At the same time, we’d like to thank them for reminding all of us that when it comes to physician-led innovation, the possibilities are truly endless. We can’t wait to see what the future holds for each of them. To learn more about the Joule Innovation grant program, each recipient and to prepare for 2019, visit joulecma. ca/grants. Have an innovation you think Joule should support? Consider applying to H the program next year. ■

Nicole Forget is the Content Manager and Stacey Palangio is the Contract Writer at Joule Inc. www.hospitalnews.com

NEWS

Runnymede launches new

HTSD Rehab program By Michael Oreskovich n February 2019 Runnymede Healthcare Centre will launch a High Tolerance Short Duration Rehabilitation (HTSD Rehab) program for adults who can benefit from intensive, short-term rehabilitation after injury or surgery. Patients in West Toronto currently have some of the longest wait times for rehabilitation. By running HTSD Rehab alongside its existing Low Tolerance Long Duration Rehabilitation (LTLD Rehab) and Medically Complex (MC) programs, Runnymede is addressing this growing demand for treatment.

WITH HTSD REHAB IN PLACE, THE HOSPITAL WILL GIVE PATIENTS BETTER ACCESS TO PROGRAMS THAT ARE IN HIGH DEMAND. With the new HTSD Rehab program in place at Runnymede, patients in the community will have increased access to treatment, where and when they need it most. “Our goal is to restore physical health and well-being to the greatest possible degree and get patients back to their everyday

lives or the next destination in their healthcare journey,” says Connie Dejak, Runnymede’s President and Chief Executive Officer. The program’s launch enhances Runnymede’s long-standing partnership with Trillium Health Partners (THP) in Mississauga. Patients from THP will have access to 35 of the new HTSD Rehab beds, which in turn will open up acute care bed spaces there and alleviate capacity pressures. ”By offering HTSD Rehab in partnership with Trillium Health Partners we are building on Runnymede’s innovation in care delivery to ensure patients get the care they need closer to home,” says Dejak. “For all of our patients, Runnymede is an essential partner on the road to recovery.” This expansion to Runnymede’s clinical programs comes just three months after the hospital announced plans to break new ground on a 200bed long-term care facility. In addition to increasing the community’s access to patient-centred care, the HTSD Rehab program will fundamentally change the face of Runnymede’s patient population. The pace and scale of change to the healthcare system today is unprecedented, but Runnymede continues to put patients first. With HTSD Rehab in place, the hospital will give patients better access to programs that are in high demand as it continues supportH ing the wider healthcare system. ■

HTSD Rehab is a new clinical program being launched at Runnymede, which will increase access to treatment for patients who can benefit from intensive, short-term rehabilitation.

Michael Oreskovich is a Communications Specialist at Runnymede Healthcare Centre. www.hospitalnews.com

NOVEMBER 2018 HOSPITAL NEWS 23

NEWS

Biomedical Technologists Keith Fernandes and Anbhu Sritharan (l-r) examine a 3D printed part in front of the 3D printer.

3D printer creates new opportunities for patients By Thomas Boyer button, some wires, a speaker, and dense lines of thermoplastic filament are the sole elements of a small box, embossed on top with the West Park logo. This device, which acts as a buzzer for patients who cannot verbally communicate, could have been made for hundreds of dollars at a manufacturing plant. But thanks to the ingenuity of West Park’s Biomed Team and a 3D printer, it was made for pocket change – in the span of hours. The 3D printer, which can create essentially any small object from a digital

THE TRUE POWER OF 3D PRINTING IS THE ABILITY TO CREATE COMPLETELY CUSTOMIZED DEVICES. THE ONLY LIMITS TO WHAT CAN BE 3D-PRINTED LAY WITHIN THE DESIGNER’S IMAGINATION.

3D model, was originally acquired to assist with prosthetics design. However, staff in the biomedical engineering department discovered that its uses were much wider. “The 3D printer was purchased three years ago, which allowed us to begin

24 HOSPITAL NEWS NOVEMBER 2018

prototyping socket designs for the prosthetics and orthotics department,” Biomedical Technologist Anbhu Sritharan says. “Soon after, we discovered that it was useful in many different applications around the hospital, and we’ve been expanding its uses ever since.”

One object the printer has created is a custom protective cap for snore sensors used by the sleep lab. Commercially, a pair of snore sensors costs over $100. By creating the caps themselves, the hospital can spend much less money: a few dollars per sensing element, and a few cents per 3D-printed cover. However, some of the most important, and novel, 3D-printed objects are directly used by patients. “The 3D printer has been very valuable in the creation of attachments and modifications to existing equipment,” Sritharan says. “In the www.hospitalnews.com

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Augmentative and Alternative Communication (AAC) clinic, 3D printing has been used to create cheaper and more personalized mounting solutions for clients.” One device – a stylus holder – was made to attach to a patient’s mobility device. Another device snaps breathing tubes onto a flexible gooseneck arm, eliminating the need for paste. One of the hospital’s most notable 3D-printed objects, a 3D-printed cranial orthosis, or helmet, was created to comfortably protect an area of a patient’s skull where the bone was surgically removed. Creating a plaster cast of a patient’s head was, until recently, the most common way of determining the correct size and shape of a custom cranial orthosis. However, this orthosis was designed using scans of the patient’s head, captured with a handheld 3D scanner.

This small box embossed with a West Park logo acts as a buzzer for patients who cannot verbally communicate. The 3D-printed shell of the helmet is very thin, but durable, says Aditi Rajendra, one of the orthotists involved with the project. “It’s only approximately two millimetres of thermoplastic,” she says. “The inside has about 10 millimetres

of o foam. It’s very comfortable for the patient, it can be comfortably worn for p about three hours.” a To print an object, a digital model must m first be designed in modelling software, which slices the 3D object into 2D w horizontal layers. Additional software is h used to convert the digital model into u instructions that the 3D printer can i recognize, much in the same way a stanr dard office printer receives instructions d to t print a document. However, the 3D printer also requires a path to follow, since all 3D printers create objects with many layers of stringy thermoplastic filament. 3D printers have come a long way in the past five years and are likely to a huge impact in healthcare as technology improves. As they become faster and capable of printing larger objects in finer detail, hospitals like West Park will be able to design more complex and durable assistive devices for any department.

“Technological advancements are enabling 3D printers to create anatomical models for surgical planning and practice, to bio-print tissues and organs, to develop custom implant devices, and – of particular interest to West Park – to manufacture prosthetics and orthotics,” says West Park IT student Clara Phillips. “Integrating 3D printing into West Park’s P&O department has the potential to significantly reduce production costs and manufacturing time, thus reducing the time it takes for a patient to receive their prosthetic or orthotic. Furthermore, 3D printing would eliminate the need for messy manual manufacturing methods, and could produce better, more comfortably fitting devices, ultimately improving patient satisfaction.” “The true power of 3D printing is the ability to create completely customized devices,” she says. “The only limits to what can be 3D-printed lay H within the designer’s imagination.” ■

Thomas Boyer is Creative Associate at West Park Healthcare Centre.

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NOVEMBER 2018 HOSPITAL NEWS 25

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Improving medication management through communication and collaboration

has the potential to improve patient safety and overall health while also reducing health-system costs,” says McCarthy, pointing out that errors can lead to costly hospital readmission.

By Nareh Tahmasian hen it comes to medication error, transitioning from one healthcare setting to another is a particularly high-risk period for many patients. Whether it’s admission into a hospital, discharge from the hospital, or admission into a long-term care facility, patients are at risk of unintentional medication discrepancies that occur when there is a change in the medications they are taking that was not intended by the original prescriber. These discrepancies can result in drug therapy problems or even adverse drug events (ADE). In Canada, up to 50 per cent of patients experience unintentional medication discrepancies upon hospital admission and at least 40 per cent at discharge. Many cases of medication error can be attributed to a lack of information pharmacists receive about a patient’s medication history. “Historically, hospital and community pharmacists have worked in silos,” says John Papastergiou, pharmacist and owner at Shoppers Drug Mart and assistant professor at the Leslie Dan Faculty of Pharmacy, University of Toronto. “Almost daily, community pharmacists are forced to make judgment calls on prescriptions from hospitals without a good understanding as to why the patient may be taking the medication.”

THE RISKS OF POLYPHARMACY “Use of multiple medications, or polypharmacy, is serious risk factor when it comes to ADEs and hospital readmissions,” says Lisa McCarthy, assistant professor at the Leslie Dan Faculty of Pharmacy and clinician scientist at Women’s College Hospital. Polypharmacy is most common among older adults, with 66 per cent of Canadians over 65 take more than five medications on a daily basis. Older adults are also more likely to experience medication changes during

CONNECTING WITH COMMUNITY

Photo Credit: Steve Southon

Lisa McCarthy (L) and Sara Guilcher are leading a team of researchers who are testing a simple but meaningful communication link to give pharmacists across care transitions immediate access to relevant patient health information.

IN CANADA, UP TO 50 PER CENT OF PATIENTS EXPERIENCE UNINTENTIONAL MEDICATION DISCREPANCIES UPON HOSPITAL ADMISSION AND AT LEAST 40 PER CENT AT DISCHARGE.

hospital stays, making the risk of error particularly high among this group. To help reduce the potential for error, Lisa McCarthy and Sara Guilcher, assistant professor at the Leslie Dan Faculty of Pharmacy, are leading a team of researchers who are testing a simple but meaningful communication link to give pharmacists across care transitions immediate access to relevant patient health information. The team is evaluating the feasibility and effectiveness of implementing the intervention, called the Pharmacy Communication Partnership, or “PROMPT,” to improve continuity of care between hospital and community pharmacists.

Currently, PROMPT is being tested during transitions from hospital to home. As part of the intervention, a hospital pharmacist directly faxes a comprehensive discharge package to the community pharmacist involved in the patient’s care. The hospital pharmacist is then accessible for follow up if needed. Fax was chosen as the first line of communication because it’s already used frequently in healthcare communications, making it the most practical and efficient tool currently available for information exchange. “By improving communication and coordination between pharmacists in each setting, our project

Community pharmacists are medication experts with valuable insights based on their long-standing relationship with patients, which makes them well-suited to assume leadership roles in medication management. “Our intervention gives community pharmacists time to prepare prescriptions in advance and request clarification if needed,” says Guilcher. “This way they can get in touch with the hospital pharmacist if they believe there may be a medication error or if another medication might be more suitable for the patient or covered by their health plan,” Guilcher says. The team is working on finding ways to improve various components of the intervention as well as investigating the contextual factors that influence implementation. “Things like ‘what are the time pressures on the hospital pharmacy side?’ or ‘how many patients can we actually do this for?’” says McCarthy, referring to the factors that affect how the intervention should be delivered under different circumstances. For example, the implementation of PROMPT in other care transitions, like from hospital to long-term care, or rehabilitation hospital to home, or implementation in rural setting where there is more interaction between different healthcare providers would all require some customization. “These findings will identify the context and mechanisms for successful implementation and scaling-up,” says Guilcher. “Our next step is knowledge translation and exploring partnerships with other hospitals across Ontario as we move forward H with scaling efforts.” ■

Nareh Tahmasian is a work-study student at the Leslie Dan Faculty of Pharmacy, Univerity of Toronto. 26 HOSPITAL NEWS NOVEMBER 2018

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Managing diabetes while in hospital By Dr. Janine Malcom and Dr. Ilana Halperin yperglycemia is common in hospitalized people, even among those without a previous history of diabetes, and is associated with increased in-hospital complications, longer length of stay and mortality. Acute illness results in a number of physiological changes or therapeutic choices that can exacerbate hyperglycemia. Hyperglycemia, in turn, causes physiological changes that can exacerbate acute illness, such as decreased immune function. These lead to a complex cycle of worsening illness and poor glucose control. Although a growing body of literature supports the need for targeted glycemic control in the hospital setting, blood glucose (BG) is often poorly controlled and is frequently overlooked in general medicine and surgery services. This is likely because the majority of hospitalizations for patients with diabetes are not directly related to their metabolic state and diabetes management is rarely the primary focus of care. Therefore, glycemic control and other diabetes care issues may not specifically addressed.

THE MAJORITY OF HOSPITALIZATIONS FOR PATIENTS WITH DIABETES ARE NOT DIRECTLY RELATED TO THEIR METABOLIC STATE AND DIABETES MANAGEMENT IS RARELY THE PRIMARY FOCUS OF CARE.

HOW SHOULD DIABETES BE MANAGED IN HOSPITAL? Glycemic targets for hospitalized people with diabetes are modestly higher than those generally advised for outpatients with diabetes as the hospital setting presents unique challenges for the management of hyperglycemia, such as variations in patient nutritional status and the presence of acute illness. For the majority of noncritically ill hospitalized people, recommended preprandial BG targets are 5.0 to 8.0 mmol/L, in conjunction with random BG values <10.0 mmol/L, as long as these targets can be safely achieved. Insulin is the preferred treatment for hyperglycemia in hospitalized people with diabetes. A proactive approach to glycemic management using scheduled

basal (long acting), bolus (fast acting) and correction (supplemental fast acting to correct high glucose levels) insulin is the preferred method. There is a growing body of evidence that shows supplemental insulin alone results in worse glycemic control and is associated with increased surgical complications. Bolus insulin can be withheld or reduced in people who are not eating regularly; however, basal insulin should not be withheld. People with type 1 diabetes must be maintained on insulin therapy at all times to prevent DKA. Insulin is often required temporarily in hospital, even in people with type 2 diabetes not previously treated with insulin. In these insulin-naive people, there is evidence demonstrating the superiority of basal-bolus-correction insulin regimens. What are safety issues to consider for diabetes management in hospital? Insulin is considered a high-alert medication and can be associated with risk of harm and severe adverse events. A systems approach that includes pre-printed, approved, unambiguous standard orders for insulin administration and/or a computerized order entry system may help reduce errors in insulin ordering. Hypoglycemia remains a major barrier to achieving optimal glycemic control in hospitalized people with di-

abetes. Standardized treatment protocols that address mild, moderate and severe hypoglycemia may help mitigate this risk. Education of healthcare workers about factors that increase the risk of hypoglycemia, such as sudden reduction in oral intake, discontinuation of parenteral or enteral nutrition, unexpected transfer from the nursing unit after rapid-acting insulin administration or a reduction in corticosteroid dose are important steps to reduce the risk of hypoglycemia.

WHAT SYSTEMS CHANGES CAN IMPROVE GLYCEMIC CONTROL IN HOSPITAL? Order sets for basal-bolus-correction insulin regimens, insulin management algorithms, and computerized order entry systems have been shown to improve glycemic control and/or reduce adverse outcomes in hospitalized people with diabetes. Computerized and mobile decision support systems (that provide suggestions for insulin dosing) have also been used and have been associated with lower mean BG levels; hypoglycemia can be an unintended consequence of tighter glycemic control. The timely consultation of glycemic management teams has also

been found to improve the quality of care provided, reduce the length of hospital stay and lower costs, although differences in glycemic control were minimal. Deployment of nurses, nurse practitioners and physician assistants with specialty training has been associated with greater use of basal-bolus insulin therapy and lower mean BG levels. Interventions that ensure continuity of care, such as arranging continuation of care after discharge, telephone follow up and communication with primary providers at discharge, have been associated with a post-discharge reduction in A1C. Providing people with diabetes and their family or caregivers with written and oral instructions regarding their diabetes management at the time of hospital discharge will facilitate transition to community care.

WHERE CAN I LEARN MORE? The 2018 Diabetes Canada Clinical Practice Guidelines has a chapter specifically dedicated to inpatient management. (http://guidelines.diabetes.ca/cpg/chapter16) Example order sets, policies and patient education material can also be found at http://guidelines.diabetes.ca/keep-patients-safe/in-hospiH tal-management â&#x2013;

Dr. Janine Malcolm MD FRCPC is an Endocrinologist at Sunnybrook Health Sciences Centre and Dr. Ilana Halperin is a Clinical investigator with the Department of Medicine, University of Ottawa and the Ottawa Health Research Institute Program Director for the University of Ottawa Fellowship program in Endocrinology and Metabolism. 28 HOSPITAL NEWS NOVEMBER 2018

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New breast cancer surgery approach improves survivorship and leaves women looking and feeling whole By Dahlia Reich London surgeon is leading a shift across Canada to new breast surgery techniques that are dramatically changing the outcome and quality of life for women diagnosed with breast cancer. About 80 per cent of women with breast cancer undergo a lumpectomy surgery in which only the tumor and some surrounding tissue is removed. While much less drastic than a mastectomy, a large lumpectomy often leaves women with a significantly distorted breast. “What’s exciting is we can now perform surgery in a way that can not only reduce the risk of the cancer returning but also drastically improves the cosmetic outcome,” says surgical oncologist Dr. Muriel Brackstone, Medical Director of the Breast Care Program of St. Joseph’s Health Care London. “Women are delighted. They are some of our happiest patients. They look cosmetically better after their cancer operation than they did before, and their cancer is gone. They also tolerate the subsequent radiation better.” It’s called oncoplastic surgery and it combines the latest plastic surgery techniques with breast surgical oncology. When a large lumpectomy is required, the remaining tissue is sculpted and molded to restore natural appearance. The technique includes a breast lift and reduction. The opposite breast may also be modified to create symmetry. Dr. Brackstone is co-founder of the Oncoplastic Partnership Workshop, Canada’s first hands-on oncoplastic surgery course for practicing surgeons across the country. She is also Director of Western University’s Oncoplastic Breast Surgery Fellowship, one of two such fellowships in Canada that trains new surgeons in this technique.

Stephanie Wilds, right, is thrilled with the results of her breast cancer surgery, which saved her breasts and left her looking better than before as well as cancer free. Her surgeon, Dr. Muriel Brackstone, Medical Director of the Breast Care Program of St. Joseph’s Health Care London.

ONCOPLASTIC SURGERY COMBINES THE LATEST PLASTIC SURGERY TECHNIQUES WITH BREAST SURGICAL ONCOLOGY. With improvements in breast imaging in recent years, pre-cancerous tissue in the vicinity of the cancer can now be more easily found, explains Dr. Brackstone. By removing those pre-cancerous lesions and the cancer, the risk of recurrence after radiation is low. The breast can be saved with good long-term outcomes, but it means a larger volume of the breast is removed. “If we did that lumpectomy the way we used to – took the piece out and

closed the skin – it initially looks good but then the fluid in that space gets reabsorbed resulting in contour deformity.” “Oncoplastic surgery is a new way of thinking for breast surgeons,” says Dr. Brackstone. The more complex cases require a team approach with plastic surgeons. “As a surgeon you’re thinking within the context of the cancer and in three dimensions with the final cosmetic view in mind.”

With oncoplastic surgery, larger breasted women can lose up to 60 per cent of their breast “and still have a beautiful, lifted reconstruction,” says Dr. Brackstone. Women don’t need prosthetics and can avoid posture and self-esteem issues that often arise with a significant breast deformity. Stephanie Wilds was 45 when diagnosed with invasive breast cancer in both breasts in July 2016. In the past, she would have undergone a double mastectomy but Dr. Brackstone was able to remove the cancer and save her breasts with oncoplastic surgery. “When I was diagnosed I didn’t have hope that I would be here in five years,” says Stephanie. “I was blown away when I learned that I didn’t have to lose my breasts and that I would be around a lot longer than five years.” While Stephanie lost about half of each breast, she is thrilled with the reduction and reshaping of her breasts. She is also cancer free. “I look better than I did before. They are beautiful. They are perfect.” says the mom of two young girls, who also underwent 15 months of chemotherapy and intravenous immune-based therapy, along with six weeks of daily radiation therapy. The purpose of the oncoplastic surgery workshop co-founded by Dr. Brackstone and four other Ontario surgeons is to provide surgeons with the skills they need and improve access to this enhanced care to patients no matter where they live. “Stephanie is a great example of how we can look past the boundaries of our specialties as surgeons and work together to redesign what we do and how we do it,” says Dr. Brackstone. “Along with good outcomes in survivorship, the new technique helps restore femininity and a sense of H wholeness.” ■

Dahlia Reich works in Communication and Public Affairs at St. Joseph’s Health Care London. 30 HOSPITAL NEWS NOVEMBER 2018

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First same-day discharge knee replacement surgery at MGH successful By Ellen Samek hen Mohamed Yusuf walked into Michael Garron Hospital (MGH) to receive his total knee replacement surgery, he never imagined he would walk out of the hospital the very same day to recover at home. The 62-year-old who immigrated to Canada from Somalia in 2005 was plagued by bad knees from arthritis that caused him to walk sideways and slightly bent over. He attributes the knee problems to running through the African landscape in his youth. “I feel so happy that I can stand up straight again and walk without any problems,” says Mohamed. “I can do the things I love again.”

TOTAL JOINT REPLACEMENT IS AN EFFECTIVE TREATMENT FOR PEOPLE WHO HAVE END-STAGE ARTHRITIS OF THE HIPS OR KNEES. Mohamed was one of two patients who participated in the same-day discharge pilot program for total joint replacement surgery. The program was established by Dr. Paul Wong, an orthopedic surgeon at MGH. The idea for this program came from a study conducted by Dr. Wong and his team to educate joint replacement patients on recovery strategies and reduce hospital stays. The study, “Reducing length of stay for total knee arthroplasty through enhanced patient education” won a Lead Wisely award at MGH’s annual

EPIC Research and Innovation Fair last year. Total joint replacement is an effective treatment for people who have end-stage arthritis of the hips or knees. The patient population that usually requires this surgery is commonly aged between 50 and 85. The surgery replaces the diseased hip or knee joint with a prosthetic one. Dr. Wong’s study originally aimed to reduce hospital stays from three days to two and a half days, but the research showed that same day discharge was possible. Early discharge is not only safe, but also leads to higher patient satisfaction and lower complication rates. Dr. Wong also found that it is essential to reduce narcotic use. The program was recognized by the Health Standards Organization as a Leading Practice, and published online earlier this month. “We found that by eliminating some of the barriers that kept people in the hospital longer, they were able to go home much sooner and recover more quickly,” says Dr. Wong, who has been an orthopedic surgeon at MGH for over 20 years. Over the span of his career, Dr. Wong has completed thousands of joint replacement surgeries. Based on his experience and the findings of his team’s study, Dr. Wong found the two biggest barriers were whether or not the patient had home support and the patient’s pre-conception of what is expected before the surgery. “We usually see patients coming to the hospital for joint replacement surgery with the mindset that they are sick and need to be in the hospital for a very long time. We found that patients with this mindset took a much longer time to recover and transition home,” says Dr. Wong.

Mohamed Yusuf is proud to stand on his own two feet again after a successful same-day discharge total knee replacement surgery. Photo credit: Ellen Samek “By changing the culture of joint replacement and empowering patients to take control of their own health, I think we will be able to do more same day discharges, in the future, for those who qualify.” Patients who qualify for same day discharge surgery would have guaranteed at-home support during their recovery (whether from family, friends, or outside services) and have no major pre-operative medical conditions. They tend to be on the younger side of the typical age range. Ultimately, the key predictor of successful same day discharge is a patient’s motivation and determination to take control of their own health and recovery. Same day discharge total joint replacement is not a new concept. Over the past few years, there’s been a resurgence. In the US, approximately five per cent of all total joint replacements are discharged the same day. Dr. Wong believes that its popularity

will continue to rise in Canada, and will become routine practice in our near future. “Same day discharge isn’t for everyone,” says Dr. Wong. “As we did with this pilot, we will continue to carefully screen patients who meet the criteria for any future same-day discharge surgeries.” Mohamed says his recovery took about 15 days in addition to five physiotherapy sessions at an offsite health centre. “Dr. Wong has changed my life,” says Mohamed with a smile. “Everyone from the hospital who helped me with my recovery was wonderful. Every week someone would call to see how I was doing.” Mohamed is currently looking forward for his next joint replacement surgery on his other knee. He is excited at the prospect of finally ditching his walking cane once and for all and H hopes he’ll be able to travel again. ■

Ellen Samek is a Communications Assistant at Michael Garron Hospital, Toronto East Health Network. 32 HOSPITAL NEWS NOVEMBER 2018

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MEDICAL TECHNOLOGY MAKING A DIFFERENCE

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NOVEMBER 2018 HOSPITAL NEWS 33

MEDEC 2018

Fifth annual

MEDEC supplement e are pleased to once again partner with Hospital News for the fifth edition of MedTech supplement. This is a terrific opportunity to share some examples of the role that medical technology can play in improving patient outcomes, advancing treatment options and contributing to health system sustainability, as well as initiatives taking place in the healthcare environment that have an impact on medical technology adoption. As the national association representing Canada’s medical technology companies, we work closely with the federal, provincial and territorial

governments, health professionals, patients and other stakeholders to help deliver a patient-centred, safe, accessible, innovative and sustainable, universal healthcare system supported by the use of medical technology. MEDEC advocates to ensure patient access to leading edge, innovative technology solutions that yield valuable outcomes. Medical technologies have the potential to contribute to many of the challenges facing Canadian health care today, including addressing hallway medicine (see Medical technology can be an important contributor to ending hallway medicine on page

Virtual Healthcare is Live and Expanding in Toronto Primary virtual care or the ability for patients to have a virtual visit with their own primary care physician or nurse practitioner has expanded in Toronto. Novari Health’s made in Ontario eVisit web and mobile technology is powering this pilot expansion in concert with the Ontario Telemedicine Network (OTN) and the Toronto Central Local Health Integration Network (TC LHIN). The Novari eVisit™ solution is already live in the Mississauga Halton, Central West and Central East LHINs serving almost 5 million Ontarians. Virtual care is transforming healthcare around the world, making it easier and more convenient for patients and primary care providers to connect. Improving timely access for patients to their primary care provider may reduce visits to walk-in clinics and crowded emergency departments with corresponding savings to the healthcare system. The solution has robust security and privacy features to protect patient medical information. Novari eVisit™ is a cloud-based solution leveraging the Microsoft Azure cloud infrastructure, and as such is highly scalable and can serve any population size. Visit www.novarihealth.com to learn more about Novari eVisit™.

34 HOSPITAL NEWS NOVEMBER 2018

Brian Lewis, President and CEO of MEDEC. 36) and improving Canada’s health system performance (see Report’s recommendations seek top five spot for Canada in Commonwealth Fund health rankings on page 40). There are tremendous examples of innovation taking place across Canada, but it crucial for our country to create an enabling environment to scaleup innovations that create value for patients and Canada’s healthcare system. To that end, we work with our partners to address barriers to the adoption of innovation through initiatives such as our Hospital to Community Collaborative, which brings together health system and policy stakeholders from a variety of different areas to advance innovation in enabling community-based care. We are also a partner in a new coalition called LabCANDx, which is a group of suppliers, users and providers of laboratory medicine that promote the adoption of laboratory medicine innovations as an enabler for value-based healthcare and to improve patient/family-centric care and health system outcomes. Furthermore, initiatives are underway in jurisdictions around the world that seek to put value-based healthcare methodologies into practice. These funding models and procurement strategies that utilize value-based

healthcare principles seek to “deliver better value for patients and increased quality per dollar spent.” (Harvard Business School Institute for Strategy and Competitiveness). Canada is no exception, and we are now seeing initiatives underway across the country that seek to put value-based healthcare methodologies into practice. To assist our members and relevant stakeholders in the understanding of key value-based healthcare concepts, methodologies and terminology, this year we were pleased to release a Value-Based Healthcare Quick Guide which can be found on our website (www.medec.org) Additionally, we’re proud to annually play host to Canada’s MedTech Conference, which is taking place once again next year on April 3 & 4, 2019 at the International Centre in Mississauga. We invite you to “Save the Date” and be a part of this engaging event focused around medical technology that brings together a wide variety of dignitaries, health system and policy leaders to share best practices and opportunities to advance Canada’s healthcare system. Our association truly values working collaboratively with our health system partners and we look forward to continue building upon this work H together in 2019. ■ www.hospitalnews.com

MEDEC 2018

Medical technology can be an important contributor to ending

hallway medicine By Pippa Wysong hen it comes to improving efficiencies in hospitals, reducing costs and getting patients home sooner, an important part of the equation lies with technology. Indeed, technologies already have a solid track record for speeding up diagnoses, leading to shorter procedures and improving outcomes. And, as new technologies are adopted, can help alleviate some of the issues that contribute to the overcrowding in hospitals and so-called hallway medicine. “If you want better patient outcomes and want to be able to address hallway medicine, you need innovation and technology,” says Nicole DeKort, Vice-President, Ontario and Marketing at MEDEC.

But Canada has sometimes been slow to adopt new technologies, she adds. This is especially true for medical technologies, yet they help get patients out of hospital and help support them in the community and in their homes. To improve this, MEDEC created the Hospital to Community Collaborative (HCC) that brings together industry along with healthcare and government partners to address barriers hindering the adoption of technologies that support chronic disease management and post-acute care patients in the community. MEDEC is the national association representing Canada’s medical technology industry, and represents approximately 100 medical technology companies. “While the issues around overcrowding in hospitals are complex,

Baxter: Accelerating Innovation to Save and Sustain Baxter is focused on helping clinicians be more efﬁcient and effective in treating patients at the bedside, in the operating room, in the intensive care unit, at home and in the dialysis clinic. This includes ﬁnding new and smarter ways to improve patient outcomes, prevent complications before they become life-threatening, and lessen the overall cost of care. In addition, Baxter is investing to accelerate the pace of product innovation, providing patients and providers access to new technologies and therapies sooner. These areas of investment include advancing the quality of dialysis care; personalizing infusion therapies to individual patient needs; expanding organ support therapies for critical care patients; and introducing new formulations and delivery methods to ensure patients’ nutritional needs are met.

WHILE THE ISSUES AROUND OVERCROWDING IN HOSPITALS ARE COMPLEX, TECHNOLOGY CAN PROVIDE SOLUTIONS. technology can provide solutions,” adds DeKort. In fact, new technologies are constantly being developed with this mind. Canada is host to more than 1,500 medical technology companies which employ more than 35,000 people. Historic examples of technologies that have improved patient flow and better outcomes include keyhole surgeries that allow for minimally invasive surgical procedures; devices that allow for diabetes and heart patients to be monitored at home instead of having to go to a hospital clinic; detailed imaging technologies which improve diagnoses or targeted therapies and devices that offer greater mobility to older or injured patients, and more. A glimpse of the future of what hospitals across Canada could be like is illustrated by Ontario’s new Humber River Hospital which opened in 2014. It is the first fully digitized hospital. Everything from its architectural design to an intricate system of roving robots, telecommunications, integration of data items with physician smartphones, electronic charts, use of barcode systems to track materials and tests, and more, help ease the patient journey through care, as well as making tasks and procedures more streamlined and easier for staff. General Electric was the company behind developing a novel centralized command centre for this.

Baxter is also providing new tools to make microsurgery more effective and efﬁcient; advancing its portfolio of leading hemostats and sealants to simplify preparation and use; and making more generic medicines available to hospitals in areas that are central to patient care.

TECHNOLOGIES THAT ARE PROVIDING RAPID DIAGONOSES, BETTER OUTCOMES

These efforts will help ensure Baxter remains uniquely positioned to help save and sustain lives throughout the patient journey, from prevention through recovery.

Hospitals are seeing an increase in the use of various rapid diagnostic sys-

36 HOSPITAL NEWS NOVEMBER 2018

tems. Some are used in hospital labs, while others are in the form of a portable, hand-held point-of-care (POC) devices. One example is Roche’s Elecsys Troponin T-high sensitive assay, a highly sensitive laboratory test that can let doctors know within an hour whether heart attack has occurred. All patients with chest pain admitted to the ER have blood samples taken and sent to the lab to test for troponin levels – an indicator of heart tissue damage. Testing often requires a second test conducted about three hours later to determine a change in troponin levels from baseline admission value. However, the highly sensitive test provides a quicker and more accurate result. “If a patient test is undetectable for troponin at admission, the vast majority don’t need the second test, freeing up an ER bed more quickly,” says François Drolet, a spokesperson for Roche Diagnostics, Canada and a participant on the HCC. In fact, he notes, in Denmark a POC troponin test is used by EMS professionals. “The test is done in the ambulance as a patient is being transported, giving a quicker idea of what treatment patients should get before they even get to the hospital, improving efficiency,” he says. Roche Diagnostics is one of several companies developing and manufacturing rapid diagnostics for a variety of medical conditions. Drolet notes that when evaluating new technologies, big-picture economics need to be taken into account, something the HCC is aiming to address. Continued on page 38 www.hospitalnews.com

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MEDEC 2018

hallway medicine Continued from page a A new technology sometimes may appear costly on the surface, but if it reduces hospital stays, speeds up diagnoses, improves patient outcomes, reduces the need for additional tests or treatments, reduces readmissions and other related benefits, it saves the healthcare system in overall expenditures. “Another game-changing technology is transcatheter aortic valve implantation (TAVI) which is replacing surgical replacement of the aortic valve,” says Dr. Natarajan, Director of Catheterization laboratories at Hamilton Health Sciences. It is less invasive than chest-opening surgery, doesn’t require a bypass machine, and more recently, can be done with conscious sedation without putting patients on a breathing machine. Each year, one-in-10 to one-in-12 Ontarians develop aortic stenosis, a narrowing of the aortic valve in which the valve thickens, gets calcified and degenerates. Some people develop severe aortic stenosis needing inter-

EACH YEAR, ONE-IN-10 TO ONE-IN-12 ONTARIANS DEVELOP AORTIC STENOSIS, A NARROWING OF THE AORTIC VALVE IN WHICH THE VALVE THICKENS, GETS CALCIFIED AND DEGENERATES. vention, but until recently 40 per cent of these patients were not eligible for surgery and half died within two years. In these high-risk patients, TAVI leads to a 50 per cent drop in mortality, Dr. Natarajan said. Now, 2,000 patients per year get aortic valve surgery and about 800 patients get TAVI. Work is now underway to investigate whether TAVI should be used in earlier disease. After standard aortic valve surgery hospital length of stay is at least five days. TAVI patients are ambulatory within six hours, and studies show discharge within 24 to 48 hours of the procedure is feasible and safe. “This early discharge pathway could proba-

bly apply to about 75 per cent of TAVI patients,” he says. The ability to monitor TAVI patients remotely would give them even more independence, Dr. Natarajan said. A clinical study, funded by Ontario’s Health Technologies Fund, is now exploring use of the mobile cardiac arrhythmia diagnostics (m-CARDSTM) from Burlington, Ontario-based m-Health Solutions. Before undergoing TAVI, patients are monitored real-time from a central monitoring station and the clinical team is alerted if a rhythm abnormality is discovered. Similarly, stable post-TAVI patients are fitted with a monitor for a mini-

mum of two weeks. This early warning system enhances collaboration between various healthcare providers, maintains continuity of care, and may reduce emergency department visits. “We are incredibly excited to partner with such innovative organizations such as Hamilton Health Sciences and Sunnybrook Hospital on this project,” says Sandy Schwenger, CEO of m-Health Solutions. “Partnerships like these, with the involvement of the Government of Ontario, allow us to bring technology like the mobile Cardiac Arrhythmia Diagnostics Service forward faster and save the lives of more Canadians.” “These are only a couple of examples of how technology is transforming hospitals and the healthcare system,” says DeKort. Along with technologies that are already in use, there are also numerous technologies under development, as well as various products currently being evaluated for use the H healthcare system. ■

Pippa Wysong is a freelance writer. 38 HOSPITAL NEWS NOVEMBER 2018

www.hospitalnews.com

MEDEC 2018

World’s first self-adjusting insulin pump coming to Canada By Melicent Lavers-Sailly ob Howe felt he knew the best way to manage his Type 1 diabetes. After living with the disease for nearly half his life, the 30-yearold former professional basketball player and entrepreneur was used to paying careful attention to his health. Howe, a resident of Dallas, Texas, had been using an insulin pump for nearly a decade. He carefully managed his diet, exercise and insulin intake to keep his blood sugar in check. He had been able to avoid the steep highs and lows in blood sugar levels that cause health complications for so many people living with diabetes. So, Howe was initially skeptical about trying the world’s first self-adjusting insulin pump – the Medtronic MiniMedTM 670G system – when it was approved for use in the U.S. two years ago by the Federal Food and Drug Administration. But after he researched the science and technology behind the MiniMed 670G, he became convinced it could benefit him. He began using the system in February 2018 and is among approximately 100,000 Americans relying on the new pump today. “I can see from my time in range, which is the main metric on the pump, that my numbers are in a much tighter range over a greater period of time. Even though I had tight control before, I feel much more confident in my decision making with the MiniMed 670G,” Howe says. “That just takes some of the stress off of me and allows me to be myself and not have diabetes be so involved in my whole life.” Canadians with Type 1 diabetes will soon also be able to access the same ground-breaking technology, which helps to stabilize glucose levels 24-hours-a-day by automatically adjusting basal insulin delivery based on real-time insulin needs. Health Canada has licensed the system for use in people with Type 1 diabetes seven

Rob Howe, who played basketball against the Harlem Globetrotters as a member of the Washington Generals, says the MiniMed 670G allows him to be more active without worrying about spikes in his blood glucose levels. years of age and older. Medtronic expects to begin commercial release of the MiniMed 670G system in Canada later this fall. Approximately 300,000 Canadians live with Type 1 diabetes. Howe says the new technology is giving him back some of the time and energy he had been burning each day managing his medical condition. “I’m spending less energy thinking about my diabetes. It’s incremental, but it adds up over time. I believe that all of life’s great treasures come from compound interest, so getting a little bit of each day back is going to add up tremendously for me long term.”

Howe, who played basketball against the Harlem Globetrotters as a member of the Washington Generals, said the MiniMed 670G allows him to be more active without worrying about spikes in his blood glucose levels. He used to remove his previous insulin pump before playing basketball or exercising heavily because he wasn’t sure how it would handle the extra exertion of energy. As a result, his blood sugars would spike during basketball and make it difficult to enjoy getting involved in a game he loved. The MiniMed 670G can be worn during strenuous exercise and con-

tinues to monitor blood glucose levels and make insulin adjustments. “Now I have the confidence to exercise and be active and know my pump is doing all of my thinking for me,” Howe says. “If my levels start to go up, the pump will correct it and if my levels start to go down, the pump will stop giving me insulin and keep me in range.” Howe said the MiniMed 670G gives him more optimism for the future, knowing he can effectively manage his Type 1 diabetes with less effort. “When I think about the next 50 years of diabetes in my life, going from 30 to 80, it gives me a lot of hope for H what’s to come.” ■

Melicent Lavers-Sailly is senior manager of communications and corporate marketing at Medtronic Canada. www.hospitalnews.com

NOVEMBER 2018 HOSPITAL NEWS 39

MEDEC 2018

Recommendations seek top five spot for Canada

in Commonwealth Fund health rankings A The Table was comprised of industry and health system leaders from across Canada and was appointed by the Trudeau government to advise it on how to support economic growth in the health and biosciences sector. The report highlights that, “A primary barrier to the adoption of innovative products and services is the traditional cost-focused bulk-buy procurement approach favoured by health systems in Canada.” This commoditization approach to procurement typically fails to facilitate the adoption of innovation and doesn’t consider that many medical technology innovations can enhance patient outcomes, improve system performance and contribute to system sustainability. According to the Cana-

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A PRIMARY BARRIER TO THE ADOPTION OF INNOVATIVE PRODUCTS AND SERVICES IS THE TRADITIONAL COST-FOCUSED BULK-BUY PROCUREMENT APPROACH FAVOURED BY HEALTH SYSTEMS IN CANADA.

dian Health Policy Institute, “research suggests that spending which increases the adoption and use of medical technologies should be viewed as an investment that will return greater potential downstream savings on total healthcare costs.”

SHIFTING TO VALUEBASED PROCUREMENT The HBEST report says that an alternative approach, Value-Based Procurement (VPB), empowers purchasers “to consider other factors beyond price alongside other critical factors such as improved patient outcomes, reduced demand for more expensive health services, increased quality of life and economic benefits.” “Implementation of value-based procurement provides one of the most important avenues for Canadian healthcare to take advantage of the benefits offered by technologies that offer high value to patients and the system,” says Armen Bakirtzian, CEO of Waterloo-based Intellijoint Surgical and a Member of HBEST. “While there are pockets of innovation taking place in Canadian healthcare, this report offers actionable recommendations for the federal government that would allow it to take a leadership role in drastically scaling up the adoption of innovation for all Canadians.” The report’s authors recommend that the Government of Canada can play two significant roles in directly leading the implementation of VBP: by working with provincial/territorial health systems and the private sector

to foster its use, and by demonstrating its use in federal departments with a direct role in health services. By working collaboratively with the provinces, territories and private sector, the report says that the federal government should lead the development of the necessary tools to facilitate the use of VBP. Given that VBP relies on measuring patient outcomes relating to the technology or service, tools such as patient outcomes measures need to be considered and agreed upon. Through this work, the report recommends first utilizing VBP “for conditions that pose a high disease burden for Canadians (e.g., cancer, heart disease, chronic obstructive pulmonary disease, diabetes) by 2025.” Additionally, the report recommends that the federal government showcase the use of VBP in one or more of its departments that have a direct role in health services. This would demonstrate how these models could be applied within the federal procurement context, enable expertise within procurement professionals and develop data on the effectiveness and impact of VPB approaches.

CREATING A PROCUREMENT INNOVATION AGENCY In addition to playing a direct role in advancing the adoption of innovation, the report also calls for the creation of a Procurement Innovation Agency, which could either be a new entity or be a part of one or more of the pan-Canadian health organizations. Continued on page 42 www.hospitalnews.com

recent report submitted to the Trudeau government provides recommendations that aim to advance Canada into the top five of the Commonwealth Fund’s healthcare system rankings by 2025. This would drastically improve upon Canada’s ninth place ranking (out of 11 countries) in the most recent 2017 edition of the Commonwealth Fund’s rankings. The Health and Biosciences Economic Strategy Table (HBEST) report recommends that this improvement in health system performance can be achieved by accelerating the adoption of innovation in Canada’s healthcare system through the utilization of value-based procurement and establishing a procurement innovation agency.

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MEDEC 2018

Report’s recommendations

Value-based procurement within Canada’s health systems

A procurement innovation agency with a joint health and economic mandate

Continued from page 40 The agency would tackle persistent procurement challenges by: “Lead(ing) a network of partners that includes representatives from provincial and territorial health departments, pan-Canadian health organizations, healthcare providers, academic institutions, the private sector and the public…(to) change the culture of health-based procurement in Canada by identifying innovations that strongly demonstrate immediate and significant value to the healthcare system and building the real-world evidence to support their procurement and adoption.” The report says that dedicated funding for the agency should be modelled after international examples of similar agencies, such as the U.K.’s NHS Innovation Accelerator – which has seen significant successes in innovation adoption and reducing health system costs since its inception (see sidebar for more details).

Specific actions from the agency would include: pre-market engagement with Canadian-based small and medium companies so that they can develop made-in-Canada solutions to Canadian healthcare needs, funding technology demonstration projects to build real-world evidence (including patient-reported outcomes) for scale-up of high-value innovations and working with partners on clear implementation plans for technologies that provide high value. While some provincial initiatives have been spearheaded around the issues that this recommendation seeks to address, its national scale would be unique. In addition to addressing procurement challenges, the HBEST report also provides the government with recommendations to improve the regulatory environment, harness digital

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Value-based procurement for areas of federal health responsibility

technology, develop and attract talent and create anchor firms. “We strongly encourage the government to adopt the recommendations put forth by the Health and Biosciences Economic Strategy Table,” says Brian Lewis, President and CEO of MEDEC. “This is an unparalleled opportunity for national leadership in addressing barriers that are currently

impeding the adoption of health innovations that are beneficial to patients and addressing significant challenges in our healthcare system.” The Health and Biosciences Economic Strategy Table report is available via Innovation, Science and Economic Development Canada at: https://www.ic.gc.ca/eic/site/098.nsf/ H eng/h_00020.html ■

Missed opportunities in Canadian Healthcare procurement Intellijoint Surgical of Waterloo, Ontario, has commercialized Intellijoint HIP, which gives surgeons real-time, intraoperative measurements to precisely select and position orthopaedic implants during total hip arthroplasty. Despite improved patient outcomes that have reduced cost and post-operative complications, the company has struggled for Canadian hospitals to adopt their technology, leading to minimal sales in Canada. In contrast, hospitals abroad have been quick to adopt the new technology, recognizing the potential to improve quality and reduce the overall cost of care. U.K. national health service innovation accelerator This entity works in partnership with the U.K.’s Academic Health Science Networks to support the adoption and promotion of proven, value-based innovations, aligning goals with NHS national priorities and local needs. Since its inception in 2015, it has supported the scale up of dozens of innovations into use in over 1000 NHS organizations. Each of these innovations has demonstrated greater quality outcomes at lower health system costs–and many are now marketed internationally. Source: Health and Biosciences Economic Strategy Table Report

42 HOSPITAL NEWS NOVEMBER 2018

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A new hope for patients at risk of esophageal cancer

Source: MEDTRONIC

MEDEC 2018

By Melicent Lavers-Sailly or Mary Hedley-Brown, the news came as a shock. A survivor of cervical cancer, she had lost her husband to cancer as well as a friend who died from esophageal cancer. It was frightening for her to get a similar diagnosis. “Ever since I was a teenager I’ve had terrible heartburn and acid reflux, but it never occurred to me that it could cause cancer in your esophagus,” she says. Acid reflux can be a sign of gastroesophageal reflux disease (GERD), which affects one in six adult Canadians. Symptoms may include heartburn, regurgitation, chest pain, sleep apnea, chronic cough or belching. Up to 15 per cent of adult Canadians with GERD may develop Barrett’s esophagus, a condition in which cells in the lining of the esophagus become abnormal after being exposed to stomach acid over an extended period of time. These abnormal cells are the primary risk factor for esophageal cancer, a deadly form of the disease. Approximately 86 per cent of people with esophageal cancer will die within five years of diagnosis. Patients with Barrett’s esophagus are routinely monitored to watch for progression to high-grade dysplasia, which is the critical step towards the development of cancer. Until recently, the only reliable treatment was an esophagectomy, or surgical removal of part or all of the esophagus. Now, however, a new and minimally invasive technology known as radiofrequency ablation (RFA) is becoming available in Canadian hospitals, giving patients such as Mary a far more positive prognosis. “When I was diagnosed with Barrett’s esophagus,” she recalls, “my family doctor would bring me in every three to six months to check it, and then when it became high-dysplasia, he referred me to Dr. Dhaliwal.”

Dr. Harry Dhaliwal is a therapeutic gastroenterologist at The Ottawa Hospital, which recently acquired an RFA system called BarrxTM. “When I did the initial diagnostic endoscopy to evaluate the Barrett’s mucosa, Mary had two nodules within that area,” he says. “When those nodules were removed, they both contained cancer. With RFA and ablative therapy, we’re able to treat patients early. This prevents the progression to high-grade dysplasia, which was previously treated with esophagectomy.” RFA technology uses current to create heat that eradicates tissues affected by Barrett’s esophagus. With the patient under sedation, the physician inserts a catheter into the esophagus. The catheter carries an inflatable balloon containing bands that emit radio waves with great precision. When the balloon is inflated, the physician delivers a burst of energy that ablates, or destroys, the abnormal cells. The body will later replace these cells with healthy ones. “RFA is a proven technology for treating Barrett’s mucosa,” says Dr. Dhaliwal. “It’s very tolerable and there’s a very durable response.” Indeed, RFA technology has been shown to be 98.4 per cent effective at eliminating dysplastic Barrett’s esophagus tissue. The outcome for Mary could not have been better. A follow-up endoscopy showed that the RFA procedure was a complete success. Since then she feels great, has got married and is starting a new life. “I really feel that a patient should be their own best friend,” she says now. “Anybody who has a history like I had should get checked.” However, Dr. Dhaliwal warns, “One of the difficulties in identifying patients with Barrett’s esophagus is that there’s a large percentage who don’t actually experience symptoms of acid reflux. They may have undiagnosed Barrett’s esophagus that we may not be aware of. We often

miss those patients, so part of the struggle for us as physicians is being able to screen patients properly and selectively.” At present there’s no consistent screening protocol for high-risk patients similar to the program for colon cancer, and healthcare resources for endoscopies are limited. “Patients who do have risk factors and symptoms of reflux for an extended period of time should be getting surveyed,” Dr. Dhaliwal says. “Even

younger patients who have a longstanding history of reflux and have Barrett’s mucosa, if there’s a family history of esophageal cancer or there’s a large segment of Barrett’s, should be considered for ablative therapy.” “It’s important to be your own advocate,” Mary adds. “Anyone who has acid reflux should be aware that it could lead to Barrett’s esophagus. If you’ve had GERD for a long time, talk H to your doctor. I was just lucky.” ■

Melicent Lavers-Sailly is senior manager of communications and corporate marketing at Medtronic Canada. 44 HOSPITAL NEWS NOVEMBER 2018

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NURSING PULSE

Making good business sense in acute care By Lesley Young ccording to RN Kathryn Hayward-Murray, senior vice president, patient care services, and chief nursing executive for Trillium Health Partners (THP), becoming a Best Practice Spotlight Organization (BPSO) while also going through a merger in 2012 united more than 10,000 employees and volunteers at three sites toward the same goal: improving patient care. BPSOs are health-care and academic organizations selected by the Registered Nurses’ Association of Ontario (RNAO) to implement and evaluate RNAO’s best practice guidelines (BPG). It was Hayward-Murray and Patti Cochrane (former CNE/VP at THP) who proposed the BPSO program to Michelle DiEmanuele, interim CEO at the time, who had a lot on her mind bringing together Credit Valley Hospital and Trillium Health Centre. “Of all the things I was thinking about, picking a team, stabilizing services and budgets, etc, becoming a BPSO was not top of the list. But as soon as it was in front of me, and we started talking, I knew it would be the perfect initiative to build a new organization and culture of quality.” DiEmanuele says building a culture is key in any restructuring, and she quickly realized how the BPSO’s proven methodology, with a set of goals and a framework by which to get there, would get people excited. The interprofessional team collaborated on the work to become a BPSO, and by the time the organization achieved designation in 2015, Trillium had implemented seven BPGs (they are currently working on three more). To note just a few of the many successes, after implementing the breastfeeding BPG, 75 per cent of new moms leaving the hospital exclusively breastfeed, compared to 54 per cent before

the BPG was implemented, says Shelly Petruskavich, director, professional practice. “It was our groundwork through the BPG that was the start of the journey to THP attaining the Baby Friendly Initiative (BFI) in 2018.” Thanks to RNAO’s healthy work environments nursing leadership BPG, Trillium has developed a unique program called Invitation to Leadership, which includes an interactive educational component, and also a formal mentorship component, says Hayward-Murray. The mentorship aspect

was a win-win, she adds, as many of the mentors get a taste of point-ofcare nursing from their mentees. So far, there have been 185 participants and a waiting list for every cohort. Being a BPSO really allows for BPGs to be woven into the work of all professionals, points out Petruskavich. This is important in a large organization like Trillium, adds Hayward-Murray, noting there are many health-care initiatives that could be undertaken. There is also the bottom-line benefit to BPSO designation, DiEmanuele

explains. “When I look at the BPSO (initiative), and the BPGs we’ve implemented, I know there is savings in duplication of work. More important is the improved patient experience to be had over time.” Being a BPSO is truly a cultural predisposition at Trillium now, says DiEmanuele. “When we think about starting something, we always look at the BPGs. When suitable, we will pull in something (from a BPG). It’s a way of doing business and a way of practice H for us.” ■

The Best Practice Spotlight Organization (BPSO) program is led by the Registered Nurses’ Association of Ontario (RNAO). This article originally appeared in a special 20th anniversary issue of Registered Nurse Journal, RNAO’s bi-monthly publication, alongside a variety of other articles celebrating two decades of best practice guidelines (BPG). RNAO is the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses’ contribution to shaping the health-care system, and influenced decisions that affect nurses and the public they serve. For more information about RNAO, visit RNAO.ca or follow us on Facebook and Twitter. 46 HOSPITAL NEWS NOVEMBER 2018

www.hospitalnews.com

NEWS

Cannabis legalization:

What healthcare professionals in hospitals should know By Dr. Mark A. Ware n October 17th 2018, Canada embarked on a significant cultural and societal transformation with the legalization of cannabis. While this is a major policy change that many would never have anticipated until recently, what isn’t changing is the 300,000+ patients across Canada who rely on medical cannabis to treat a wide number of conditions including, but not limited to, chronic pain, anxiety, insomnia and nausea. For the past two decades, my research team focused on advancing the medical community’s understanding of cannabis through clinical studies of the safety, efficacy and effectiveness of cannabis and cannabinoids in pain and symptom management. I understand that cannabis as a medicine continues to be a contentious issue amongst healthcare practitioners and academics, but it is important to not lose sight of how therapeutic use of cannabis may positively impact patients every day in this country and across the globe.

are only now beginning to address the reality and challenges of patients’ rights to cannabis access and use. In this article, I wish to consider some of these factors specifically related to hospital and inpatient care.

CONTINUITY OF CARE One of the primary objectives for HCPs is to understand their patient’s treatment and medication history. Documenting whether or not a patient is using cannabis before entering a hospital is necessary in order to better understand how to best manage their medication intake while hospitalized. This must include use of cannabis (for either recreational or medical use), in terms of amount, frequency and duration of use. This information may have important implications for treatment decisions. For instance, if a patient requires surgery, they are typically prescribed pain relief medications afterwards, but for patients that use medical cannabis to manage their chronic pain, they may not respond

DOCUMENTING WHETHER OR NOT A PATIENT IS USING CANNABIS BEFORE ENTERING A HOSPITAL IS NECESSARY IN ORDER TO BETTER UNDERSTAND HOW TO BEST MANAGE THEIR MEDICATION INTAKE WHILE HOSPITALIZED. While it remains difficult to predict the impact that cannabis legalization will have on healthcare, it is clear that healthcare professionals (HCPs) working in a hospital setting will need to know about cannabis as it relates to patients and staff in this evolving environment. While a legal and regulated medical cannabis program has been in place in Canada for the past 20 years, many levels of the healthcare system

well to prescription pain relievers alone and may therefore need access to cannabis to better manage their pain perioperatively. Patients who use cannabis regularly or are cannabis dependent may go into withdrawal from their cannabis use. Sometimes in these cases, nabilone, a prescription synthetic cannabinoid may be administered, but this may not provide an adequate response to all patients. In the case of

medical users, allowing the patient to use medical cannabis may be necessary; in Quebec, this is a requirement, and must be provided free of charge to hospitalized patients. Ultimately, hospitals need to ensure they have policies and procedures in place to account for a patient’s cannabis use in order to ensure continuity of care. Ideally, HCPs also need to understand the type of cannabis that their patients are using in terms of format and levels of THC and CBD, and then source the appropriate products.

MANAGING ACCESS Many hospital pharmacists don’t know that they can purchase and administer cannabis for medical purposes. It is legally permitted to ship cannabis to a pharmacist in a hospital as long as this is authorized by the person in charge of the hospital. Hospital pharmacists can order cannabis on behalf of the hospital by completing a written order and sending it to a licensed producer. On receipt of a prescription, written order, or authorization document, the hospital pharmacist may administer cannabis to a person under treatment (in- or out-patient). A common misconception amongst HCPs that may have led to the lack of cannabis access in hospitals is the idea that the only way to consume cannabis is by smoking. Cannabis administration has significantly evolved; vapourizers (which heat cannnabis to volatilize the active cannabinoid ingredients) are now available as licensed medical devices, and oils and softgel capsules can now replicate the delivery and dosing accuracy of other orally administered medicines. Just like other medications, pharmacists can therefore order and store cannabis with instructions on how to administer

it, including potential side effects and drug interaction information which can be communicated with the physicians and nurses.

HEALTH AND SAFETY Patient safety is another important consideration. By providing access to cannabis through the hospital pharmacy, patients who use cannabis will receive their medication from a licensed producer, a Health Canada approved source, rather than from unregulated illicit sources. Hospitals will need to consider occupational health issues such as exposure to second hand vapour by attending HCPs. This risk has recently been shown to be minimal in nurses administering cannabis by vapourization in a clinical trial, but such issues need to be identified and addressed.

IDEAL SETTING FOR CLINICAL TRIALS Hospital settings are ideal places for clinical trials. Dedicated negative pressure rooms have bene used to administer inhaled cannabinoids for trials, while for oral cannabis use there is no reason to have specialized facilities. Establishing such policies within hospitals may facilitate important research to address the considerable gaps that continue regarding the use of cannabis is a variety of forms. On October 17th 2018, we witnessed the legalization of recreational cannabis in Canada. For healthcare practitioners and pharmacists in hospitals across the country, it’s imperative that they ask the necessary questions to understand a patient’s cannabis use, recording that information, then developing a treatment plan, and providing access that will allow for the best outH come possible for patients and staff. ■

Dr. Mark A. Ware MBBS MRCP(UK) MSc is Canopy Growth’s Chief Medical Officer and is responsible for the advancement of research and Spectrum Cannabis, Canopy Growths global medical cannabis brand.He is an Associate Professor in Family Medicine and Anesthesia at McGill University and over the past 10 years he has served as the Director of Clinical Research of the Alan Edwards Pain Management Unit at the McGill University Health Centre, and Executive Director of the non-profit Canadian Consortium for the Investigation of Cannabinoids. www.hospitalnews.com

NOVEMBER 2018 HOSPITAL NEWS 47

NEWS

Drug checking expands in Vancouver By Carrie Stefanson eople who use drugs now have additional tools to check them for toxicity. Vancouver Coastal Health (VCH) has partnered with PHS Community Services Society and Lookout Housing and Health Society to buy two more drug-checking machines. Drug checking is an emerging harm reduction strategy that may help prevent overdose deaths. The new Fourier-Transform Infrared Spectrometers (FTIR) will rotate between supervised consumption sites and overdose prevention sites in Vancouver. They can test a range of substances, including opioids, stimulants and other psychoactive drugs such as MDMA. The machines work by identifying the molecular fingerprint for each drug sample.

FOURIER TRANSFORM INFRARED SPECTROMETER (FTIR Spectrometer) • Detects a wide variety of compounds as well as fentanyl and fentanyl analogues; • Can provide information about how much of a substance is present; • Portable (desktop-size machine); • Analyzes a sample in under two minutes. “Contaminated street drugs are taking lives every single day so we are always looking to add more innovative tools to our toolbox,” says Judy Darcy, Minister of Mental Health and Addictions. “The more knowledge we have about what is contaminating the illegal drug supply the better equipped we are to stem the tide of the overdose crisis.” “We know that drug-checking along with other harm reduction practices and programs can help people make safer choices,” says VCH Medical Health Officer Dr. Mark Lysyshyn. A recently published study by Dr. Lysyshyn and other substance-use experts found people who received a positive drug check before using drugs were 10 times more likely to reduce their dose and 25 per cent less likely to overdose.

VCH drug checking technician Jeremy Kalicum and PHS Community Services Society peer supervisor Daniel Beaverstock check a drug sample with new spectrometer. “When people come in to check their drugs it can encourage them to use their drugs in a supervised setting so they’re not using alone and overdosing alone, says Amy Villis, director of health services, Lookout Housing and Health Society. “We know that using alone is a huge risk factor when it comes to dying of a drug overdose, and no one has ever died of an overdose at an overdose prevention site or a supervised consumption site.” Vancouver Coastal Health currently uses two drug-checking technologies: the FTIR Spectrometer and fentanyl test strips. The test strips detect the presence of fentanyl, including some fentanyl analogues like carfentanil. The strips are more widely available than the spectrometer, but don’t

give the detailed chemical makeup of a substance. Both methods provide an opportunity to connect drug users to other services and supports, and ensure they have life-saving take home naloxone kits.

BENEFITS OF DRUG CHECKING • Increase awareness of fentanyl and other contaminants; • Encourage discussion about harm reduction; • Track the toxicity of the drug supply. “The new spectrometers are another asset in our arsenal of education, overdose prevention and harm reduction tools,” says Coco Culbertson, senior manager, PHS Community Services Society. “We’re looking for-

ward to reaching out to the broader community so that drug users across the region feel welcome to check their drugs. We’re optimistic that this tool will be informative to both drug consumers in the Downtown Eastside and the broader community of drug users.” Vancouver Coastal Health is responsible for the delivery of $3.3 billion in community, hospital and residential care to more than one million people in communities including Richmond, Vancouver, the North Shore, Sunshine Coast, Sea to Sky corridor, Powell River, Bella Bella and Bella Coola. VCH also provides specialized care and services for people throughout BC, and is the province’s hub of health care education H and research. ■

Carrie Stefanson is the Public Affairs Leader at Vancouver Coastal Health. 48 HOSPITAL NEWS NOVEMBER 2018

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NEWS

New clinical protocol

after general surgery cuts opioid prescribing in half n recent years deaths from opioid overdoses have become one of the most common injury-related deaths in North America. The continent also has the highest per capita rate of opioid prescription in the world. Recognizing the role that opioid prescribing plays in the national opioid crisis, a team of researchers at Lawson Health Research Institute and Western University have developed a new clinical protocol called STOP Narcotics. A study demonstrating the efficacy of their protocol was presented at the American College of Surgeons Clinical Congress in Boston, Massachusetts on October 24. The protocol includes a combination of patient and healthcare provider education and an emphasis on non-opioid pain control. The study found that they were able to reduce the overall amount of opioids being prescribed after general surgery by 50 per cent while still adequately treating a patient’s post-operative pain. “By significantly reducing the amount of opioids prescribed, this decreases the exposure risk and potential for misuse of narcotic medication,” says Dr. Luke Hartford, a resident in general surgery at Western’s Schulich School of Medicine & Dentistry and first author on the study. “This also decreases excess medication available to be diverted to individuals for whom it was not intended.” The study involved 416 patients at London Health Sciences Centre (LHSC) and St. Joseph’s Health Care London who underwent laparoscopic cholecystectomy or open hernia repair. They received medication for post-operative pain through the standardized protocol, specifically acetaminophen (Tylenol) and a non-steroidal anti-inflammatory drug (Naproxen) for the first 72 hours post-surgery.

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THE RESULTS SHOWED THAT IN THE STOP NARCOTICS GROUP, COMPARED TO A CONTROL GROUP, THERE WAS A 50 PER CENT REDUCTION IN THE NUMBER OF OPIOIDS BEING PRESCRIBED. The protocol instructs physicians to write a limited prescription of 10 pills of opioids (Tramadol), with an expiry date of seven days after surgery, with instructions for the patient to fill this prescription only if adequate pain control was not otherwise achieved. There are also instructions on proper disposal of unused medication for the patient. Dr. Ken Leslie, scientist at Lawson, associate professor in the Department of Surgery at Schulich Medicine & Dentistry, and Chair/Chief of the Division of General Surgery at London Health Sciences Centre led the implementation of the new protocol. “We recognized that before STOP Narcotics, every surgeon had a different approach to pain control, and that most surgeons were prescribing more narcotics than are actually needed,” says Dr. Leslie. “When we looked at the data from this new protocol, we saw that the patient’s pain-control was just as good with this pathway, without a huge prescription for narcotics.” The results showed that in the STOP narcotics group, compared to a control group, there was a 50 per cent reduction in the number of opioids being prescribed. They also demonstrated that only 45 per cent of patients actually filled their opioid prescription, compared to 95 per cent in the control group, and they were also able to increase appropriate disposal of excess opioid medication from seven per cent in the control group to 23 per cent in

the STOP Narcotics group. The levels of reported post-operative pain were the same in both groups. The group now hopes to expand the protocol for applications beyond general surgery. “If we can decrease the opioid exposure risk in our patients, and

decrease the amount of excess medication available for diversion, and spread this to other institutions and surgical procedures and specialities, this has the potential to significantly impact the opioid crisis,” says Dr. Patrick Murphy, a resident in general surgery at Schulich Medicine & Dentistry and co-author on the study. The study, “The Standardization of Outpatient Procedure (STOP) Narcotics: A Prospective Noninferiority Study to Reduce Opioid Use in Outpatient General Surgical Procedures,” is published in the Journal of the AmerH ican College of Surgeons. ■

NOVEMBER 2018 HOSPITAL NEWS 49

LONG-TERM CARE NEWS

Digestive changes with aging:

Lower digestive tract By Dale Mayerson and Karen Thompson iseases of the lower digestive tract can cause pain, embarrassment and isolation for seniors in longterm care. The lower digestive tract includes the small intestine and the large intestine, which is also known as the colon.

STRUCTURE AND FUNCTION The small intestine is approximately seven metres long and is coiled in the abdomen. It is referred to as “small” because it is narrow. Partially digested food from the stomach enters the small intestine where it is bathed in digestive enzymes from the pancreas and bile from the gall bladder. These enzymes help to further break down food particles and release nutrients, which are

then absorbed into the blood stream and transported throughout the body. After these nutrients are absorbed, the next step is removal of waste material through the large intestine. This waste can include undigested plant skins, excess bile and other materials. The large intestine is about 1.5 metres long and wraps around the small intestine. As the waste travels through the large intestine, water is absorbed back into the body. The waste material condenses and solidifies as it moves through the large intestine, and is evacuated through the anus in the process of defecation.

THE MICROBIOME The large intestine is home to about 700 types of bacteria numbering approximately 100 trillion. This bacterial

environment is known as the “microbiome” and there is growing evidence that these bacteria are an important factor in our health. The microbiome is affected by where we were born, what we eat, how we live, and other factors. Imbalances in the microbiome are now being associated with certain diseases, including diabetes, asthma, autism and even acne. Research is ongoing and we can look forward to learning more about the microbiome in the future.

CONDITIONS IN THE LOWER DIGESTIVE TRACT

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Lactose intolerance is due to the lack of an enzyme in the small intestine that breaks apart the milk sugar called lactose. Lactose is made up of two molecules linked together that must be separated to be absorbed into the blood stream from the small intestine. If the body does not make the necessary enzyme, these two molecules stay linked and can cause intestinal gas, bloating, pain, and rectal bleeding. Fortunately, there are now many lactose free products available, making it easier to follow a reduced lactose free diet than in the past.

Celiac disease requires a lifelong avoidance of gluten, which is the protein found in the grains rye, barley and wheat (including triticale, spelt and couscous). Oats are contaminated in the fields by “drift” and only oats marked as “gluten free” are allowed. Gluten triggers an immune response in the body, causing the lining of the small intestine to malfunction, leading to the possibility of anemia, osteoporosis and malnutrition. The intestine returns to normal after about six months of following a gluten free diet. Constipation may be diagnosed when bowel movements are hard to pass, infrequent, or cause bloating, pain and discomfort. This situation can develop from lack of fibre in the diet, from poor food and fluid intake, lack of exercise, and from neurological conditions. They can become worse for someone who depends regularly on over the counter laxatives. Constipation is also a common side effect of certain medications. Chronic constipation may lead to rectal bleeding and/or haemorrhoids that can be painful and interfere with a person’s daily activities and interactions. www.hospitalnews.com

LONG-TERM CARE NEWS

EACH MEDICAL CONDITION OF THE LOWER DIGESTIVE TRACT HAS ITS OWN COURSE OF MEDICATIONS AND TREATMENTS. Diarrhea is the presence of loose or watery bowel movements, where the movement of food through the digestive system is too fast. Occasional diarrhea can happen as a result of food poisoning, but can also be due to food intolerances, or as a side effect of medications. Doctors are challenged to diagnose reasons for chronic diarrhea, although there are many digestive problems that can cause diarrhea as a side effect. Dehydration is a big concern, since water does not have a chance to be reabsorbed back into the body as it would with normal transit time through the intestine, leaving the person water deficient and eventually malnourished. Irritable Bowel Syndrome (IBS) is a disorder that affects the large intestine. Signs and symptoms include cramping, abdominal pain, bloating, gas, and diarrhea or constipation, or both. Doctors depend on patient symptoms to

diagnose IBS, since there are no definitive medical tests to identify the illness. However, internal imaging tests are helpful to check for problems. Ulcerative Colitis is a severe inflammation of the inner lining of the colon that interferes with the body’s ability to digest food and absorb nutrients. Symptoms can include severe and bloody diarrhea, abdominal pain and cramping, nausea and vomiting, decreased appetite, weight loss, mild fever, anemia and loss of body fluids. Crohn’s disease is an inflammation of any part of the digestive system, but appears most often in the area where the small and large intestine join. Patches of inflammation are intermittent in the intestine, and in serious cases can penetrate through the lining of the intestinal wall. Symptoms may include diarrhea, abdominal and anal pain and cramping, blood in the stool.

Diverticulosis is the development of “diverticula” or small pouches that develop over time along the inner lining of the large intestine. Diverticulosis has no symptoms but paves the way for diverticulitis, which is an inflammation in the diverticula. This happens when seed remains and other fibres are trapped in the diverticula and lead to an abscess, infection and in more severe cases a perforation in the intestine.

HOW TO MANAGE LOWER DIGESTIVE TRACT ISSUES All issues are diagnosed and strategies for management are individualized. Each medical condition of the lower digestive tract has its own course of medications and treatments. There are, however, some basic ways that residents in LTC can avoid or minimize the pain and discomfort of

these illnesses. It is essential to eat a healthy diet with whole foods and an adequate amount of fibre. Fibre comes from whole grains, vegetables, fruits and other plant foods. Fluids are also needed to promote a healthy digestive system – this can be in the form of water, milk, juice, tea and coffee, as well as high fluid foods such as soup, salad, yogurt and pudding. Daily physical activity of any kind also helps the digestive system to work more effectively – staying in bed or sitting all day in a wheelchair can make these digestive problems worse. Encourage gentle movement and ask for support from the LTC home to support a healthy lifestyle for residents as much as possible. Simple diet and exercise changes will improve health, or at least, work to prevent worsening digestive illness H and disease complications. ■

Dale Mayerson, B Sc, RD, CDE, and Karen Thompson, B A Sc, RD are Registered Dietitians with extensive experience in Long-term care. They are co-authors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide” and have participated for many years on the Ontario Long Term Care Action Group, an advocacy group of Dietitians in Canada.

LONG-TERM CARE NEWS

Reducing

harm

from unnecessary antibiotic use in long-term care By Rita Ha and Bradley Langford t has been estimated that up to 50 per cent of prescribed antibiotics in longterm care homes (LTCH) are not needed. Overuse of antibiotics, particularly in older adults, has been associated with an increased risk of harm. These harms include increased risk of side effects, Clostridium difficile infection (CDI), and infection with antimicrobial-resistant organisms (AROs). Infections with AROs in long-term care residents are also associated with more severe infection, hospitalization, increased risk of death and increased cost of care. Antibiotic overuse also contributes to increasing rates of antimicrobial resistance, which has become a significant public health concern. A retrospective analysis by Daneman et al (JAMA Internal Medicine 2013) examined the prevalence of antibiotic use in LTCHs in Ontario and found the majority of treatment courses were at least 10 days in duration. Yet, randomized controlled trials and meta-analyses have demonstrated that short courses of antibiotics (seven days or less) for commonly seen infections in long-term care, including cystitis, pneumonia and cellulitis, result in similar outcomes compared to long durations (more than seven days). Additional advantages to short courses include less risk of side effects, less risk of CDI, and less risk of AROs. Public Health Ontario has developed two suites of resources to address the overuse of antibiotics in long-term

care. The first suite, titled Shorter Is Smarter, focuses on the evidence to support shorter courses of antibiotic treatment for long-term care residents. The second suite, titled Antimicrobial Stewardship Essentials in Long-Term Care, aims to help guide LTCHs to develop an antimicrobial stewardship program (ASP).

SHORTER IS SMARTER All antibiotic use drives antimicrobial resistance. Prolonged antibiotic use kills susceptible bacteria and allows resistant organisms to thrive and multiply. When shorter courses of antibiotics are as effective as longer courses, prolonged antibiotic use promotes unnecessary antimicrobial resistance. We encourage long-term care prescribers to prescribe short durations of therapy, when appropriate, especially in cystitis, pneumonia and cellulitis.

RECOMMENDATIONS TO REDUCE DURATION OF ANTIBIOTIC TREATMENT FOR COMMON INFECTIONS IN LONG-TERM CARE • Cystitis: Treat ≤ 7 days. For uncomplicated cystitis, evidence supports 3 days of trimethoprim-sulfamethoxazole or ciprofloxacin, or 5 days of nitrofurantoin. Asymptomatic bacteriuria should not be treated in long-term care. • Cellulitis: Treat 5-7 days. Treatment for 5 to 7 days is appropriate

ANTIMICROBIAL STEWARDSHIP IS AN APPROACH TO ENSURE ANTIBIOTICS ARE AND REMAIN EFFECTIVE FOR INDIVIDUALS AND THE POPULATION IN GENERAL as long as there has been some improvement in erythema, warmth, tenderness, or edema. • Pneumonia: Treat 5-7 days. Treatment for 5 to 7 days is appropriate in residents with pneumonia who are clinically stable and afebrile for 48 to 72 hours.

ANTIMICROBIAL STEWARDSHIP ESSENTIALS IN LONGTERM CARE Antimicrobial stewardship is an approach to ensure antibiotics are and remain effective for individuals and the population in general. While there is much focus on antimicrobial stewardship in hospitals, it is recognized antibiotic use needs to be addressed in long-term care as well. Long-term care residents present unique challenges to antimicrobial stewardship. The perception of risk can be variable amongst clinicians, caregivers and family members of residents. Antibiotics are often prescribed due to subjective influences, even when there is little evidence antibiotics will benefit. Yet, we know they are a vulnerable population, prone to infection and colonization with AROs. Antimicrobial steward-

ship involves implementing strategies that target influences and decisions around antibiotic prescribing that can be modified through knowledge and behaviour changes. Quality improvement steps for an ASP may begin with forming a comprehensive team that can impact antibiotic use in the home, and setting antibiotic use criteria and guidelines for common infections. Evidence-based antimicrobial stewardship strategies selected for implementation should be monitored and evaluated for changes in clinical outcomes to residents and antibiotic use metrics in the home. Continuous quality improvement and feedback will also ensure antimicrobial stewardship efforts and awareness are sustainable within the home. We encourage LTCHs to approach antimicrobial stewardship as an evidence-based quality improvement initiative. Understand the key components of antimicrobial stewardship programs and explore examples of successful antimicrobial stewardship initiatives and evidence-based strategies. Promoting the judicious use of antibiotics can improve the quality of care and support the safety of longH term care residents.■

Rita Ha is a Pharmacist Consultant and Bradley Langford is the Pharmacist Lead of the Antimicrobial Stewardship Program at Public Health Ontario. 52 HOSPITAL NEWS NOVEMBER 2018

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LONG-TERM CARE NEWS

How can seniors care not be seen as a

‘risky business’? By Michael Kary here are times when almost on a weekly basis it seems like the news media in Canada report on the alleged mistreatment of, or substandard care being provided to seniors in long-term care, assisted living or home health. These stories have entered the public’s consciousness, helping them to form a negative impression of seniors care. In particular, the tragic Elizabeth Wettlaufer case in Ontario where a nurse was charged with the murder of eight residents in an Ontario longterm care home has caused shockwaves among seniors, their families, and among care providers themselves. While not on the same scale as the horror surrounding the Wettlaufer case, other stories showcasing elder abuse or mistreatment have also shaped a narrative around seniors care. For example, while a September 2018 BC Office of the Seniors Advocate report highlighted significant reductions in the use of antipsychotics in long term care (about 31.2% decline over five years), this positive development was largely overshadowed by media reports that showed the use of these drugs as way too high. Not surprisingly, these news reports feed into a public perception where seniors are being over-medicated, elder abuse is running rampant, and that the care being provided to seniors is of poor quality. Long-term care, in particular, has been challenged by stories describing substandard care. However, it overshadows what most family members and care providers know – that excellent, vital care is delivered daily in the overwhelming majority care homes across Canada. This does not mean seniors care providers do not have a responsibility to address service gaps where they exist. But the sector does have a role to play in preserving its own reputation. By not telling a more positive story, there are several implications. Along with stigmatizing views associated with continuing care, these perceptions can make it more difficult

to recruit much needed health professionals to seniors care. Overall, many seniors when surveyed are quite satisfied with the care they receive. Care providers themselves work hard to improve the quality of seniors lives, and also say they are happy with their career choice. Such a narrative may overshadow many of the positive stories – like system wide improvements in providing care, or improving quality of life for seniors including reductions in use of antipsychotics, or the many heart-warming stories that are occurring daily in seniors care. So how do care providers address the challenge they face from negative stories? Of course, they must ensure that the care is excellent. But what else can the sector do? BC Care Providers Association (BCCPA) will be diving into a discussion on this topic at a special Care to Chat on November 23, 2018 entitled Risky Business, at the Terminal City Club in downtown Vancouver. For this Care to Chat, panelists representing both national seniors care companies and the media will have a frank discussion regarding the current state of continuing care in BC and Canada, as well as how it is portrayed in the media. The panel will also discuss ways to proactively represent the positive side of the work happening in seniors care, including through crisis management, as well as better dealing with the stigma and misconceptions of continuing care. This event also builds on an April 2015 Care to Chat BCCPA hosted, which looked at some of the prevailing myths and misconceptions of BC’s continuing care sector following a major public survey undertaken by BCCPA earlier that same year. We hope you can join us November 23rd for what is expected to be a very engaging and productive discussion. In particular, we hope you will join us and the panel to share your ideas on how we all can work together to address reputaH tion challenges facing the sector. ■

Michael Kary is Director of Policy & Research at BCCPA. 54 HOSPITAL NEWS NOVEMBER 2018

A demonstration of Motiview

Want to innovate in seniors’ care?

Collaborate By Rebecca Ihilchik anada is undergoing an extraordinary demographic transformation. By the year 2036, those aged 65 or over will make up 25 per cent of the population, according to Statistics Canada. And we’re far from alone. The World Health Organization predicts that by 2050, the

world’s population aged 60 years and older will double from about 900 million to more than two billion. As the population ages, so does the number of older adults with dementia. Nearly 7.7 million new cases of dementia are diagnosed every year worldwide. As existing healthcare approaches struggle to keep up with this demo-

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LONG-TERM CARE NEWS

graphic shift, an exciting innovation boom is occurring in seniors’ care. But in order for innovation to have a broad and lasting impact, healthcare professionals, industry, and medical and technology-based organizations can’t work in silos. Innovation thrives through collaboration. How can this be accomplished? At the Baycrest-led Centre for Aging + Brain Health Innovation (CABHI), we make sure good ideas get the exposure they deserve by building strong partnerships. CABHI helps innovators in Canada and around the world to develop, test, validate, and accelerate their promising innovations in the field of aging and brain health, ensuring the brightest solutions in seniors’ care are shared and adopted across borders. CABHI currently supports more than 195 projects, including international innovations from the United States, Portugal, Norway, Israel, and Taiwan, amongst other countries.

IN ORDER FOR INNOVATION TO HAVE A BROAD AND LASTING IMPACT, HEALTHCARE PROFESSIONALS, INDUSTRY, AND MEDICAL AND TECHNOLOGY-BASED ORGANIZATIONS CAN’T WORK IN SILOS. INNOVATION THRIVES THROUGH COLLABORATION. One such CABHI partner is Norwegian company Motitech, which is the creator of Motiview: a motivational device that encourages exercise in older adults and people with dementia. Users are positioned on a stationary bicycle in front of a screen that simulates views of landscapes from around the world. The technology has been in use in Europe since 2012, but Motitech faced obstacles engaging an unfamiliar North American market. CABHI matched Motitech with three leading seniors’ care organizations in Canada in order to validate the technology in a North American setting. The scientific evi-

dence gathered from these trials will be used to accelerate the product to the Canadian market. The partnership also benefits the seniors’ care organizations and older adults in their care, who are now are able to access a cutting-edge technology they may not have otherwise had an opportunity to explore. One trial site resident who used the technology mentioned that she “loved” using Motiview to exercise. “Usually, it’s so boring that I would get off one of these bikes,” she said. “But I spent a good five minutes on the bike, which is great considering my lung capacity.”

This Norwegian-Canadian CABHI collaboration is one of many. CABHI projects have engaged more than 500 partners and collaborators, and CABHI is continuously forming strong new partnerships — all of which result in healthier patients, better-equipped healthcare professionals, and a stronger, diversified healthcare system. Many older adults, caregivers, healthcare professionals, and innovators face similar types of challenges when it comes to aging and providing care for an aging population. By taking advantage of the expertise, intellectual capital, and original thinking from around the globe, CABHI can innovate together with our partners to tangibly impact health outcomes for the world’s aging population. Most importantly, we can provide each older adult with the best aging experience the world has to offer. Interested in learning more? Visit www.cabhi.com or get in touch at H info@cabhi.com. ■

Rebecca Ihilchik is the Marketing & Communications Specialist at the Centre for Aging + Brain Health Innovation (CABHI).

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LONG-TERM CARE NEWS

New app aims to help people in early stages of dementia By Margaret Polanyi new mobile app aims to help people with early dementia or mild cognitive impairment to manage daily activities and keep track of how they are doing, providing greater independence. The novel technology guides users through their day. Using audio, text or visual prompts, it reminds people to carry out tasks and activities such as taking medications, going to appointments, preparing meals as well as making healthy food choices. Called DataDay, the app also helps people track their cognition, mood and physical activity. It captures information as users engage with it, reminding them what they’ve done and charting any changes in their condition. Its name is a play on “day-to-day” because it structures and follows users’ daily routines. Canadian dementia researcher Dr. Arlene Astell spent nine years developing DataDay, which was unveiled at the AGE-WELL Annual Conference in Vancouver. Dr. Astell co-cre-

ated the app with people who have dementia. “Most people, once they have a diagnosis go home and live life with dementia. We want to give people something they can use for personal support and to keep track of how they are doing,” explains Dr. Astell, who holds a Research Chair in Dementia Wellbeing at the Ontario Shores Centre for Mental Health Sciences in Whitby, Ontario. AGE-WELL supported research focusing on the needs of older adults, caregivers and clinicians in using the app, while the Baycrest-led Centre for Aging + Brain Health Innovation (CABHI) financed the technical development of the app and portal. UKbased New Dynamics of Aging funded the first phase of the technology. Beta testing of DataDay is now starting in the Durham Region in Ontario. The app, or a device with it installed, will be provided initially to patients of local memory assessment clinics, which will keep track of users through a special portal for those who opt in.

DataDay is made for Apple and android smart phones and tablets. “We’ve made the way you interact with it and the type of information collected responsive to what users would like. They helped shape it,” says Dr. Astell. One of them is Alex Vanderzand, 75, of Pickering, Ont., who was diagnosed with mild cognitive impairment in 2014 and feels that DataDay will be a “real benefit” to keep track of activities and record what he’s done each day. “When I first got the diagnosis, I felt like I was thrown to the wolves,” says Vanderzand, who is especially concerned about being a burden to his wife Penny, 73. She’s also part of the testing process for the app and thinks caregivers will find it helpful too. “It’s going to give everybody a tool to help function,” she says. DataDay is designed for people with a range of types of dementia, including Alzheimer’s disease, frontotemporal dementia and primary progressive aphasia. It is intended for use from the early stages of cognitive decline to

moderate dementia, and for mild cognitive impairment, which many people experience before dementia. “The aim is for people to start using DataDay as early as possible. We hope that once the app becomes part of their daily routine, they will keep using it as their dementia progresses,” says Dr. Astell, adding that it is best if a health service, such as a memory clinic, assists with set up and monitoring. Once the early roll-out in Durham is completed in March 2019, the plan is to make the app widely available through memory clinics. A French version will be created. By capturing accurate information on how someone is doing, the app can help users, caregivers and their clinicians decide whether or not additional health services are needed. It’s hoped that this will cut down on emergency room visits, she says. “We can give people with dementia some control over their lives – and better plan services when they need H help.” ■

Margaret Polanyi is Senior Communications Manager, AGE-WELL Network of Centres of Excellence (NCE). 56 HOSPITAL NEWS NOVEMBER 2018

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LONG-TERM CARE NEWS

Fall Prevention Month:

Where are the resources? By Marguerite Oberle Thomas

ospital staff has good reason to express concern about falls in the workplace. Thankfully, help is

available. November is Fall Prevention Month. Organizations and individuals in Canada and beyond are encouraged to come together this November to coordinate fall prevention efforts for a larger impact. The campaign supports this goal by providing a website to facilitate knowledge and resource sharing. Now in its fourth year, the Fall Prevention Partners continue to promote the motto “It takes a community to prevent a fall: we all have a role to play.” It’s not too late to check out the website which offers toolkits of evidence-informed resources, and a calendar where people can post events they are hosting. Organizations can participate by sharing resources, taking

ideas for activities from the toolkit and adapting them to their own setting, and sharing them on our calendar. New this year, the campaign offers a toolkit supporting children’s fall prevention (ages 0-6). The Fall Prevention Community of Practice, sponsored by the Ontario Neurotrauma Foundation, offers the opportunity to join the no-cost communication platform Loop. Via Loop, the CoP can provide setting-specific knowledge as well as sharing falls prevention knowledge from a variety of geographic settings. We strive to provide evidence informed and promising practices to all our members. Started in 2015, the Loop discussion section connects members with each other as well as with our knowledge centre. Examples of recent topics include: •Non slippery flooring, compliant flooring

Personalized home care services

Support is just a phone call away.

•Assessment tools, screening tools •Lighting when arising at night With over 2300 members, you can tap into “on the ground” experiences as well as learn about other knowledge products. The Registered Nurses of Ontario Clinical Best Practice Guidelines (RNAO BPGs) contain a wealth of knowledge on preventing falls and reducing injuries from falls – everything from assessments to universal precautions to policies. Another Partner organization, Osteoporosis Canada published “Putting the Brakes on Breaks” – a bone health program with three main pillars: Fall Prevention, Osteoporosis Identification and Management and Post Fracture Care. Join us on Loop for the latest in fall prevention – ongoing newsletters, webinars, event notices, private groups, workspaces and knowledge H sharing. ■

Falls in Canada

• Falls cause 85% of seniors' injury-related hospitalizations, 95% of all hip fractures, $2 billion a year in direct healthcare costs, and over one third of seniors are admitted to long-term care following hospitalization for a fall. • The average Canadian senior had to stay in hospital 10 days longer for falls than for any other cause. • Falls can result in chronic pain, reduced mobility, loss of independence and even death. • Fifty percent of all falls causing hospitalization happen at home. • Injuries due to falls rose 43% between 2003 and 2008. • Deaths due to falls rose 65% between 2003 and 2008. • The good news is that falls are preventable and action can be taken by all. Read the full report for more at: www.publichealth.gc.ca/seniors

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NOVEMBER 2018 HOSPITAL NEWS 57

FROM THE CEO’S DESK

Children’s health care network is advancing pediatric care across Ontario By Lauren Ettin aking care of a child who is sick is one of the most emotionally, and often physically, challenging tasks faced by families and caregivers. And navigating the province’s complex health and social systems can make this even tougher. We’ve heard from families that services can be fragmented, inconsistent and poorly coordinated, and that they can’t always get the care they need in their own communities. All of this can negatively impact a child’s health. For these reasons, The Hospital for Sick Children, CHEO, and Holland Bloorview Kids Rehabilitation Hospital established Kids Health Alliance (KHA) in 2017. KHA is a not-forprofit network of healthcare organizations that collaborate to make tangible improvements in care for children and youth. The network currently includes the three founding specialty pediatric hospitals and five community hospitals in Southern and Eastern Ontario. Underpinning our network are a number of key guiding principles, including a commitment to patient-centred care that helps ensure children and youth are able to access the best care when they need it and where they need it. We are committed to leveraging the unique expertise of all of our partners, facilitating the spread and scale of what we know works, making evidence-based decisions and planning for sustainability from the start to ensure we are using resources efficiently and effectively. KHA’s first major initiative is advancing care for children in community hospital emergency departments. We know that 85 per cent of children and youth go to their local emergency department rather than a pediatric hospital when they need urgent care. Through KHA, community hospital partners have participated in pediatric-focused clinical skill building and simulation training, implemented

Lauren Ettin

WE KNOW THAT 85 PER CENT OF CHILDREN AND YOUTH GO TO THEIR LOCAL EMERGENCY DEPARTMENT RATHER THAN A PEDIATRIC HOSPITAL WHEN THEY NEED URGENT CARE. best-practices in pediatric care, monitored and managed pediatric-specific data to inform quality improvements, established collaborative communities of practice, and focused on creating child-friendly approaches to care. We are also working on implementing a common approach to treating children presenting to emergency departments with symptoms of asthma. Together, we have celebrated the success of our partners. Markham Stouffville Hospital has reported that due to support from KHA for skill

building and simulation training, they have identified several quality improvement opportunities – including implementing a best practice for sepsis management. Orillia Soldiers’ Memorial Hospital has focused on improving a child’s journey in the hospital and has developed a Pediatric Emergency Department Scorecard to help manage and monitor pediatric cases. KHA has helped Pembroke Regional Hospital bring more pediatric expertise to front line care, and plan ways to make their physical space more child friendly. Our

newest partner, Humber River Hospital, has already started seeing the benefits of bringing together various areas of the hospital that provide care to children and youth. In addition to focusing on quality and safety in emergency departments, KHA community hospital partners will continue to advance their commitment to excellence in pediatric care delivery by extending work into neonatal intensive care and inpatient units. All of these tangible improvements not only mean better care for children and families, but also represent a more efficient way of delivering healthcare. Through KHA, partners don’t have to work in isolation when it comes to providing the best care possible for children; together, they can access a community of support and expertise, and implement evidence-based improvements more quickly. As we continue to grow our KHA network with additional community hospitals, we are also actively exploring other partnership opportunities. A child’s health journey may take them through a complex system that includes specialized pediatric hospitals, community hospitals, community pediatricians, mental health services, children’s development and rehabilitation services, and homecare services. We are aiming to expand the KHA network to include organizations across the continuum of care so that care is more consistent and coordinated, of high quality, with seamless transitions between providers. Sustainable, impactful change in the delivery of pediatric healthcare requires collective commitment, a relentless focus on quality and safety, and deliberate alignment of priorities focused on efficiencies. We know that by working together to improve access and health outcomes for children and youth across Ontario, our best can be H even better. ■

Lauren Ettin is the Executive Director of the Kids Health Alliance. 58 HOSPITAL NEWS NOVEMBER 2018

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NEWS

The hospital of the future and wireless power By Michael Gotlieb echnology giants like Google, Apple and Microsoft are moving into healthcare technology as opportunities emerge in a growing market. Healthcare organizations are going through a digital transformation with administrators under pressure to introduce innovative solutions into their hospital infrastructure. As Apple’s CEO Tim Cook stated when he introduced the Apple Watch, “health care is big for Apple’s future.” In addition to mobile devices, other disruptive technologies like artificial intelligence and robotics (for surgery and as service robots) have immense potential for increasing hospital efficiencies, reducing costs and improving patient outcomes. An emerging technology that’s poised to make its way into hospitals is wireless power. Wireless power technology for the consumer market started back in the 1990s with the electric toothbrush. Since then, it has shifted into commercial applications such as mobile phones, as industries are turning to wireless power to reduce battery anxiety and the use of cables and connectors. Battery power is consistently identified as an issue in clinical settings – and with good reason. Poor battery management can knock medical devices out of action and compromise patient care. It can also cost hospitals a lot of money, not to mention causing battery anxiety. Similarly, charging cables and cords open up the possibility of people tripping over them, or bending to plug them in, thereby risking injury or worse; forgetting to plug them in altogether. From a health and safety perspective, reducing the number of cables and cords can improve the safety and efficiency of healthcare workers. Mobile access to medical equipment is becoming more important than ever before. Medical carts, diagnostic equipment, hospital beds and medical monitors are constantly moved between locations in a hospital and re-

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quire a reliable charging source. “Has anyone seen the power cord?” “Is this charged?” I bet this sounds familiar. Medical equipment manufacturers are paying attention to wireless power and finding ways to integrate it into their next-generation products. Breakthroughs in wireless power technology are enabling it to do more and go further. In much the same way that our phones and televisions are ‘smart,’ we are building intelligence into the next generation of wireless power technology, and healthcare environments can leverage this built-in intelligence to increase operational efficiencies. Medical carts, hospital beds, power wheel chairs, automated cleaning robots and surgical instruments are just some of the equipment using this leading-edge technology. And we can expect to see a lot more. Take the example of a critically-ill patient being cared for with the help of multiple electronic monitors and pumps. With wireless power, the patient can be easily moved between medical units for tests and procedures. There will be no issues with battery drainage and plugging in multiple devices when the patient is being moved. The entire time the patient is being moved, the electronic monitors are being ‘trickle’ charged using wireless power with charging spots set up in stations in the hospital. “Medical technologies are bringing benefits to the healthcare industry, resulting in greater operational efficiencies,” says Dr. Greg Browne, Vascular Surgeon at St. Clare’s Mercy Hospital in St. John’s, Newfoundland. “Ensuring that the equipment doctors and nurses use to care for and monitor patients is charged as it is moved around the hospital, is something we depend on. If some of the devices and equipment can be charged using wireless power, it would certainly be a benefit.” Today, a hospital room with a wireless power transmitter can replace or

extend a wall receptacle powering medical equipment by merely setting the device near the power plate so physicians and patient care teams don’t need to worry about making an effort to charge equipment. The work we’re doing in our power electronics lab is taking wireless power to new levels by combining proximity sensing, data communications and wireless power into a single utility. The hospital of the future will have multiple applications powering wirelessly, performing the function that’s expected of them – without staff stressing about battery status.

The nature of wireless power technology makes it easy to integrate into existing applications with a high safety rating. The non-heating of metal, capacitive sensing, delivery of high power levels and other performance characteristics, make it practical for users to take advantage. You can expect to see more medical equipment with built-in wireless power charging in the future. The impact of this disruptive technology will be positive. Staff will use the equipment will use it as they always have without having to worry about power outlets and H batteries. ■

Michael Gotlieb is the CEO of Solace Power, a Canadian developer of next-generation wireless power solutions. For more information, visit www.solace.ca.

NOVEMBER 2018 HOSPITAL NEWS 59

ETHICS

What to wear?

The ethical benefits and challenges of wearable devices By Andria Bianchi he prevalence of using wearable devices to monitor aspects related to one’s health has increased in recent years. Some devices have functions that are meant to serve specific populations, such as electronic glasses for people with low vision, bionic exoskeleton suits for people with lower extremity weakness, and smartwatches with applications that are used to detect, and potentially predict, seizures. In addition to devices that are meant to benefit people with particular health conditions, other wearable devices are becoming frequently used among our entire population. The Fitbit is an example of a wearable device that is used by people who want to monitor aspects related to their health, even if they do not necessarily have health concerns that will directly benefit from constant monitoring at the present time. The Fitbit can be used to calculate one’s heart rate, the number of steps that one takes, the amount of time that one exercises, sleeps, etc. Other companies have developed similar products given the increased demand for wearable devices. Wearable devices may help people who want to be held accountable to someone/something when it comes to managing aspects related to their health. Consequently, these devices may lead to positive health-related outcomes. However, there are also many uncertainties and ethical concerns about how wearable devices can and might be used. Questions about privacy, safety, and data management are often considered by ethicists and other professionals alike. Some of these questions are: Where is a person’s information being stored? Who owns the data? Can a person withdraw their data once collected? Is it possible that a person’s data could influence their health, travel, and/or life insurance?

A response to the last question was recently provided by John Hancock, a U.S. division of Manulife (a Canadian insurance company). As reported by The Conversation and the Canadian Broadcasting Corporation, John Hancock has a life insurance program that offers people the opportunity to save on their insurance premiums and obtain other rewards if they use wearable devices with activity trackers. Although customers are not required to track their activities, they will have the opportunity to receive benefits and discounts if they do. Some ethical concerns about the John Hancock program have been highlighted in recent reports. For instance, John Hancock’s role in data interpretation and ownership, as well as how personal data may be used in the future are questioned from a privacy standpoint. The accuracy of activity trackers is also a concern. The

Fitbit algorithm is specifically designed to calculate steps and so it may not acquire accurate information about other activities (e.g. swimming, biking, etc.). This is problematic if insurance premiums are based on calculated activity levels. Another ethics consideration is that of equity. The principle of equity involves providing people with the means to attain equal opportunities based on their individual circumstances, and the John Hancock program may be problematic from this perspective. If insurance premiums depend on information acquired from activity trackers, then it seems likely that members of our society who are already disadvantaged may be the ones who are required to pay more. One reason that some people may be required to pay higher premiums is because those with financial constraints may not be able to purchase a wearable device. Furthermore, even if people

can purchase fitness trackers, their life circumstances may prevent them from being active. For instance, a single parent working two jobs, a person with physical impairments, a caregiver who is unable to leave home, etc. may not be active enough to attain insurance benefits. The idea that these populations ought to pay higher premiums because of their life circumstances is of ethical significance. Ultimately, I recognize that wearable devices can contribute to beneficial outcomes. I do, however, wonder whether consumers are provided with sufficient information to make purchasing choices that align with their values, preferences, and beliefs regarding the current and potential future state of society. Given the rate at which technology continues to advance, we ought to consider the ethical strengths and vulnerabilities of these devices to help prevent and mitH igate potential risks. ■

Andria Bianchi, PhD, is a Bioethicist at the University Health Network and a board member of the Canadian Bioethics Society. 60 HOSPITAL NEWS NOVEMBER 2018

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NEWS

Positive patient ID for phlebotomy:

Improving

safety when drawing blood By Amber Daugherty eah Jaikaran doesn’t miss the laborious process of scanning through seemingly endless numbers of printed labels looking for the right match to go with a tube of blood that’s just been drawn. A new system being introduced at St. Michael’s Hospital, called positive patient ID, is getting rave reviews for “how convenient and simple it is,” says the medical laboratory technician, adding that it took the team a couple of days to get used to going electronic.

bile devices and portable printers. The device can scan a patient’s wristband to confirm the technician is drawing blood from the right person for the right test. The mobile device tells them what test is required, what tubes are needed and what time blood needs to be drawn. The portable printer then spits out a label on the spot and all of the relevant information is digitally submitted in real time to the laboratory. “We take patient safety very seriously,” says information technology coor-

USING POSITIVE PATIENT ID ADDS AN EXTRA CHECK TO REDUCE THE POTENTIAL FOR MIXING UP PATIENT SAMPLES. AND IT’S MAKING THE WHOLE PROCESS QUICKER AND MORE EFFICIENT. Health-care teams are constantly searching for new and effective ways to improve patient care – especially to find ways to make care safer. Phlebotomy, the process for drawing blood, is something that happens hundreds of times a day at a hospital like St. Michael’s and was identified as an area worth investing in improvement. With the introduction of positive patient ID, medical laboratory technicians are now starting to carry mo-

dinator Drake Yip. “Using positive patient ID adds an extra check to reduce the potential for mixing up patient samples. And it’s making the whole process quicker and more efficient.” Another benefit of the system is that any urgent requests can be flagged on the technician’s mobile device – they flash on the screen and show up in red compared to the routine tests in black and timed tests in blue. “The system updates every 30 seconds, which is especially helpful if

someone needs a blood draw quickly – we see it immediately and can respond right away,” says Jaikaran. The new system launched mid-June and is currently supporting technicians drawing blood at the bedside. The next step is to use the same process for blood transfusions, by scanning patients’ wristbands as well as the blood products they’re receiving to enhance patient safety.

“The laboratory is always looking at how we can increase patient safety and enhance overall quality,” says Dawn-Marie King, director of Laboratory Medicine and Diagnostic Imaging. “That includes looking at how we can bring in new technology – in this case, it’s a small change that’s making a huge difference for both our staff and our H patients.” ■

Amber Daugherty is a Senior Communications Advisor at Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital. www.hospitalnews.com

NOVEMBER 2018 HOSPITAL NEWS 61

PRODUCT SPOTLIGHT

New tests for diagnosing heart attacks faster S

Philips’ new Ingenia Ambition X 1.5T MR is the latest advance in the Ingenia MRI portfolio he Ingenia Ambition X provides leading-edge MR imaging capabilities while helping to increase overall productivity, combining its revolutionary BlueSeal magnet with innovations that are designed to enable single operator workflow and speed up exam times by up to 50 per cent. Incorporating Philips’ breakthrough BlueSeal fully-sealed magnet, the Ingenia Ambition X is Philips’ first MR system to enable helium-free operations, reducing the chance of potentially lengthy and costly disruptions, and virtually eliminating dependency on a commodity with an unpredictable supply. The fully-sealed system does not require a vent pipe and is around 900kg lighter than its predecessor, significantly reducing the siting challenges presented by conventional magnets and lowering construction costs. The Ingenia Ambition X includes a range of innovative features that combine to deliver a step-change in productivity. With Philips’ EasySwitch

solution, the BlueSeal’s magnetic field can be easily turned off if an item becomes stuck in the bore. Once the problem is resolved, an in-house or Philips technician can initiate an automated ramp-up to bring the magnet back to field, minimizing operational downtime. The Ingenia Ambition X combines guided patient setup and Adaptive Intelligence-driven SmartExam analytics for automatic planning, scanning and processing. Philips Compressed SENSE is an advanced acceleration application that can accelerate exam times by up to 50 per cent. In addition, Philips VitalEye is a unique approach to detecting patient physiology and breathing movement, using technology and algorithms to intelligently extract signs of breathing. When used in combination with VitalScreen, it allows routine exam set-up time to occur in less than a minute, even for less experienced operators. Together, these innovations help to standardize and speed up workflow, allowing clinicians to focus on the H patient. ■

62 HOSPITAL NEWS NOVEMBER 2018

iemens Healthineers in Canada is helping to shorten the time doctors can diagnose a life-threatening heart attack with the introduction of two assays that offer unparalleled precision. Health Canada has licensed for sale High-Sensitivity Troponin I assays (TnIH)1 for the Atellica® IM, ADVIA Centaur® XP/XPT, Dimension® EXL™, and Vista® in vitro diagnostic analyzers from Siemens Healthineers to aid in the early diagnosis of myocardial infarctions – commonly known as heart attacks. When a patient experiencing chest pain enters the emergency department, a physician orders a blood test to determine whether troponin is present. As blood flow to the heart is blocked, the heart muscle begins to die in as few as 30 to 60 minutes and releases troponin into the bloodstream. The high-sensitivity performance of the two new Siemens Healthineers TnIH assays offers the ability to detect lower levels of troponin at significantly improved precision at the 99th percentile, and detect smaller changes in a patient’s troponin level as repeat test-

ing occurs. This design affords clinicians greater confidence in the results with precision that provides the ability to measure slight, yet critical, changes to begin treatment. As science progresses, guidelines for determining high-sensitivity also evolves. These TnIH assays meet the latest industry guidelines. “Precision at the low end is important to minimize analytic variation that could confuse a clinician’s assessment of a clinically significant change,” says Matthew Coughlin, Laboratory Diagnostics, Siemens Healthineers Canada. “With the data from the TnIH assay in hand, physicians have the ability to more quickly diagnose and treat patients with suspected heart attacks.” Pain in the throat and chest is the second most common reason why Canadians go to the emergency room, with over 300,000 visits in 2016-17, but only 3.2 per cent of those visits lead to the patient being admitted for further treatment . Armed with data to properly triage patients sooner or to exclude myocardial infarctions, the Siemens Healthineers TnIH assays can help support testing initiatives tied to H improving patient experience. ■

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