Hospital News April 2014 Edition by Hospital News

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GERONTOLOGY/PALLIATIVE CARE/ HOME CARE/RURAL AND REMOTE:

Canada's Health Care Newspaper

Geriatric medicine and aging-related health issues. Innovative approaches to home care and palliative care delivery. Care in rural and remote settings: enablers, barriers and approaches.

INSIDE Nursing Pulse .....................................13 Caregiving ........................................... 16 Evidence Matters ...............................22 From the CEO's desk..........................23 Travel ...................................................25

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Acetaminophen What you need to know By Allan H. Malek

n January 14, 2014, the U.S. Food and Drug Administration issued a strongly worded recommendation to American health care providers regarding prescription-based pain relievers containing

acetaminophen. Specifically, the recommendation calls for a limit of 325 mg of acetaminophen per dosage unit to avert liver toxicity. However, moving north into Canada, we hear no similar warnings whatsoever. So are we missing some-

thing or is this much ado about nothing? Perhaps the correct answer is no to both questions. First, unlike the United States, Canada does not have the same concerns given the very small number (72) of Health

Canada-approved acetaminophen-based prescription combination products. Of these 72 products, 59 are traditional prescription products and 13 are narcoticbased. Continued on page 8

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HOSPITAL NEWS APRIL 2014

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In Brief

Campaign launched to better inform Canadians about Fellowship designation The Royal College of Physicians and Surgeons of Canada launched a public awareness campaign to better inform Canadians about the high standards created and met by the more than 37,000 certified Royal College Fellows practising specialty medicine nationwide. "When patients see a specialist, they should know that our Fellowship is the national standard for specialty medical expertise in Canada," says Royal College CEO Andrew Padmos, MD, FRCPC. "When patients see our designation next to their specialists' name, they can be confident in the high standards these doctors meet." Active Fellows of the Royal College practise in 65 different medical or surgical specialties, such as Pediatrics to Psychiatry and Orthopaedic Surgery. Only Royal College Fellows can use the designations FRCPC (Fellow of The Royal College of Physicians of Canada) or FRCSC (Fellow of The Royal College of Surgeons of Canada). "Our research indicates the majority of Canadians don't know what Fellowship with the Royal College actually means, even though many recognize the letters in a doctor's credentials," says Royal College President Cecil Rorabeck, OC, MD, FRCSC. "Patients can see this designation and be confident that their physician or surgeon has met, and continues to meet, Canada's national standard for specialist expertise." Elements of the awareness program, called Fellowship Matters, include a new website – Fellowshipmatters.royalcollege. ca – an eight-week online advertising and social media campaign, and a poster for medical settings, such as doctors' offices. The website provides information regarding Fellowship and what it means for patients, along with a link to the Royal College directory so patients can see if their H specialist is a Royal College Fellow. ■

Making care safer from hospital to home care Whether it is inside the operating room or inside our homes, the last decade has brought advances in health care technology, evolving disease patterns, and an aging population – making the delivery of healthcare in Canada more complex. With increasing complexity comes increased risk. Accreditation Canada and the Canadian Patient Safety Institute (CPSI) continue to work to identify and reduce risks in the delivery of care. A new report, Making Care Safer from

Hospital to Home Care, published by Accreditation Canada and CPSI, examines some of the major risks to patients that exist in Canada's health care system and shares patient insights, resources, and evidenced-based approaches to minimize those risks. This report focuses on three areas of risk: •Venous thromboembolism (VTE), a serious and common complication for surgical patients, which is the second most

common cause of excess length of hospital stay and the third most common cause of excess hospital costs. •Surgical care, where patients with surgical site infections spend 60 per cent more time in an intensive care unit and are five times more likely to be readmitted to hospital following their initial discharge. •Home care, where 130,000 Canadian home care clients suffer a harmful incident every year, half of which are H preventable. ■

Boosting self-esteem prevents health problems for seniors The importance of boosting self-esteem is normally associated with the trials and tribulations of adolescence. But new research from Concordia University shows that it’s even more important for older adults to maintain and improve upon those confidence levels as they enter their twilight years. That’s because boosting self-esteem can help buffer potential health threats typically associated with the transition into older adulthood. A new study published in the journal Psychoneuroendocrinology, led by psychology researchers Sarah Liu and Carsten Wrosch from Concordia University’s Centre for Research in Human Development found that boosting self-esteem can buffer potential health threats in seniors. Results showed that maintaining or even improving self-esteem could help prevent health problems. “Because selfesteem is associated with psychological wellbeing and physical health, raising self-esteem would be an ideal way to help prevent health problems later in life,” says Liu. In terms of implications for healthcare, there are several. By highlighting the role self-esteem plays in older adults’ physical health, it can inform interventions that emphasize the importance of self-esteem and its maintenance over time. What's more, self-esteem can also contribute to how health care promotions or inventions are received. "If self-esteem can be a mechanism that allows for adaptive

coping in stressful circumstances, public health educational and promotional materials would be better received," says Liu. It can also reduce the costs for older adults’

health care needs, if self-esteem can ameliorate consequences of cortisol dysregulation, it can improve the quality of life for H older adults. ■

Canada lacking when it comes to newborn hearing screening Too many provinces and territories still don't have adequate programs in place to screen babies for hearing loss and monitor children for hearing problems, says Speech-Language and Audiology Canada (SAC). A report card issued by SAC and the Canadian Academy of Audiologists reveals far too many babies in Canada are not being screened for hearing loss at birth. What's more, many provinces and territories do not have adequate programs in place to support and monitor children over the long-term. "The initial newborn hearing screening is really just the first step. It's an extremely important step, but it's just the first one," says Dr. Roula Baali, audiologist and SAC Board Director. "When we talk about early hearing detection and intervention we are really talking about a comprehensive strategy to not only screen babies for hearing loss at birth, but also provide timely diagnosis

and intervention programs for children who have hearing problems and surveillance of those who do not." The new report card is a cross-country snapshot and astonishingly, it ranks over half of the provinces and territories in Canada as insufficient in at least one of the two categories it assessed: coverage and quality. Only British Columbia has excellent rankings in both. Permanent childhood hearing loss has been described by some experts as a neurologic emergency. Studies show that extended periods of auditory deprivation can have a significant impact on a child's overall brain development. "Hearing loss affects a child's understanding and use of language. It can also affect their cognitive, social, emotional, academic and communication development. The sooner we can detect a hearing problem, the better the chances for improvement and future H success," explains Dr. Baali. ■

NOW AVAILABLE New Edition of Standard on Plume Scavenging Surgical smoke plume poses a real threat to the health and safety of health care workers. It is not only found in traditional acute care settings but also in vision correction, dental offices and other health care settings. The 2nd edition of Z305.13 - Plume Scavenging in Surgical, Diagnostic, Therapeutic, and Aesthetic Settings - contains key updates that help plume-generators ensure that preventative measures are in place and current best practices are met.

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Canadians need more care and less politics

It’s the end of an era. The 2004 Canadian Health Accord has expired and along with it we say goodbye to the Health Council of Canada – which was established as an oversight body, to assess and share progress (or lack thereof) on health care reform set out by the Accord. Many are sounding the alarm. Experts argue that, without the national voice of the Council and established common goals across the country, health care reform will stall, discrepancies in care between provinces and territories will increase; and inequities will grow. With the expiration of the 10 year, $41-billion dollar agreement between the federal government, provinces and territories comes a great deal of uncertainty. The new funding formula promises $32 billion this year, and will increase six per cent annually until 2017. After that future increases will be tied to GDP growth plus and an escalator of three per cent or more for inflation. Headlines read “It’s a sad day for Canadian healthcare,” and health care reform advocates are warning of an increasingly American-style health system. Demands are being made for a new oversight body, a new Health Accord, and more federal tax dollars. The Tories, on the other hand, are adamant that more money is not the answer. While they acknowledge their role to enforce the Canada Health Act, they maintain it is the job of the provinces and territories to provide services to their jurisdictions. They have a point, but the issue isn’t quite as black and white. In spite of being one of the biggest health care spenders in the OECD, Canada is in the middle of the pack

when it comes to the value we get for our money. When you look at quality of care in comparison to other countries, Canada is actually faring quite poorly. I don’t think more money is the answer. If spending were indicative of quality healthcare, the United States would be the best in the world, in most comparisons they are faring worse than Canada, and far worse than the top performing OECD health systems. The highest quality health care systems in the world spend far less than we do so I disagree that pouring more money into healthcare is the answer.

Our current health care system is not sustainable – spending more money is not an option, let alone a solution Let’s be honest – and take a long hard look at the past 10 years. In theory, the Health Accord was the answer to a poorly performing system. In reality, it didn’t provide the reform we had hoped for. Ten years later, we aren’t where we should be – progress has been made in many areas, but it has been modest at best. People are still waiting far too long to see their family doctor, have surgery, and receive treatment – perhaps not as long as in 2004, but we still wait longer than we should. Theoretically, the Health Council of Canada was developed to monitor

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progress and inform the public about problems and areas to be improved and, in an ideal world, the Council would have had the authority to hold underperforming provinces accountable. In reality, The Health Council made great strides in educating the public about the system’s shortcomings and sharing best practices to spearhead improvements; however they were unable to mandate best practices or hold provinces and territories accountable. The council was definitely useful, but could have been invaluable if given the authority (and autonomy) to actually fix the problems they identified. Canada’s journey to health care reform has been slow going. It has seen its fair share of scandal and wasted taxpayer dollars – to the tune of $1 billion in one such scandal alone. One billion dollars! How can we squander a billion dollars and then balk when cutbacks have to be made? While I am not convinced pouring more money into our system will lead to this much-talked about health care reform, I am positive that the health care system needs oversight – a watch-dog – and not just one in name; one that can bark and even bite when necessary. The fact of the matter is our current health care system is not sustainable – spending more money is not an option, let alone a solution. It’s time to hold political leaders accountable and implore them to base their health care platforms on patients, not politics. Federal leadership, oversight and accountability are where actual health care reform will start. Unfortunately, they too have been taken off the table. The expiration of the Accord was a H sad day for healthcare indeed. ■

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Spreading health care innovations By Paulette Roberge

new pan-Canadian initiative is spreading innovative approaches that have successfully improved patient care and value-for-money. The Canadian Foundation for Healthcare Improvement launched the Spreading Healthcare Innovations Initiative, providing funding, coaching and other support to teams from Canadian health care organizations interested in implementing promising practices in their own facilities and regions. “For over a decade, CFHI has helped health care delivery organizations implement new ways of working that improve quality and value-for-money and we’re pleased to accelerate this work,” says CFHI President Maureen O’Neil. These practices will now be shared among organizations participating in two 12-month collaboratives of up to 10 teams each. The first collaborative focuses on reducing inappropriate antipsychotic medication use in long–term care, where one in three residents is administered these medications without a diagnosis of psychosis. There is also significant variation among rates in different long–term care homes, pointing to the potentially inappropriate use of these medications.

needs-based approach that reduces reliance on hospital-based care. Providing patients and their families with self-management education, action plans, psychosocial and spiritual care support, and advance care planning, INSPIRED lowered emergency room visits by 62 per cent and hospital admissions by 64 per cent over a six-month period at Capital Health’s Queen Elizabeth II Health Sciences Centre in Halifax where it was implemented by respirologist, Dr. Graeme Rocker, and his team.

COPD is the fourth-leading cause of death in Canada and a primary cause of hospital visits. “INSPIRED narrows the gap between the care people need and the care they were receiving in our conventional health care system,” says Dr. Rocker, who is also CFHI’s Clinical Improvement Advisor. “By providing patients with individualized care based on their needs, we’ve been able to improve how they cope with their COPD. I’m looking forward to sharing this approach with

Paulette Roberge is a Senior Communications Specialist at the Canadian Foundation for Healthcare Improvement.

Make the healthy choice for you and your patients.

The Spreading Healthcare Innovations Initiative is providing funding, coaching and other support to teams from Canadian health care organizations

A CFHI-supported team at the Winnipeg Regional Health Authority implemented an approach that helped providers better use data from the Resident Assessment Instrument/Minimum Data Set to identify patients who may benefit from non-drug therapies to treat behavioural issues associated with dementia. “By looking at our resident’s personal histories rather than just their medical files, we were able to improve their quality of life and save health care dollars,” says Cynthia Sinclair, WRHA’s Manager of Personal Care Home Special Projects. The new model reduced by 27 per cent the number of residents on antipsychotic medication among a cohort at one facility, without any increase in behavioural symptoms or use of physical restraints. “We are excited to be collaborating with CFHI again to help other organizations make similar improvements,” adds Sinclair. The deadline for teams to apply to this collaborative is April 15, 2014. The second collaborative spreads the successful INSPIRED model of care for people with chronic obstructive pulmonary disease (COPD). INSPIRED–Implementing a Novel and Supportive Program of Individualized Care for patients and families living with REspiratory Disease–provides hospital-to-home support to patients and families living with COPD using a holistic, www.hospitalnews.com

other organizations across Canada.” Teams interested in the INSPIRED collaborative should apply by June 30. Potential applicants are encouraged to take part in CFHI’s online workshop on the same topic, from April 22-June 26. For more information, visit cfhi-fcass.ca/ H innovation. ■

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Managing expectations in

long-term care By Lauren Schwartz

lacing a loved one in a longterm care facility can be overwhelming. The reality of longterm care in Quebec often involves long waiting lists but short notice when it actually comes time to move in. This can mean a period of adjustment for both the new resident and their family, as decisions must often be made quickly. Being informed about what to expect in long-term care can help ease the transition for the new resident and all involved family members. Dr. Mark Karanofsky, a physician at Jewish Eldercare Centre, stresses that the move to long-term care means a switch in focus from quantity to quality. The goal is to ensure and maintain a high quality of life for each resident on a day-to-day basis. The goal of long term care rehab, for example, becomes more about maintaining mobility than about regaining lost abilities. Unlike an acute care facility (i.e. hospital) where there is a focus on getting better and doctors seeing you on a daily basis, Dr. Karanofsky says long-term care residents can expect less “hustle and bustle” as they

settle into their new surroundings: “It’s as if the patient is at home and when they need help, a doctor comes to visit them in their home setting.” Dr. Karanofsky explains the initial goal “is to help the resident settle in, determine their needs and respond best to them.” Rosalie Dion, the Director of Nursing at Donald Berman Maimonides and Jewish Eldercare Centre points out the resident’s family is very much involved in determining needs in their initial meeting with the multidisciplinary team. The team is made up of professionals from various

Unlike an acute care facility (i.e. hospital) where there is a focus on getting better and doctors seeing you on a daily basis long-term care residents can expect less “hustle and bustle” as they settle into their new surroundings.

Donald Berman Maimonides resident Faye Amdursky with RN Annie Tremblay. departments (rehab, social work, nursing, dietary). Dion reinforces the team’s objective: “It’s all about quality of life,” she says. “Our goal is to ensure residents are well taken care of in their new milieu de vie”. In long-term care, much emphasis is placed on the resident’s day-to-day living through recreational activities and stimulation, quality of food and living environment. Donald Berman Maimonides and Jewish Eldercare Centre are the first longterm care centres in Canada to achieve gold-designation with Planetree; an international organization that focuses on individualized resident-centred care. Amy Fish, Director of Quality and Clinical Services at both centres, says she is guided by the Planetree principles of resident-centred care. “We consider the

life journey of every resident,” she says. “We do this by recognizing the importance of human interactions and stimulation–in the many music activities we offer, the variety of foods our residents can eat and the creative ways our staff are always thinking outside the box in order to best personalize care for each and every resident.” Dr. Karanofsky says the highlight of his career as a physician was when he helped enable a centenarian resident–a lifelong hockey fan–to take in a Montreal Canadiens game at the Bell Centre. H Now that’s long-term care! ■ Lauren Schwartz is a Communications Officer at Donald Berman Maimonides Geriatric Centre and Jewish Eldercare Centre.

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Falls and fall prevention: What about the older faller? By Stephen Katz

ernando Torres-Gil, gerontologist, advocate and former US Assistant Secretary of Aging, says about falling, that “if we do not make this a topic of public discourse, if we do not get the issue of falls prevention into the conventional wisdom, if we do not make it sexy and glamorous, then we will not be prepared for the inevitable falls of more than 75 million baby boomers, who are marching to their inevitable, actuarial destiny.” But Torres-Gil’s scenario may already be upon us. The gerontological literature portrays a frightening picture of the frequencies, injuries, hospital costs and deaths associated with falls. In Canada falls are a major cause of injury, a reason for entering care facilities, a factor in morbidity, and an annual health care expense estimated at $2.4 billion. TheWorld Health Organization’s WHO Global Report on Falls Prevention in Older Age (2007) estimates that 28 to 35 per cent of people 65 years and older fall each year, with the fall rate increasing with age. Risk of falling for older people is a formidable daily presence. And the fear of falling itself can create tremendous anxiety. Falls are not simply physical events because the process of falling for older people includes entry into professional worlds of

care and prevention. In such worlds, research demonstrates that older people tend to describe a fall as loss of balance, or a result of slipping and tripping, whereas health professionals generally refer to the events leading to injuries and ill health.

What falls mean to people is as important as what falls do to them, and such meaning should be part of risk-prediction and fall prevention programs. Thus, lay definitions express what it feels like to fall and are important sources of data because they indicate a person’s embodied relationship to their environment(s). Indeed, older people have been found to think of falls as less important than other health factors, and that the professional documentation is out of keeping with their own experiences. However, risk-prediction and prevention programs often overlook such subjective perceptions in favor of measuring risk factors. Symbolically, participation in fall-prevention programs can signify loss of control and a person’s decline in embarrassing and stigmatizing ways. They have fallen in more ways than one.

Fall prevention programs helpfully focus on individual behavioral change (exercise regimes, healthy living, medication regulation) and environmental modifications (better lighting, non-slip surfaces, safe outdoor areas), but again, social contexts matter too. Assistive devices are a good example. Grab-bars, non-slip surfaces, and easy-to-reach faucets are very useful, but they evoke issues around social support, independent living, and affordable ‘agefriendly’ housing. For example, in Canada, despite the fact that 10-15 per cent of all non-syncopal at-home falls happen in bathrooms, fewer bathtub grab-bars are installed in privately owned buildings than in buildings publicly owned. Since one third of all Canadian seniors live in apartment buildings, this is a political issue and not simply one of individual choice. Gender has also been shown to be a crucial variable in fall prevention because the image of women’s bodies is that they are weaker, more vulnerable, and more risk-prone (especially after menopause due to osteoporosis). It is true that women fall more often and suffer more fracturerelated falls than do men, but we also have to consider the cultural bias that depicts female physical strength as unfeminine and older female frailty as natural. Women

are often given a higher number of medications and some falls may be attributable to women’s use of psychotropic drugs and not necessarily their lack of physical endurance. This is all to say that the moment of a ‘hard’ fall, despite being a physical event, brings into focus a series of relationships between faller and environment, social and status roles, and new identifications of what it means to be older against an ageist society obsessed with fears of loss of physical control. Since older people rely on their subjective, interpretive, and adaptive resources as well as family and social supports, their narratives of how falls happen are important to listen to and take into account. What falls mean to people is as important as what falls do to them, and such meaning should be part of risk-prediction and fall prevention programs. The older body that falls or is at-risk of falling is a window from which to view the contingent nature of the aging process, and the ways in which biography, culture, politics, biology, and the human spirit are H connected together. ■ Stephen Katz is a Professor at Trent University, Department of Sociology and Centre for Aging and Society.

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Acetaminophen

Continued from cover

Of the traditional prescription products, there are none that contain more than 325 mg of acetaminophen. And of the 13 narcotic-based products, only five contain an amount of acetaminophen that exceeds 325 mg (all actually contain 500 mg) and each of these is a non-prescription codeine-based product. In other words, there are no Canadianapproved prescription-only products containing more than 325 mg of acetaminophen on the market. In the United States, many of the affected products contain opioids such as codeine, oxycodone, and hydrocodone, and the acetaminophen content in these products can be as much as 750 mg per dose.

All substances are poisons; there is none which is not a poison. The right dose differentiates a poison from a remedy. Second, while the FDA recommendation may have no formal application to Canadian health care providers, it is certainly not much ado about nothing. We live in an era where post-marketing surveillance is in everyoneâ&#x20AC;&#x2122;s best interests â&#x20AC;&#x201C; patients, providers, governments, and pharma companies â&#x20AC;&#x201C; but we may be placing too much focus on the new and â&#x20AC;&#x153;me-tooâ&#x20AC;? drugs, and not enough (or at the very least less) on those that are supposedly â&#x20AC;&#x153;tried and true.â&#x20AC;? A tremendous amount of time, money and effort is spent evaluating the longterm effects of prescription medications. But with an increasing number of prescription-to-OTC (over-the-counter) transitions occurring as a means of driving more

and more self-care and decreasing the economic strain on the health system, are we losing some element of control or sending mixed messages to the public? Could we be suggesting that because OTCs have unrestricted access that they are inherently safe and harmless? Or could it be that health providers have unknowingly abdicated their collective responsibilities on OTC oversight? Perhaps the question providers, patients, regulators and all pharma stakeholders might want to ask about these older and more trusted products is: â&#x20AC;&#x153;Does familiarity breed contempt?â&#x20AC;? Health care providers both north and south of the border have always had the responsibility of educating and creating awareness among the patients they care for about the appropriate and inappropriate use of prescription and OTC remedies. With respect to OTCs, there are myriad products in pharmacies and grocery stores (and to a lesser extent on gas station and convenience store shelves) that can overwhelm and perhaps confuse patients, or their caregivers, who are attempting to self-medicate. And of these products, the vast majority include acetaminophen as one of several active ingredients. Whether the patient is looking to treat a headache, fever, back pain, sinus cold, flu, migraine or a mild case of insomnia, odds are that the selection they make will contain acetaminophen along with at least one or several other ingredients. And why not? With more than five decades of experience on the Canadian OTC market, acetaminophen is a great success story. So why all the fuss? In the early 1500s, the Swiss physician Paracelsus stated: â&#x20AC;&#x153;All substances are poisons; there is none which is not a poison. The right dose differentiates a poison from a remedy.â&#x20AC;? From this we can extrapolate that concurrent ingestions of therapeutic doses of a drug from multiple prescription or OTC remedies can be equally poisonous.

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HOSPITAL NEWS APRIL 2014

Reports of acetaminophen overdoses seem to be on the rise. A Toronto Star article from February 21, 2014 cites a number of statistics from unidentified internal Health Canada reports â&#x20AC;˘ â&#x20AC;&#x153;There is extensive literature evidence to support the association of acetaminophen and hepatotoxicity. Cases of severe liver injury, including liver failure, associated with acetaminophen have occurred in Canada.â&#x20AC;? â&#x20AC;˘ â&#x20AC;&#x153;While most cases of severe hepatotoxicity are the consequence of intentional overdose, some cases have occurred in association with recommended or near-recommended doses taken over several days to weeks.â&#x20AC;? â&#x20AC;˘ â&#x20AC;&#x153;The estimated incidence of annual hospitalization for acetaminophen overdose in Canada is 27 to 46 per 100,000 persons, with an estimated incidence of accidental acetaminophen overdose of three to eight per 100,000 persons.â&#x20AC;? Unfortunately, these statements speak not to the likely cause(s) of acetaminophen toxicity, but rather the frequency of its occurrence. However, the unidentified Health Canada report goes on to suggest that â&#x20AC;&#x153;Accidental overdose of acetaminophen appears to be multifactorial and may be due to: lack of consumer understanding of the potential safety concerns associated with acetaminophen and awareness of the inclusion and amount of acetaminophen in both over-the-counter and prescription products that they may be taking (e.g. combinations, single ingredient and multiple formulations).â&#x20AC;? While knowing the causes can be very important, not knowing them doesnâ&#x20AC;&#x2122;t imply a hard stop to our efforts to mitigate their occurrences. Primary, secondary and tertiary care providers all play a role in helping to mitigate the issue, insofar as all are interacting with the patient and recommending opportunities for self-care. We may prescribe, recommend or dispense a prescription-based or OTC product, and such activities require some degree of oversight, education and dialogue with the patient or caregiver. These conversations typically advise patients on how, when and why to take a particular product, but concentrate less on what to avoid at the same time. Patient empowerment is an important element of a strong and sustainable health care system. However, adhesive labels on acetaminophen-based prescription combination products or the size-four font on an OTC multi-symptom cold remedy cannot

and will not replace the knowledge and expertise that health care providers, most notably pharmacists, can and should provide to patients. With the power of the Internet, pharmaceutical marketing of OTCs and U.S.based direct-to-consumer advertising, Canadian patients are being continuously bombarded with ads for new products and brand extensions, often with misleading messages. In addition, there appears to be a desire by manufacturers to make (and by patients to buy) multi-symptom products, citing convenience and cost-effectiveness. However, as most health providers know, these products most often lead to dosing with one or more ingredients for which there are no symptoms to treat. Call it what you will, it is an inappropriate use of medications. But the health professions have not yet pushed back to say this is not right. Maybe the U.S. FDA announcement can shed a brighter spotlight on acetaminophen usage beyond prescription combination products in both the United States and in Canada. It is unfortunate that it will take unintentional (but predictable) overdoses to have us take action. There is still a place for multi-symptom combination products containing acetaminophen. It is not the product that is the villain. Rather, it is the people around the product that bear the ultimate responsibility for its rational use. This includes pharmacists, pharmacy technicians, physicians, nurses, nurse practitioners, dentists, dental hygienists, other health care providers and, of course, patients. Whether weâ&#x20AC;&#x2122;re looking at an acetaminophen-based combination product (prescription or OTC) or a general OTC remedy, the message has to be that while these products can be beneficial in one instance, they can be dangerous, if not lethal, in others. We can no longer remain complacent on the historical safety profile of OTCs. Pharmacists and technicians are perhaps best poised to embrace this message. Whether your patient comes to the pharmacy counter with an acetaminophen-based product, or they are being discharged from the hospital and you have an opportunity to discuss their discharge order, engage in a conversationâ&#x20AC;&#x201C;and do not be afraid to ask the questions that you, as health providH ers, would ask your own family members. â&#x2013; Allan H. Malek, B.Sc(Bio)(Pharm) is Senior Vice President, Professional Affairs, Ontario Pharmacists Association. www.hospitalnews.com

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

Focus

Improving and integrating

palliative care By Andrea MacLean

ise didn’t know she had it in her. She didn’t know she had the skills and the strength to grant her husband Roger his last wish – to die at home. “I knew from the start he wasn’t going to get better,” says Lise. “As soon as they took out his prostate for the first time – I was scared.” Lise wasn’t alone in her experience, supporting her in the background 24/7 was the Regional Palliative Consultation Team (RPCT). The Regional Palliative Consultation Team is a bilingual, outpatient service funded by the Ministry of Health and LongTerm Care, sponsored by Bruyère Continuing Care and the Champlain CCAC. The Team includes the full-spectrum of nursing services and has recently been enriched with the addition of five new Nurse Practitioners. The RPCT promotes the application of the Canadian Hospice Palliative Care Association standards of practice. “The first time Lise called she was in a real crisis at home,” says RPCT nurse Maryse Bouvette. Lise tells of how she needed the RPCT to help her and her husband. “Dr. Frances Kilbertus our family practitioner and

Lise (right) and Dr. Frances Kilbertus worked together to ensure her husband’s wish of dying at home could be granted. Maryse came to see Roger at the house,” recalls Lise. “Dr. Kilbertus looked at him and said, ‘How can I help you?’ He said, ‘I want to die at home, and I want you to make that possible.” The RPCT is a unique collaborative model which leverages inter-professional expertise, with a focus on building capacity for palliative and end-of-life expertise/ management in primary care and fosters greater integration across the health system. “It’s a big decision for a family or essentially a community which has assembled around someone whose life is ending,” says Dr. Kilbertus, Roger’s practitioner. “It can

Telemedicine means better care

be someone’s wish (to die at home) but you really need to have the support in your home and she was willing to support him. Lise has an enormous amount of courage.” The RPCT works collaboratively with: family physicians, nurse practitioners and primary health care teams, Champlain CCAC service providers, community nurses, hospitals, hospices, long-term care facilities, colleges and universities, and Champlain CCAC Care Coordinators. Anytime help is required to support patients with a life limiting disease, the caring and expert team of palliative experts is there to help 24 hours a day, 7 days a week. The RPCT promotes improvements and integration of palliative care by establishing links and building partnerships. Palliative care consultations are done with health care providers, by phone, email, fax, video conferencing as well as in client’s home, LTC facilities, hospices etc. The service covers the entire Champlain region. “He was my soul mate. My love. I never knew such a gentle man could exist,” says Lise. “You do this type of care because of love in many ways. It represents an enormous commitment to another person,” explains Dr. Frances Kilbertus. “The day he passed away, I called the RPCT and they told me, ‘Lise, we’re going to go through this together. You are not alone,” Maryse says, “She was not alone in a way because Lise knew there was this virtual support. That support could come at the time that she needed it.” “I lay down in the bed beside him and I held him in my arms and I told him, ‘I love you very much and you gave me a lot

Who Can Refer to the Regional Palliative Consultation Team •Primary care providers •Community hospitals with no palliative care services •Long-Term Care Homes •Retirement Homes •Nurses providing end-of-life care in the community •CCAC Care Coordinators •Other palliative care resources How to Reach the Regional Palliative Consultation Team – 1 800 651 1139 and I’ll never forget everything you gave me. You loved me for myself and I never thought anybody would. Then he lifted his head but he didn’t open his eyes. And then he stopped... he stopped breathing. I got out of bed and Maryse came in the room and she took me in her arms and she said, ‘You did such a good job taking care of Roger. I’m so proud of you.” Maryse remembers, “We were able to be there for her at the time she needed it. She knew she could count on someone and she felt heard. I think that’s the most important thing.” The Regional Palliative Consultation Team made it possible to give Roger his dignity to stay at home. Like he always H wanted. ■ Andrea MacLean is the Communications Manager at Bruyère Continuing Care.

By Nancy Lefebre

aint Elizabeth has partnered with four Health Links to create a new program that uses telemedicine personal video conferencing technology to link patients who have complex health issues (multiple co-morbidities and/or chronic diseases) with teams of health care professionals. The program relies on Ontario Telemedicine Network (OTN) technology and the engagement of patients and primary care physicians across the Toronto Central Local Health Integrated Network (LHIN). The TIP (Telemedicine Impact Plus) Nurse Facilitator program started late last summer and is being offered through the four early adopter Health Links. They have contracted with Saint Elizabeth to provide four nurses from our Toronto Central Service Delivery Centre to work on this initiative, which is funded by the Toronto Central LHIN, through its Health Link strategy. The key goals of the program are to: · Improve access to inter-professional resources for solo family physicians · Improve quality of care for patients www.hospitalnews.com

· Reduce avoidable emergency visits and hospital readmission rates, and · Leverage telemedicine technology The TIP Nurses assist in identification of patients and providers, gather health information to share across the transitions in care, and create a standardized approach for sharing information within the circle of care. Here’s how it unfolded for Agnes Oriade, a Saint Elizabeth TIP Nurse Facilitator for the Mid-Toronto West Health Link, during the facilitation of her first one-hour case discussion. In this particular case, Agnes was at the solo family physician’s office, with the patient and family, while the inter-professional team was located at a downtown OTN site. Agnes connected via OTN technology with her laptop and speakers. Prior to the videoconference, the patient had been seeing numerous specialists individually, but her health wasn’t improving. She has a complex medical history, including an eating disorder, obesity, and mental health issues related to her eating behaviors. Continued on page 14 APRIL 2014 HOSPITAL NEWS

10 Focus

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

The future of health care delivery:

Telehomecare

it easier for Dr. Goel to meet the complex care needs of his patients – many with chronic diseases, like Beatrice, who frequently end up in hospital if they are not monitored closely. He says Telehomecare helps him care for patients in ways he normally couldn’t. For example, Dr. Goel received an instant message from Beatrice’s Telehomecare nurse alerting him that Beatrice had a rising fever and cough. Dr. Goel was immediately able to get a prescription to Beatrice over the phone. Without daily monitoring, Dr. Goel may have become aware of Beatrice’s worsening condition too late to avoid hospital admission.

By Dr. Michael Guerriere

s the role of technology in our daily lives grows, more and more Canadians are turning to digital tools to manage their health and well-being. By empowering Canadians to take control of their health, these new tools are proving beneficial not only to patients but to health care providers and the health care system. One innovative program is Telehomecare. Working with TELUS Health and funded by the Ontario Ministry of Health and Long-Term Care and Canada Health Infoway, the Ontario Telemedicine Network (OTN) has developed an integrated Telehomecare service that provides daily health monitoring and weekly health coaching for patients with Chronic Obstructive Pulmonary Disease (COPD) and Chronic Heart Failure (CHF). OTN is a leader in telemedicine solutions that enable health care organizations and health care professionals to provide virtual care. OTN’s CEO, Dr. Ed Brown, believes programs like Telehomecare will lead to an improved and more sustainable health care system. “Leveraging technology helps health care professionals provide better care and better value at the same time, particularly for patients with chronic disease who benefit the most from home monitoring,” he says. Thousands of Canadians already use TELUS Home Health Monitoring (HHM) in Ontario, Quebec and British Columbia. Telehomecare focuses on empowering Ontarians to learn how to manage chronic conditions like CHF and COPD to prevent exacerbations. As a result, the

Leveraging technology helps health care professionals provide better care and better value at the same time, particularly for patients with chronic disease Dr. Goel and his patient Beatrice. OTN-TELUS HHM partnership, together with the Local Health Integration Networks (LHINs), Telehomecare delivery organizations, hospitals and Community Care Access Centres, are reducing system costs, emergency room visits and hospital admissions. Telehomecare patient Beatrice, 77, explains how the system has affected her daily life: “Telehomecare has definitely

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improved my quality of life. I feel like my nurse is there with me every day,” she says. “I have personally learned a lot in the process like understanding the impact that managing my diet, exercising and thinking positively can have on my health.” OTN Telehomecare was recommended to Beatrice by her physician, Dr. Sanjeev Goel, a family physician at Wise Elephant Family Health Team. The program makes

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HOSPITAL NEWS APRIL 2014

In the first phase of OTN Telehomecare implementation, patients with CHF and COPD were enrolled in the North East LHIN by the North East CCAC, in the Central West LHIN by William Osler Health System (Osler) and in the Toronto Central LHIN by Toronto Central CCAC. “The outcomes have been remarkable,” says Laurie Poole, a Registered Nurse and VP, Telemedicine Solutions at OTN. Early results from the Central West LHIN based on Osler’s utilization data indicate a 71 per cent reduction in hospital admissions and a 43 per cent reduction in ER visits. More, Poole says the level of patient satisfaction with Telehomecare is tremendous. As Beatrice put it, “I really can’t believe the care I’m getting. I never expected it.” For Matt Anderson, Osler’s President and CEO, Beatrice’s reaction is exactly what the Telehomecare partnership is all about – commitment to better care for the community. The team at William Osler’s knows firsthand the value of Telehomecare. Anderson says there has been remarkable co-operation between Osler, OTN and TELUS as well as the Central West LHIN and the CCAC. “With any new program, there were challenges to overcome in implementation, but when you have a program with such clear clinical benefits, it makes it easier for people to rally around it. The barriers are low and the return high,” says Anderson. Telehomecare can grow in a number of ways too and Anderson envisions the program evolving to address other illnesses and eventually being used in a truly preventative way. Dr. Ed Brown agrees. “We are thrilled to see use of this technology platform accelerating and the benefits beginning to be realized in the community. It’s a win for paH tients and the health care system.” ■ Dr. Michael Guerriere is chief medical officer at Telus. www.hospitalnews.com

Focus 11

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

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APRIL 2014 HOSPITAL NEWS

12 Focus

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

Continence program improves quality of life for seniors By Marcus Guido, Laura Robbs and Priti Patel

tigma silences many seniors into keeping their bladder and bowel control issues secret; however a Regional Continence Program for Seniors in the Mississauga Halton area is helping to end this silence. According to Laura Robbs, a Trillium Health Partners Clinical Nurse Specialist and the Program's Clinical Coordinator, the stigma of incontinence can negatively affect seniors so they stay at home and miss out on some of their favourite activities, which can lead to depression. The Regional Continence Program aims to battle this stigma. The Regional Program's goal is to improve the health, wellness and quality of life for seniors by improving access to assessment and treatment of incontinence, including urinary and fecal incontinence and constipation. The Program applies a unique three-pronged approach – clinic visits, home visits and public education. It provides continence services for seniors with a range of needs – from those who are well to those with frailty and cognitive impairments. Clients are seen by a Nurse Continence Advisor (NCA) – a Registered Nurse who has advanced education in the

Right to left: Cheryl Raycraft, Administrator at Allendale, Laura Robbs, Continence Nurse, Velvet Tupper, Continence Nurse, Joanne Chen, Manager, Seniors’ Services, Trillium Health Partners. conservative treatment of incontinence. The Regional Program is part of an inter-professional Seniors Services team that enables NCAs to link seniors to other specialized professionals, such as geriatricians (physicians who specialize in caring for older adults), nurse practitioners, pharmacists,

social workers and occupational therapists as well as to a continuum of services (e.g. Falls Prevention Programs). The Regional Program's five communitybased continence clinics are located in Milton, Oakville, Mississauga and two in south Etobicoke. Continence home visits are provided across the Mississauga Halton LHIN area for seniors who are frail and unable to access a clinic; home visits require a referral from a physician or Community Care Access Centre. In both home and clinic visits, focused and specialized nursing assessment and conservative treatment are provided for seniors who are experiencing urinary incontinence, urinary frequency, nocturia, issues with urinary catheters, frequent bladder infections, fecal incontinence and constipation. There is no cost to the seniors for home or clinic continence visits.

Stigma silences many seniors into keeping their bladder and bowel control issues secret.

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HOSPITAL NEWS APRIL 2014

Referrals to the Regional Program are encouraged from seniors themselves, their families and from health professionals. By calling one central number (416-5214090), seniors who are 65 and older can book their own appointments at one of the five clinics. The Nurse Continence Advisors also provide education for the public as other area residents need increased continencerelated knowledge to improve their bowel and bladder function. Popular education sessions given at retirement homes, community groups and hospitals include topics such as, “Healthy Bladder Habits as We Age” and “Avoiding Constipation with Aging.” As part of the Regional Program's first year evaluation, clients and health providers were surveyed. Data collected through pre and post questionnaires indicated that the Program has had a positive impact on the lives of seniors in the Mississauga Hal-

ton region. Evaluators found that incontinence-related psychological, emotional and functional quality of life significantly improved after treatment in the program. A pharmacist who responded to the survey commented, “I used to always recommend laxatives and alpha blockers for constipation, now I refer clients to the continence program to learn other strategies that are extremely effective to manage chronic constipation.” Self-efficacy (i.e. how confident seniors attending the continence program feel in managing their incontinence under different circumstances) also significantly improved. As one health care professional shared, “A client was getting up every hour at night to urinate and he reported very poor quality of life as a result of lack of sleep. The nurse was able to fit him with a condom catheter and this client now reports that he sleeps like he hasn't been able to in years. He is very happy.” Lastly, seniors involved in the Regional Program have had statistically significant decreases in falls, emergency visits related to urinary tract infections, and hospital admissions related to both urinary tract infections and bowel problems. Thirty-one per cent of survey respondents reported that they visited the hospital's emergency because of a fall and eleven per cent visited because of a urinary tract infection. Those numbers dropped to six and two per cent, respectively. “Reaching a higher quality of life means the clinics are successfully helping seniors fight the stigma of incontinence,” concludes Robbs. For more information on the Regional Continence Program for Seniors, please contact Clinical Coordinator, Laura Robbs at extension 905-848-7580 ext. 3267 or at laura.robbs@trilliumhealthpartners.ca. If you live in the Mississauga Halton LHIN and would like to make an appointment at one of Program's continence clinH ics, call 416-521-4090. ■ Marcus Guido, Laura Robbs and Priti Patel work at Trillium Health Partners. www.hospitalnews.com

Nursing N ursing P Pulse 13

New guideline on safe sleep says back is best for baby By Marion Zych

set off recommendations rec ecoommendations d aimed aimed d at creating a safe sleep environment for infants was unveiled in Toronto in February. The recommendations, contained in a clinical practice guideline titled Working with families to promote safe sleep for infants 0-12 months of age, were developed by the Registered Nurses’ Association of Ontario (RNAO). “A lot of myths and misunderstanding about the best way to position a baby still exist, and we hope this guideline will lay the debate to rest,” says Elyse Maindonald, a nurse practitioner with the Windsor Family Health Team, who led the panel of experts that created the guideline. Maindonald says the panel reviewed the evidence and came to the conclusion that the safest place for an infant to sleep is on their back, and alone, in a crib that meets Canadian safety standards. Maindonald says cradles and bassinets with sides that allow air flow are also considered safe places for a small infant to sleep. RNAO’s guideline backs up previous research that strongly encourages parents to avoid using blankets, pillows and other forms of sleep aids for their baby, including positioing devices, head coverings and soft toys, which can all block an infant’s airway.

The panel conducted a comprehensive review of all the factors that can affect and shape a child’s safe sleep environment. “Given what we know about Sudden Infant Death Syndrome (SIDS), we feel confident that putting a baby to sleep on his/her back along with other important considerations, such as not smoking and the importance of breastfeeding, greatly reduces risk,” says Maindonald.

The ‘back is best’ recommendation applies throughout the first 12 months of a child’s life. The guideline also lists sleep surfaces that are not recommended for infants. They include: an adult’s bed, sofas, couches, armchairs, playpens, swings, strollers, slings and car seats. While would-be and new parents may be tempted to choose from a myriad of baby products, the guideline recommends

a firm rm mattress matttress and fitted tte sheet are all that is n is eedeed to create the ssafest sleep surface needed forr a baby. ba Maindonald says many people believe it is necessary to keep a sleeping baby warm with blankets and head coverings, but the evidence runs counter to that idea. “Infants over two months of age who are overheated are actually at an increased risk of SIDS,” she says. Yolanda Guitar, a mother whose fourmonth-old son died of SIDS in 2004, says she hopes the guideline lends credibility to an issue that’s important but one few people want to talk about. Guitar sat on RNAO’s panel and is certified as a safe sleep expert. “We need to make sure that this subject is discussed more openly, whether it’s during prenatal classes or after a woman has given birth in hospital. This shouldn’t be a taboo topic.” Dr. Monique Lloyd, who leads guideline development for RNAO, says she hopes the guideline will be embraced by nurses and health-care organizations alike. “We want every nurse armed with the latest evidence about how to create as safe a sleep environment as possible so they can share this information with new parents,” H she says. ■ Marion Zych is director of communications for RNAO, the professional association representing registered nurses in Ontario.

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APRIL 2014 HOSPITAL NEWS

14 Focus

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

Better communication leads to better palliative care By Enrique Saenz

erhaps more than most other areas of healthcare, palliative care depends on close, timely communications between all medical professionals and caregivers to provide clients with optimal care. In a hospital setting, where everyone is in one place, this is relatively easy to accomplish. But the palliative care team at Toronto Central Community Care Access Centre (TC CCAC) faced a challenge: how to achieve hospital-level communication to support their in-home care? Toronto Central CCAC has a strong palliative team serving an increasing number of people with terminal illnesses who want to stay at home as long as possible. Properly prepared, with supports and appropriate medication, dying at home can be the right choice for many people. Palliative care team members include care coordinators, nurse practitioners and a pharmacist from TC CCAC, nurses and personal support workers from service provider organizations, and physicians from the Temmy Latner Centre for Palliative Care and Hospice Toronto. When TC CCACâ&#x20AC;&#x2122;s commitment to integrated care expanded to include palliative care clients, the palliative team and its partners had to come up with solutions to present itself to clients as a single team. The first step to appearing like one team was to act like one, and that meant ongoing communication about each client. The Toronto Central CCAC Palliative Program looked at best practices for palliative homecare and found evidence supporting the use of daily morning meetings. When a trial of the technique using conference calls was first proposed, there was not much support for it. Team members worried it would take too much time away from client care, which none of them could afford to lose. Adjustments were made along the way, and the morning meeting, now called â&#x20AC;&#x2DC;the huddleâ&#x20AC;&#x2122;, has become a daily conference call between all team members. A few principles are strictly followed: the meeting starts on time, takes no longer than 15 minutes, is moderated by the care coordinator and follows the SBAR technique when introducing a new client with a prob-

Huddles are about improving communication among the health care team members. lem or update (Situation, Background, Assessment and Recommendation). In evaluating and revising the huddle, Quality Improvement techniques were used, including tracking how many clients were discussed, how many calls were avoided, and the level of satisfaction of both professional participants and their clients. The huddle was first tested with teams from three of nine districts in Toronto Centralâ&#x20AC;&#x2122;s catchment area. At first, the teams thought the huddle was an extra task. But after one or two months, they couldnâ&#x20AC;&#x2122;t live without it. The team found that between one-11 clients were discussed per huddle, with a median of six. More striking, a median of nine calls were avoided per huddle. Team members, especially nurses, were no longer spending hours on the phone trying to track

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down other team members or get authorization from a doctor. The satisfaction of participants was increased and clients now actually understood the many people involved in their care were a single, integrated team. TC CCAC care coordinator Leslie Randl found that â&#x20AC;&#x153;the huddles help increase trust between team members, and create a feeling of shared responsibility.â&#x20AC;? Huddle discussions are limited to highpriority topics. A support worker may report that a client seems to be deteriorating, and is having difficulty breathing. As a result, a nurse may volunteer to go to the home right away. The physician may commit to visiting in the afternoon. A doctor may report the first signs of bedsores on a clientâ&#x20AC;&#x2122;s back, and treatment is quickly agreed upon and a personal support worker sent out that day. With immediate dialogue and discussion, immediate action can occur, improving patient care. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s valuable to get updates on patients that the RNs are seeing on a more regular basis, especially when a patientâ&#x20AC;&#x2122;s status is changing daily,â&#x20AC;? says Dr. Marnie Howe of the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital. The initial success has led to plans to expand to all nine district teams. For team members, the benefits are significant. There is less stress and greater satisfaction. Weâ&#x20AC;&#x2122;re more proactive. We love our work. And the huddles have been crucial to building the teams. Previously, we didnâ&#x20AC;&#x2122;t know each other. Now we often organize joint home visits, and go out for lunch once a month. Weâ&#x20AC;&#x2122;re H a real team. â&#x2013;

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HOSPITAL NEWS APRIL 2014

Continued from page 9

The patient was tired, and felt that no one could help her. Her mother, who is her primary caregiver, didnâ&#x20AC;&#x2122;t think this time was going to be any different either. The hour-long videoconference included the patient, her mother, her family doctor, an internist, psychiatrist, dietician, social worker and representative of the Toronto Central CCAC. The patient wasnâ&#x20AC;&#x2122;t just an observer, as the team asked her numerous questions during the session. At the end of the hour, the team came up with a number of recommendations for the patient and her family doctor, as well as a coordinated care plan which would continue to evolve reflecting the complex care that was required. The client was referred to an eating disorder group as well as an art therapy group, as the team discovered during the videoconference that she loved art. In the past, this had not been recognized or explored.

The Telemedicine Impact Plus Nurse Facilitator program started late last summer and is being offered through the four early adopter Health Links.

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Telemedicine video conferencing

Enrique Saenz, is the Client Services Manager, Palliative Care Program Toronto Central CCAC.

The experience has rejuvenated the patientâ&#x20AC;&#x2122;s confidence in her future. â&#x20AC;&#x153;I canâ&#x20AC;&#x2122;t believe the entire team took time out of their busy day to talk to me about my challenges,â&#x20AC;? she said afterwards. â&#x20AC;&#x153;I would have gotten up at three in the morning for that, and Iâ&#x20AC;&#x2122;m not a morning person.â&#x20AC;? Indeed, finding a time when all members of the caregiving team are available is a challenge, even though the video link means they donâ&#x20AC;&#x2122;t all have to be in the same place. The key, according to Agnes, is engaging with the family doctors, and they usually prefer to have the conferences first thing in the morning, before they get busy with other patients. When they see the results, the doctors are supportive. The patients that are referred are more complex and are the ones that â&#x20AC;&#x2DC;keep the physician up at nightâ&#x20AC;&#x2122;. In this case, the family doctor was happy to have a team of professionals to help her find a sustainable solution to the patientâ&#x20AC;&#x2122;s health needs. â&#x20AC;&#x153;The goal of TIP is to support the patient and the family doctor, and reduce hospital visits,â&#x20AC;? says Agnes. â&#x20AC;&#x153;Some of these patients were going to the ER every week, which costs the system a lot of money, and many of these people were falling between the cracks.â&#x20AC;? During a recent follow-up, the patient reported that sheâ&#x20AC;&#x2122;d registered for the art therapy program and had started doing more art work at home, to take her mind off binge eating. The internist on the team has also referred her for bariatric surgery to deal with her weight issue. Itâ&#x20AC;&#x2122;s too early to judge the long-term results of TIP, for this patient and others, but the team is optimistic. â&#x20AC;&#x153;Thereâ&#x20AC;&#x2122;s less going in circles,â&#x20AC;? says Agnes. â&#x20AC;&#x153;You get results when youâ&#x20AC;&#x2122;re not going in circles.â&#x20AC;? Or, as the patientâ&#x20AC;&#x2122;s mother puts it, â&#x20AC;&#x153;For the first H time, I feel weâ&#x20AC;&#x2122;re moving forward.â&#x20AC;? â&#x2013; Nancy Lefebre is Senior Vice President, Saint Elizabeth Health Care. www.hospitalnews.com

Focus 15

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

Keynote Speakers

Dr. Samantha Nutt Sunday June 1

Mr. Ray Zahab Monday June 2

Dr. Ian Stiell Tuesday June 3

Dr. Mel Herbert Tuesday June 3

Mr. Jeffrey Simpson Wednesday June 4

Dr. Jeffrey Turnbull Wednesday June 4

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For more information visit caep.ca/Conference APRIL 2014 HOSPITAL NEWS

16 Caregiving

A geriatrician can help

aging loved ones By Bart Mindszenthy

hen my mother was sliding deeper into her years and what eventually was diagnosed as a form of dementia, we were at a loss as to what to do. My parentâ&#x20AC;&#x2122;s family doctor was doing all he knew how to do, and in fact acknowledged that heâ&#x20AC;&#x2122;d reached the edge of his knowledge and expertise. My motherâ&#x20AC;&#x2122;s behaviour was becoming more and more erratic and unpredictable. The cocktail of medications heâ&#x20AC;&#x2122;d prescribed just didnâ&#x20AC;&#x2122;t seem to be doing anything that gave my mother sustained peace and comfort. I was told to go to the Alzheimerâ&#x20AC;&#x2122;s Society and check out workshops specifically geared to family members. I did that, signed up, attended the series, got a lot out of it, but it still got me no closer to discovering some kind of specific help for my mother and at that point, our family. Thatâ&#x20AC;&#x2122;s about the time when a family friend who was a retired nurse suggested I get my mother to visit a geriatrician. A what?

Geriatricians are a huge help It took me a while to find one. Thatâ&#x20AC;&#x2122;s because there are so few of them. Across Canada there are less than 300 geriatricians. Theyâ&#x20AC;&#x2122;re booked pretty solid, overworked, underpaid and amazingly dedicated to their calling.

A geriatrician is what I call a holistic medical physician for the aging and elderly. A geriatrician looks at all aspects of an aging personâ&#x20AC;&#x2122;s life: mental, physical, emotional. A comprehensive assessment is the first step, followed by a review of all medications, lifestyle, and current issues and behaviour. Then a recommended program for moving forward that is realistic and helpful to the patient and the family.

What we got from the experience I organized for my mother to see her geriatrician about every two months for the first three years of her steady but managed decline. It was always a difficult visit; he was always behind, and my mother was always tense and apprehensive. Yet when the appointment finally got underway, it was always good and productive. He was the epitome of patience. She got calmer, more articulate, and more cooperative. And appointments usually lasted at least half an hour or more; no rush. The big win for us all was that her geriatrician took that holistic look and approach to her health. And he was incredibly astute in reviewing all her medications, and I mean all: physician prescribed, over the counter drugs, naturopathic-recommended pills. Each was examined and re-

viewed for interactions, benefits, and possible benefits and cautions to be carefully considered. Plus he tracked any specialists my mother was seeing and outcomes of appointments and any tests. As important, he was a very gentle, understanding person, which in turn helped make my mother more calm and cooperative.

Staying with it My mother ended up in a nursing home and slowly but surely deteriorated on all fronts. We knew a cure was out of the question. The challenge for us all was to keep her calm, comfortable, and safe; to give her the best possible quality of life as she got into her mid nineties and was ever more consumed by her dementia. My mother remained relatively stable for several more years. And I made it a point to have not only her nursing home physician see her regularly, but to get my mother to her geriatrician on a quarterly basis for another two years. It was only when she started failing physically and sliding downward cognitively that we agreed the actual process of moving her to the geriatricianâ&#x20AC;&#x2122;s office for an appointment was too stressful; that the benefits of his care were declining on par with her health. So we stopped going, though on a fairly

regular basis I called him or his assistant with updates and to ask for advice, which was always gladly given.

Find one; be patient There are three ways to find a geriatrician. Ask your family physician. Check with your local hospital or health network, or go to www.canadiangeriatrics.ca and use the â&#x20AC;&#x2DC;contact usâ&#x20AC;&#x2122; section to get in touch with this group. Because there are so few geriatricians in Canada it usually takes time to get an elderly parent or other loved one in for even an initial visit. So be patient, get in line sooner than later (get a referral from your parentsâ&#x20AC;&#x2122; family physician if you can, or yours), and be persistent. From my own experience and all Iâ&#x20AC;&#x2122;ve learned from others across the country, a good geriatrician can make a huge difference for the better in your familyâ&#x20AC;&#x2122;s journey into the world of aging and all its related H issues and challenges. â&#x2013; Bart Mindszenthy is co-author of the Parenting Your Parents series of books; to read more, visit www. parentingyourparents.ca. He is a best-selling author on the issues and challenges of caregiving in the family as well as other topics.

â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s my pleasure to say â&#x20AC;&#x2DC;thank you.â&#x20AC;&#x2122; Your knowledge DQG FRQĂ&#x20AC;GHQFH JXLGHG XV WKURXJK DOO WKH WLPH <RX ZHUH OLNH WKH OLJKW DQG WKH KRSH LQ WKH GDUN HVSHFLDOO\ LQ WKH Ă&#x20AC;UVW FRXSOH RI \HDUV , DP JODG LW LV RYHU VXFFHVVIXOO\ 7KDQN \RX Âľ â&#x20AC;&#x201C; A.W.

HOSPITAL NEWS APRIL 2014

www.hospitalnews.com

Focus 17

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

First Three Days initiative aims to improve care for frail elderly patients By Michelle Tadique

t. Joseph’s Health Centre is committed to recognizing the unique needs of patients and improving their experience in hospital, while providing high quality and safe care. One approach to enhancing care is through the First Three Days initiative, which focuses on frail elderly patients, enabling them to get home sooner by maintaining their independence and sometimes functioning even better than when they arrived in the emergency department (ED). “Studies have shown that lying in bed for 24 hours is when you start to see muscle atrophy, and you become weaker,” explains Occupational Therapist Neelam Bal. “The first three days is a key period to get involved with patients and from day one we were getting the patients up and moving and starting our assessments.”

There can be innovation without technology and in this case it means changing the way people think about caring for the elderly Through this initiative, we are able to identify frail elderly patients in the ED, as they are admitted to the Medicine Program, who can benefit from the expertise of Geriatrics, Nursing and Occupational Therapy staff through early, coordinated interprofessional assessment and treatment that starts within the first 24 hours of their hospital stay. Two years since the First Three Days pilot project started, this home-grown program has been successful in helping patients maintain their function so they don’t lose strength or their ability to perform normal activities; at the same time reducing the amount of time frail seniors stay in hospital. “We are seeking to prevent the deterioration of general function that we see so commonly in hospitalized patients,” says Dr. David Tal, Chief of Geriatric Medicine. “A frail senior can lose muscle strength so quickly. Someone that was walking comfortably with a cane or walker, gets put on bed rest for two days, and then can’t stand. The goal is to treat the acute medical problem and not to lose ground in their ability to function, to spend those first three days already making the person feel better.” Ultimately this initiative is looking to change the culture of care, as Dr. Tal explains. “We want to change people’s understanding so that the automatic approach to care is to get the person up and moving, doing normal activities such as sitting up in a chair, rather than the common care of bed rest.” www.hospitalnews.com

Senior care is an important area of focus for St. Joe’s as a community teaching hospital caring for the over half a million people living in Toronto’s West End. Thirty-four per cent of residents living in neighborhoods surrounding St. Joe’s are over the age of 65 with nearly 14,000 patients over the age of 70 coming to the ED in the last fiscal year. So why focus on frail elderly patients? Dr. Tal explains that these are individuals who are 70 years of age and older, have a degree of cognitive impairment, are taking multiple medications, live alone, and have had falls or are at risk for falls. All of these issues combined put them at higher risk for complications, making early intervention and assessment that much more critical for this group. Patients 70 years and older also account for 35 per cent of overall ED admissions and tend to stay in hospital longer – nearly eight days, versus an average of three and a half days for patients younger than 70. They are also three times more likely to be re-admitted to hospital than others. The First Three Days improved functional independence for patients by 50 per cent in the pilot project. “Our patients were also able to get home sooner. This is also about empowering our patients because we want them to feel that they can do for themselves and we’re here to support them in doing that,” says Bal. Due to the success of the initiative over the last two years, additional funding has been provided to expand this approach to integrate more members of the interprofessional team, including physiotherapy, social work and rehabilitation assistant care. This additional support from the Toronto Central Local Health Integration Network will enable us to further evaluate the First Three Days program over the next six months, learning how to best incorporate this important aspect of care. “The First Three Days is a great example of how interprofessional collaboration is really improving the patient experience,” says Shelley DeHay Turner, Interim Vice President of Clinical Programs. “We have reduced the length of stay by half a day and are aiming to reduce it even more to a full day. If we continue to demonstrate its success, we hope to explore opportunities to expand this for patients even more.” “The First Three Days is all about people. It’s not about buying a new widget or device,” says Dr. Tal. “There can be innovation without technology and in this case it means changing the way people think about caring for the elderly and using the expertise of our professionals early in the H course of a patient’s treatment.” ■ Michelle Tadique is a Communications Associate at St. Joseph's Health Centre Toronto.

Dr. David Tal (centre) and Occupational Therapist Neelam Bal (right) meet with patient Diane as part of the First Three Days initiative.

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18 Focus

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

Baycrest launches mental health website for seniors By Steph Parrott

aycrest Health Sciences has launched a mental health website designed specifically for older adults who are struggling with depression. Created by Baycrest’s Chief of Psychiatry, Dr. Robert Madan, the site (www. baycrest.org/mentalhealth) is both a multimedia resource and a source of encouragement for older adults who are struggling with or recovering from illness, and their families. There are many biological, psychological and sociological factors unique to older adults that play a role in late-life depression. In older age, people can start to suffer many losses. It could be the loss of a spouse, loss of employment and the friendship of co-workers, loss of identity after retirement, loss of cherished friends who pass on, the loss of one’s own health and mobility due to chronic disease or serious illness, or the loss of one’s cherished home with the transfer to a nursing home. Any of these losses can be emotionally devastating and trigger the onset of depression. “The website helps users understand late-life depression in a way that is friendly, engaging and positive,” says Dr. Madan. “We want people to understand that depression is not a normal part of aging that is to be expected and endured.” The importance of reaching out for help is emphasized throughout the website. Despite the difficult subject matter, the site

gives visitors a sense of hope that if they are experiencing depression they can recover with the help of a doctor and the right treatment. This message is driven home not only through the words of the medical experts in short video vignettes, but also through the candid and powerful stories of two people who have experienced late-life depression. Evelyn Burns-Weinrib shares her experience with depression and a suicide attempt. “I was 78 and I felt I was losing control of my health and my life,” she said in her story that appears on the website. “As an independent woman I felt as though my declining health would leave me with nothing positive to look forward to.” Now, two years later, Burns-Weinrib has recovered. “I am sharing my story because I am now an advocate for seniors’ mental health issues. I want the discussion of depression put on the table, not kept under it,” she says. “I will talk about it whenever and wherever I can.” Burns-Weinrib is so dedicated to this mission, she was moved to make a generous donation to help with the website’s development. The project has also received funding from the AFP Innovation Fund and the Geoffrey H. Wood Foundation. Burns-Weinrib’s story touches on another important aspect of late-life depression addressed on the website: the issue of stigma. Dr. Madan says this is particularly important for older adults. “Public aware-

Dr. Robert Madan led the development of a new website on seniors’ mental health with the support of Evelyn Burns-Weinrib who has experienced late-life depression and is an advocate on the issue. ness campaigns have helped dispel many of the common myths about depression and mental illness and increased the general public’s understanding that these are medical illnesses just like diabetes or heart disease,” he explains. “But this is a recent development and many older adults have grown up with the idea that depression is something you can’t talk about openly because it’s perceived as a personal failing or a weakness.” Visitors to the website will find a wealth of information on the causes of depression symptoms and latest treatments. The treatments section covers medications, different types of psychotherapy, electroconvulsive therapy, and explanations of

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how each of these treatments is used and chosen by patients and health care professionals. Visitors can watch videos where experts in geriatric mental health deliver information in a style that is warm, personable and consumer friendly. “Using this multi-media approach, we’re introducing viewers to physicians and psychologists like the ones they would meet when they seek help,” says Dr. Madan. “We’re demystifying the process and giving the viewer an idea of what they can expect.” The site also tackles what is perhaps the most challenging subject – suicide and self-harm, an important issue in geriatric mental health. In Canada, adults 65 and older have the highest suicide rate of any age group. “It was important for us to cover this topic,” says Dr. Madan. “We wanted to explain to people that thoughts of suicide and death are common symptoms of depression and that if they are experiencing these symptoms they need to talk to someone and get help from a health care professional as soon as they can.” Dr. Madan says the site will be a useful tool for physicians to use in their practice and make their patients aware of this important supplemental resource. “We know that many people are looking for medical information online now. It’s my hope that individuals with late-life depression and their family members can find this site and understand that there’s no need to suffer,” he adds. “With the help of health care professionals, seniors who are experiencing depression can find effective treatment that works for them to achieve remission of their symptoms.” Dr. Madan hopes to expand the site in future to include information modules on anxiety as well as bi-polar disorder, demenH tia, and other topics. ■ Steph Parrott is a Public Affairs Specialist at Baycrest Health Sciences. www.hospitalnews.com

Focus 19

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

Mount Sinai’s ACE Strategy the traditional hospital model for older adult care By Dr. Samir K. Sinha

hile older adults currently represent 14.6 per cent of Ontario’s population, they account for over one-third of the province’s acute care hospitalizations and 60 per cent of its hospital days. This is largely because older adults, more often than other patients, experience inter-related chronic and acute health and social issues and require more complex types of health services, particularly in acute care settings. With Canada’s older population expected to double in the next 20 years, the imperative is clear, acute care hospitals need to transform how they resource, organize, and deliver care for older adults. Over the past few years, our team at Mount Sinai has seen significantly improved outcomes for older patients as a result of rethinking existing care models and integrating new approaches in every clinical area of the hospital. In 2010 we launched an Acute Care for Elders (ACE) Strategy, aimed to improve the quality of life and care for older patients during the acute phase of their illness and after they leave the hospital. Now three and half years later, as the first acute care hospital in Canada to make geriatrics a core priority, our ACE strategy has garnered national attention for delivering dramatically better results. I am particularly pleased to be working with a number of hospitals across the country, and as far away as China, to help replicate elements of our ACE Strategy. It is great to see how new ideas in health care practices can spread and strengthen the entire system.

ACE: Better care, less time and money Since 2009/10 Mount Sinai has seen a 32 per cent increase in the number of patients 65 years of age and older it serves annually. However, despite this increase in older patient volumes, Mount Sinai’s ACE strategy has also allowed the hospital to reduce its average total lengths of stay per patient by 28 per cent and decrease its ALC days by 18 per cent. Our older patients are now more likely to go directly home from the hospital instead of nursing homes, and are less likely to be readmitted. Older patients are also more satisfied with our care. Indeed, through integrating geriatric care principles into every area of the hospital, the hospital is now delivering clearly better patient and system outcomes. What has been most impressive, were the minimal financial investments required to support this transformative model. Instead it required a different approach to the way we work. Indeed, the ACE strategy has reduced our overall care costs for the older patients we serve by more than $6.4 million in 2012/2013 alone.

ACE: How it works The ACE Strategy at Mount Sinai ensures caring for older patients is maximized with an inter-professional, team-based approach, no matter where the patients are cared for. This helps ensure every aspect of their care gets addressed accurately and efficiently in the emergency, inpatient, outpatient and home-based settings. Much of www.hospitalnews.com

Dr. Sinha reviews his patient’s care plan with his team in Mount Sinai’s Acute Care for Elders (ACE) Unit, which offers frail older adults customized care in an elder friendly environment. this collaborative work has been facilitated through the development of innovative IT communication tools, and the implementation of screening and ‘geriatricized’ care protocols that promote mobility, and the use of the most appropriate medications in older patients. Under the ACE strategy, Mount Sinai has implemented a series of other evidence-informed tailored interventions to create a seamless continuum of care throughout the hospital. Here are some examples: • All patients 65 and older presenting to our Emergency Department are screened first for geriatric issues so their treatment plan can be tailored accordingly with the support of a Geriatric Emergency Management (GEM) Nurse when needed. Mount Sinai now has the largest GEM Nursing Program in Ontario that operates seven days a week and helps more patients get home with the appropriate ongoing community and outpatient supports. • As the latest ACE Strategy model to be recognized by Accreditation Canada as a Leading Practice, the hospital’s Ben and Hilda Katz ACE Unit, offers hospitalized frail elders care that is tailored specifically to their unique needs in an environment specifically designed to support frail older adults. Patients admitted to this unit are seen by all members of the inter-professional team and are encouraged to be more active and independent during their hospital stay, for example, by walking to the bathroom instead of using a commode chair and staying out of bed most of the day including during their meal times. • Hip fractures can be devastating for older adults. Therefore, a first-of-its kind Orthogeriatrics Hip Fracture Service at Mount Sinai brings together an integrated team of orthopaedic surgeons, geriatricians and hospitalists to comprehensively treat older patients with hip fractures, and to better avoid common complications like delirium and institutionalization. • We know that older adults may need extra support during hospitals stays, which is why a unique program called Maximizing Ageing Using Volunteer Engagement (MAUVE) was developed to train volun-

teers to offer an extra layer of emotional and functional support to hospitalized older adults. This program has also been named a Leading Practice by Accreditation Canada with other hospitals now following our lead as they implement similar programs.

ACE: Helping elders return to the community Recognizing that our patients not only come from the community, but that when they leave the hospital they often need support to remain active and independent, Mount Sinai’s ACE Strategy embraces strong and meaningful collaborations with community care organizations like the Toronto Central Community Care Access Centre (TC-CCAC) and the SPRINT Senior Care Community Support Services

Photo, Kevin Kelly

Agency. Mount Sinai has also partnered with a unique program called House Calls that brings primary and specialty care directly into the homes of older housebound patients allowing even nursing home eligible patients to have the opportunity to age in the place of their choice, which is at the heart of what ACE is all about. Indeed, Mount Sinai has much to be proud of but what is exciting is that its clinicians are looking to continually build on what it learns and achieves to ensure living longer and living well remains something H we can all achieve together. ■ Dr. Samir K. Sinha is the Director of Geriatrics at Mount Sinai and the University Health Network Hospitals in Toronto, and the Provincial Lead, Ontario’s Seniors Strategy.

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APRIL 2014 HOSPITAL NEWS

20 Focus

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

Plain Language Labelling Initiative overdue By Richard Parcels

any seniors have trouble with the labels on prescription drugs. The print is too small to read, and the words are often medical terms they donâ&#x20AC;&#x2122;t understand. For example, if a senior suffers from indigestion, the label doesnâ&#x20AC;&#x2122;t say â&#x20AC;&#x2DC;indigestionâ&#x20AC;&#x2122;. It says dyspepsia, but unless youâ&#x20AC;&#x2122;re a doctor or pharmacist, who knows what that means? By the same token, if an elderly person has muscle pain, the term on the label is myalgia, and for joint pain itâ&#x20AC;&#x2122;s arthralgia. Such words are used because the labels are written by health care professionals like physicians or clinicians. The potential for taking incorrect dosages, or the wrong medication, is real. Finally, something is being done. Last June the federal government announced the Plain Language Labelling Initiative. The announcement was made by Leona Aglukkaq, Minister of Health, who was accompanied by two MPs. One of them was Terence Young of Oakville. In 2000 Youngâ&#x20AC;&#x2122;s teenage daughter died of heart arrhythmia after an adverse reaction to a drug. The drug was later deemed to be unsafe and taken off the market. Problems with the labels of prescription drugs can be even worse for seniors, many of whom donâ&#x20AC;&#x2122;t have an advocate looking out for them. The ultimate goal of this initiative is to improve the safe use of drugs by making drug labels, as well as safety information, easier to read and understand.

The proposed regulations apply to drug manufacturers, and encompass both prescription and non-prescription drugs for human use. For the record, â&#x20AC;&#x2DC;plain languageâ&#x20AC;&#x2122; is described as communication that the public understands the first time they read it or hear it, which is often not the case with dyspepsia and myalgia. Proposed amendments to the Food and Drug Regulations, which are part of Health Canadaâ&#x20AC;&#x2122;s Plain Language Labelling Initiative, would: â&#x20AC;˘ standardize the format of non-prescription drug labels to help consumers locate important information â&#x20AC;˘ require companies to include contact information on labels so consumers can report problems and adverse drug reactions â&#x20AC;˘ require manufacturers to provide mock-

ups of labels and packages for review as part of drug product applications, and â&#x20AC;˘ require manufacturers to provide evidence that drug names wonâ&#x20AC;&#x2122;t be confused with other authorized products. This has been a public process. After the announcement was made, the government kicked off a three-month period for public consultation on the issue. That period closed on September 6, 2013. The Plain Language Initiative goes beyond simplifying words. It also includes fact tables that would be on the inner and outer labels of non-prescription drug products (in both English and French), as well as mock-ups of every label to be used for drug products. The label mock-ups would be required for new applications for prescription drug products, as well as for products used in doctorsâ&#x20AC;&#x2122; offices. The latter might include liquids that dilate the eyes in an eye examination; such products do not require a prescription and are not found in a drug store. These labels are important. One of the goals of the initiative is that outer labels on the carton of drug products would contain point-of-purchase decisions. So, if you are a senior with a heart condition, it will say right on the outer label to not take this drug, or to take no more than two tablets a day. This way the consumer knows to avoid the product, or how much of it to take. As for inner labels within the packaging, they would be crystal clear about instructions. For example, the inner label might

tell you to discontinue use of the item and consult a health care professional if you experience dizziness or a rash. Or it might tell you how long to take it if your symptoms persist. The labels and packaging for these products are a serious problem for many seniors, especially those who self-medicate, and for people whose first language is not English or French. The labels contain vital information about the drug including recommended dosage, how often to take it, where to store it, and warnings or precautions. According to Health Canada, one in nine visits to emergency wards in hospitals is the result of medication, and 68 per cent of those visits are preventable. The intent of the Plain Language Labelling Initiative is to: â&#x20AC;˘ Improve and maintain the health of Canadians â&#x20AC;˘Reduce health costs â&#x20AC;˘Decrease the number of visits to hospital emergency rooms â&#x20AC;˘Help identify risk (in terms of potential side effects or adverse events) from taking a drug by making the label more visible and easier to understand. The government is still reviewing all comments received during the public consultation process, but letâ&#x20AC;&#x2122;s hope the Plain Language Initiative becomes law soon. H This one is a no-brainer. â&#x2013; Richard Parcels is Director, Regulatory Services, for Quality & Compliance Services Inc.

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GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

Focus 21

Geriatric community

outreach service By Anne Kelly

arl Sheriff is a 92-year-old war veteran with advanced heart and lung disease and a strong desire to live out his days at his Kitchener home. He has been hospitalized several times in recent years and fears that the next time he will end up in a long-term care facility. “I don’t want to be separated from my sweetheart,” Earl says of his wife, Gert, also 92 and committed to helping Earl, despite being legally blind. Although Earl rebounded following his other hospitalizations, he began to struggle at home after a 16-day stay at St. Mary’s General Hospital in Kitchener, Ontario earlier this winter. Weakness and shortness of breath prevented him from leaving home to see his family doctor, who does not make house calls. He receives some home care service, but was reluctant to call an ambulance for fear of being admitted to hospital. Instead he was referred to an innovative geriatric community outreach service, offered by the geriatrics team at St. Mary’s for frail elderly patients who are housebound and at risk of frequent emergency department visits and hospital admission. The program began in 2011 and focuses on transitional support to address acute issues and chronic disease management with the goal to enhance the quality of care for these vulnerable individuals. Hellen Jarman, a specialized Geriatric Nurse Practitioner visits referred patients in their homes or retirement homes, an average of two to three times per patient. She can assess them and initiate a plan of care, order diagnostic tests, prescribe medications, provide patient and caregiver education and link them with community services. Many initial visits occur within 24 to 28 hours after discharge from the emergency department. When needed, one of three Geriatricians at St. Mary’s accompanies her on outreach visits. “This is really state of the art,” Dr. Nicole Didyk, one of the Geriatricians, says of the home visit approach by the geriatric team. “We want to give the right care in the right place with the right people. If there are barriers to people getting the care they need because of a desperate fear of being separated from their loved one, then let’s go see them,” she says. Other barriers may include mental health issues, dementia, delirium or physical barriers that mean calling an ambulance is the only way to access care. In 2013 the outreach team had 143 referrals. They conducted 235 home visits, and 33 retirement home consultations. As a result, 33 per cent of patients avoided an emergency department visit and 34 per cent avoided an admission to hospital. Referrals come from many sources, including the Geriatric Emergency Management (GEM) nurses in the St. Mary’s Emergency Department, as well as inpatient units, retirement homes and the local elder abuse team. “This is a very patient driven program,” says Ms. Jarman. “We provide them with the knowledge and the tools to fulfill what www.hospitalnews.com

Earl Sherriff and his wife, Gert, share a lighter moment in their Kitchener home with Hellen Jarman, a Geriatric Nurse Practitioner (left) and Dr. Nicole Didyk, a Geriatrician. The two geriatric specialists are part of a community outreach service for housebound frail older adults. they want. People do better at home. They’re very engaged and involved because you are respecting their wishes.” On her initial visit to Earl, Ms. Jarman changed an antibiotic he was on for a recurrence of pneumonia. When she came back a week later, his breathing had improved and he had been able to get out of bed a few times. Dr. Didyk, accompanied her and provided a referral for a visit from a member of the community’s pain and symptom management team. Back at St. Mary’s Ms. Jarman called the Community Care Access Centre and the Department of Veteran’s Affairs to see if Earl could access additional help, as well as the Ministry of Health to request an in-home chest x-ray. Sandra Hett, Vice President of Patient Services and Chief Nursing Executive at St. Mary’s is fortunate to have so many levels of geriatric expertise to offer within the hospital and outside its walls. “I don’t know of another community in Ontario offering this specialized multidisciplinary approach to outreach and it speaks to St. Mary’s commitment to serving the vulnerable with dignity and respect,” says Ms. Hett. Dr. Didyk said that while not all outreach patients can be spared a hospital visit, she knows of five or six who would have been admitted to long-term care homes without the care and referrals to community supports provided by the outreach team. “Outreach is definitely keeping people in their homes,” Dr. Didyk says. Earl, is grateful that his wishes are being supported in a patient-centred way. “It’s H what this country needs,” he says. ■ Anne Kelly is a Communications Specialist at St. Mary’s General Hospital in Kitchener. APRIL 2014 HOSPITAL NEWS

22 Evidence Matters

Self-monitoring of blood glucose in Type 2 Diabetes By Kasia Kaluzny

duces long-term complications of diabetes or mortality, and more research is also needed on the effect of SMBG in gestational diabetes. The cost-effectiveness analysis found that SMBG performed nine times a week in patients not using insulin was associated with an incremental cost of $113,643 per quality-adjusted life-year (QALY) gained, relative to no SMBG. This cost exceeds commonly accepted thresholds, which means that SMBG for this group is not cost-effective.

ype 2 diabetes is a growing epidemic with significant implications for Canadians and the Canadian health care system. One aspect of diabetes management that has recently come under scrutiny is the practice of self-monitoring of blood glucose (SMBG). The test strips used for SMBG represent one of the largest expenses in diabetes management, with some estimates showing that more money is spent on test strips than on all oral antidiabetes medication combined. Recently, several public drug plans in Canada have made changes to their reimbursement policies surrounding test strip coverage. What do these changes mean for patients, and what does the evidence show?

Assessing the evidence In 2009, CADTH performed a systematic review of randomized controlled trials (RCTs) and observational studies comparing SMBG with no SMBG, or comparing SMBG frequencies. Meta-analyses were conducted to pool trial results, when appropriate. The results are summarized as follows: Patients with type 2 diabetes using insulin – studies were few and of low quality, but evidence suggests that SMBG is associated with improvements in glycemic control, as measured by a change of approximately -1% in haemoglobin A1C from baseline.

Recommendations * Public and private plans combined; type 1 and type 2 diabetic patients combined. Calculations based on 22% insulin users vs. 78% non-insulin users. Patients with type 2 diabetes not using insulin but using oral antidiabetes drugs (e.g., metformin) – SMBG resulted in a pooled A1C difference of -0.25%, which is statistically significant but not considered clinically significant. Patients with type 2 diabetes who do not take any antidiabetes drugs – SMBG resulted in a pooled A1C difference of -0.05%, which is not statistically or clinically significant. For all patient groups, there was little or no evidence to suggest that SMBG improves patients’ quality of life, satisfaction, and body weight. Longer term studies are needed to determine whether SMBG re-

A panel of experts developed recommendations based on the CADTH findings. For patients using insulin, the panel recommends that SMBG should be individualized to guide adjustments to insulin therapy. In adults with type 2 diabetes using basal insulin, SMBG up to 14 times a week should suffice in most cases. For most adults with type 2 diabetes not using insulin, the panel recommends that routine SMBG is not required. Therefore, patients managing their type 2 diabetes using oral antidiabetes medication, diet, or exercise do not need to self-monitor their blood glucose as frequently, and this will not negatively affect their health. The panel notes that every once in a while, short-term testing may be helpful for patients if they are experiencing unstable glucose levels, acute illness (e.g., flu), if they are pregnant or trying to become pregnant, or if they are changing their medication or

routine (e.g., travelling). More frequent testing can also benefit patients who are at higher risk of hypoglycemia because of inadequate diet, unforeseen exercise, history of severe hypoglycemia or hypoglycemic unawareness, or if they are taking medications that carry a higher risk of hypoglycemia, such as drugs in the sulfonylurea class (e.g., glyburide, gliclazide, glimerpiride).

Testing for a reason It is important to keep in mind that SMBG is only as useful as the action it triggers, whether that means adjusting insulin dose, taking glucose, changing diet, or finding motivation to exercise more. It’s these changes that lead to better glycemic control – not the act of SMBG itself. In other words, most patients with type 2 diabetes will benefit more from focusing on other aspects of diabetes self-management. Testing their blood glucose less often will not negatively affect their health, and it will free up time and resources. CADTH calculated that if these recommendations are put into practice and patients who don’t use insulin tested less often, more than $260 million could be freed up each year for spending on other health technologies. This is an important consideration when operating within a health care system that has finite resources. To read more about SMBG, visit www. H cadth.ca/smbg ■ Kasia Kaluzny is a CADTH Knowledge Mobilization Officer.

NOMINATE A NURSING HERO! Hospital News’ 9th Annual Nursing Hero Awards COMMITMENT DEDICATION COMPASSION LEADERSHIP Look around you. Have you been inspired, encouraged or empowered by an employee or a colleague? Have you or your loved one been touched by the care and compassion of an outstanding nurse? Do you know a nurse who has gone above and beyond the call of duty? Now is your chance to acknowledge and recognize the nursing heroes in your facility or community.

nual 9th AnSING UR

HWEARRO DS! A

Hospital News will once again salute nursing heroes through our annual National Nursing Week (May 12th to 18th) contest. We hope you will share your stories with us so that we can highlight the exceptional work that our nurses are doing and how they touch our lives. Nominations can be submitted by patients or patients’ family members, colleagues or managers. Please submit by April 15th and make sure that your entry contains the following information: Full name of the nurse Facility where he/she worked at the time Your contact information Your nursing hero story Along with having their story published, the winner will also take home: 1ST PRIZE: $1,000 Cash Prize

2ND PRIZE: $500 Cash Prize

3RD PRIZE: $300 Cash Prize

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Please email submissions to editor@hospitalnews.com or mail to: Hospital News, 610 Applewood Crescent, Suite 401, Vaughan, ON, L4K 0E3

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From the CEO's Desk 23

St.Mary’s

Lean journey promising, requires time and focus

By Don Shilton

n early 2011, St. Mary’s General Hospital in Kitchener began a journey of continuous quality improvement using Lean methodologies – one of the first Ontario hospitals to do so. In launching Lean, we set an ambitious goal of identifying and completing 1,000 improvements throughout the hospital in our first year. We exceeded that goal, an impressive achievement given that the Lean approach requires significant culture change and staff support. As President, I was proud that our staff had embraced Lean. They felt empowered at their daily unit huddles to identify barriers to improving performance and patient care. Together they brainstormed solutions and took on projects as part of our 1,000 Better Ways initiative. St. Mary’s is a busy 150-bed facility with 1,200 staff, regional cardiac and thoracic surgery programs, and large day surgery, medicine, emergency and diagnostic imaging programs. With so many competing demands on people’s time, it can be difficult to sustain such gains. In year two of our Lean journey, we started to lose some steam. We were challenged with maintaining a structure for keeping us focused on what was important in our organization. To help keep us on track and see the gains I believe are possible through Lean, in September of 2013 we entered into a three-year partnership with KPMG to help us embed the Lean Management System (LMS) practices across the organization in a phased approach with intensive training for staff and managers. One thing we have learned is to streamline the number of projects throughout the hospital and to focus on those that align with our organizational goals. Lean methodologies provide a defined process, driven largely by data, to determine a problem, trial potential solutions and measure their success. All of this work takes time. Significant progress has been made toward our goals for 2013-14. Here are just a few of our recent accomplishments. We reduced staff injuries by 25 per cent by identifying root causes of staff injury through unit huddles and data analysis. In 2014-15 we are aiming for a further 25 per cent reduction in staff injuries. We have reduced length of stay for admitted patients in the emergency department from more than 20 hours to about 13 hours, well on our way to our targeted length of stay of eight hours or less. Since many patients who are admitted through the department are transferred to our general medicine unit, we looked at ways to improve patient flow on that unit. We implemented a simple but effective strategy of visual cues to improve discharge planning by better tracking discharge readiness for the unit’s patients. These patients are primarily elderly with multiple co-morbidities and can receive care from up to 12 different disciplines. These visual cues foster realtime conversations among team members, improve collaboration, and allow discharge www.hospitalnews.com

to occur in a more timely and organized fashion. Another exciting Lean initiative is in our Endoscopy unit. All unit staff met to map out a patient’s journey from arrival to discharge, in order to identify time spent that does not directly benefit the patient. The goal is to eliminate wasted time and reduce length of stay while ensuring safety and quality outcomes. Improvement ideas that are “quick wins” are addressed at daily huddles. Those that are more complex go to a newly formed unit leadership council and those that relate to Quality Based Procedures go to a new physician committee. Both the physician committee and leadership council meet monthly, a structure which builds in sustainability for the gains we make. Using Lean has also helped us establish clear guidelines for corporate projects and criteria for choosing them (i.e. those that are mandatory/legislative and linked to operational goals, longer term strategy). We have established a daily two-hour “protected time zone” for managers, directors and vice-presidents to engage in structured conversations about the progress of projects and other improvement work. In this way we can continuously monitor progress, remove barriers and provide coaching to help keep work on track. We have also reviewed the amount of time managers and staff spend on various committees with a view to significantly reducing those commitments and to free up more time for our managers and staff to participate in Lean initiatives. This will be an evolving process but my initial goal is a 25 per cent reduction in total hours spent by management in regularly occurring committees. Options to be explored to accomplish this goal include: eliminating some committees; reducing the frequency of others; reducing the length of time of meetings; and reducing the number of people who attend. Lean implementation at St. Mary’s has been solidly backed by our board of trustees. Recently our board became one of the first in Ontario to start each monthly meeting with a board huddle. Board members from ThedaCare, a health care system in Wisconsin considered to be an American leader in Lean management, have travelled to St. Mary’s to provide coaching for our board, and the U.S. based Healthcare Value Network has recorded one of these huddles for presentation at the Lean Healthcare Summit in Los Angeles in June. To implement Lean well can take five to 10 years. We are just beginning our third year and continue to learn how to navigate through challenges and keep teams motivated. Success on this journey requires focus, commitment and persistence. However, the opportunities are endless to create an environment where patients, families, and caregivers are happier, safer and more enH gaged. They deserve no less. ■ Don Shilton is President, St. Mary’s General Hospital.

Don Shilton

APRIL 2014 HOSPITAL NEWS

24 Focus

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

Specialized Geriatric Services a model of regional teamwork By Kelly Kay

Anne Marie Peters (in red), Social Work Student and Occupational Therapists Sandra Trudell (centre) and Cailin Dutante (far right) consult on a client's care plan.

HOSPITAL NEWS APRIL 2014

t is 8:00 a.m. and Sarah Gibbens, Geriatric Emergency Management (GEM) Nurse, reviews the chart of 85-yearold Albert*. Albert came to the Emergency Department at Northumberland Hills Hospital in Cobourg after a fall in his home in nearby Port Hope. Gibbens learns that Albert was seen several months ago at the Peterborough Regional Health Centre’s Geriatric Assessment and Intervention Network (GAIN) clinic – and with his permission, she calls her specialized geriatrics colleagues to discuss his care plan. Andrea Jack, GAIN Nurse Practitioner, receives Sarah’s call and remembers Albert. She reviews the teams’ assessment findings –a comprehensive assessment and detailed recommendations that include her input and that of an occupational therapist, pharmacist, physiotherapist, social worker and a specialist in geriatric medicine. Andrea learns that since Albert was last seen, his wife has passed away and he is now living alone in his two-story house. Sarah’s current geriatric assessment of Albert paints a picture of a person who has become increasingly frail and who is having difficulty managing day-to-day. Andrea recalls that Albert’s wife was his primary caregiver and the love of his life and she realizes this loss is enormous for Albert. Andrea and Sarah

arrange a conference call with Albert’s family physician in Port Hope to review his care plan and Sarah’s recent assessment findings. The three arrange to speak with Albert and his daughter, who lives in Winnipeg. Together, they determine Albert might benefit from intensive case management, a service available through the new GAIN team located in Port Hope. Sarah and the Emergency Department team clear Albert medically, a close call as falls can signal significant underlying problems and result in considerable consequences for older people. Albert is met at the Emergency Room by a personal support worker from the Port Hope GAIN team who escorts him home and helps him settle in. A GAIN Care Coordinator arrives at Albert’s home the next morning. She consults with the team and reviews all of the assessment information from Sarah, his family doctor, and Andrea’s team and, with this in mind, begins what will be a longstanding relationship with Albert. Albert’s GAIN Care Coordinator will help organize all of the services that will support Albert at home, which may include adult day programming, assistive living services, home care and other supports and she will keep close contact with his family doctor and the rest of the GAIN Team. Continued on page 25

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Travel 25 Continued from page 24 While Albert is a fictitious patient and this scenario is merely illustrative, his story is all too real to the more than 96,000 older adults living in the Central East Local Health Integration Network (LHIN) who meet a definition of frailty. These individuals are the focus of the Central East LHIN specialized geriatric services coordinating body, the Regional Specialized Geriatric Services (RSGS). Specialized geriatric services are intended to help older people with complex health concerns that threaten their independence and function. The aim of these services is to create the best health experience for frail older adults in the Central East LHIN and to help them remain at home. In addition to those programs described above (e.g. GEM, GAIN), specialized geriatrics includes Behavioural Supports Ontario (BSO), comprised of trained health professionals and programming helping older people with challenging behaviours resulting from dementia, neurological disorders and mental health and addictions related concerns. Rounding-out the services available in the Central East LHIN is the Nurse Practitioners Supporting Teams Averting Transfers (NPSTAT) program. The NPSTAT program is a team of Nurse Practitioners who assist residents of Long-Term Care facilities experiencing acute health concerns in order to help avoid transfers to hospital, and to support their return home as quickly and as safely as possible. The effective coordination of specialized geriatric services can’t come too soon in the Central East LHIN. With a frail older adult population that is expected to grow by 27 per cent over the next 10 years, this year the RSGS launched its inaugural and ambitious strategic plan that focuses on three priorities: improving care, fostering excellence and increasing awareness. The strategic plan will help the Region design and coordinate services, beginning with an innovative, ground-up design process for one of the largest specialized geriatric service providers, GAIN. It is a model of coordination that is paying off. This model includes an investment of more than $9.2M and has engaged more than 50 stakeholders, including older adults, family caregivers and front-line health professionals in the design of new local teams, such as the one envisioned for Port Hope, and a regional structure that links them together. Karen Lee Boulton, BSO Senior Manager for the Central East LHIN, knows firsthand about the building of an effective regional structure to support specialized geriatrics. Through a quality improvement approach, she and her team have spent the past two years strengthening supports in Long-Term Care across the Central East LHIN from Scarborough to Haliburton and many points in between. Not far away in Whitby, Jeff Gardner, Nurse Practioner, Program Director and his team of 10 Nurse Practitioners who form the expert NPSTAT team serving the Central East LHIN, are compiling educational information about specialized geriatrics. This information is part of a regional orientation program, spearheaded by the RSGS. The program will support new health professionals joining one of the Region’s four specialized geriatrics programs and others working with frail older adults to offer the highest quality, age-appropriH ate care to clients like Albert. ■ Kelly Kay is the Executive Director of the Regional Specialized Geriatric Services. www.hospitalnews.com

The 25 best beaches in the world By Paul Johnson

ver wondered what are considered to be the best beaches on the planet? According to online reviewers on Tripadvisor, the best beach in the world – where even the sharks are supposedly friendly – is in Brazil. Baia do Sancho 1. Baia do Sancho Fernando de Noronha, Brazil Best time to go: Year-round 2. Grace Bay Providenciales, Turks and Caicos Best time to go: Year-round 3. Flamenco Beach (Playa Flamenco) Culebra, Puerto Rico Best time to go: Year-round 4. Rabbit Beach Lampedusa, Islands of Sicily Best time to go: May–September 5. Whitehaven Beach Whitsunday Island, Whitsunday Islands Best time to go: Year-round 6. Playa de ses Illetes Formentera, Balearic Islands Best time to go: Year-round 7. Anse Lazio Praslin Island, Seychelles Best time to go: Year-round 8. Lanikai Beach Kailua, Hawaii Best time to go: Year-round 9. Rhossili Bay Swansea, United Kingdom Best time to go: July–September 10. Playa Norte Isla Mujeres Best time to go: Year-round 11. Playa Paraiso Beach Cayo Largo, Cuba Best time to go: Year-round 12. Praia dos Carneiros Tamandare, Brazil Best time to go: Year-round 13. Lopes Mendes Beach Ilha Grande, Brazil Best time to go: December–March 14. The Baths Virgin Gorda, British Virgin Islands Best time to go: Year-round 15. Playa de las Catedrales Ribadeo, Spain Best time to go: July–August 16. Ka’anapali Beach Lahaina, Hawaii Best time to go: Year-round 17. Elafonissi Beach Elafonissi, Greece Best time to go: May–October 18. Cala Mariolu Baunei, Italy Best time to go: May–September 19. White Beach Boracay, Visayas Best time to go: December–May

lies on the fantasy archipelago of Fernando de Noronha, Brazil, just a short flight from Sao Paolo. In fact, Brazil can lay claim to three of the best beaches in the top 25, as can Australia. Collectively, Europe performs surprisingly well with six more beaches from the 20. Turquoise Bay Exmouth Exmouth, Australia Best time to go: May–October 21. Anse Source d’Argent La Digue Island, Seychelles Best time to go: Year-round 22. Cable Beach Broome, Australia Best time to go: Year-round 23. Playa Manuel Antonio Manuel Antonio National Park, Costa Rica Best time to go: Year-round

25, whilst the likes of the Maldives and Mauritius are notable in their absence, and only two beaches in the whole of Asia make an appearance. Anyway, for what it’s worth, these are the top 25 beaches in the world according to TriH padvisor reviewers. ■ 24. Camp’s Bay Beach Camps Bay, South Africa Best time to go: November–April 25. Radhanagar Beach Havelock Island, Andaman and Nicobar Islands Best time to go: November–April Paul Johnson has worked in the travel industry for approximately 20 years and, more specifically, in the online sector since the very earliest days of the WWW. This article is reprinted with permission from www.aluxurytravelblog.com

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26 Focus

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

Online program improves access to

mental health services By Cindy Woods

ental Health Services at The Scarborough Hospital (TSH) is embarking on an innovative research project that uses modern technology to deliver Cognitive Behavioural Therapy (CBT) to some of its Outpatient Program clients. CBT is a widely used form of psychotherapy in the treatment of anxiety and depression. Demand exceeds supply, however, especially with long wait lists, a shortage of therapists and a lack of access to a therapist beyond regular business hours. Also, many clients suffering

from symptoms of depression or anxiety are resistant to taking part in group psychotherapy, a core aspect of CBT. This is where technology comes in– using the internet to provide CBT online to certain outpatient clients. “The world of psychiatry has shifted, and we’re less pill-based now,” explains TSH Psychiatrist Dr. David Gratzer. “Major studies show the vast majority of people with mild or moderate depression respond as well on medications as they do therapy, particularly CBT. And, people with moderate depression actu-

ally do better with both medication and CBT.” Given the barriers some clients face in participating in CBT, the search was on for other forms of delivering this type of therapy. “We want to offer something where our clients could continue their daily work, family or school obligations and still do CBT on their own time, at their own pace,” explains Faiza Khalid-Khan, TSH Patient Care Manager, TSH’s Inpatient and Outpatient Mental Health. Dr. Gratzer’s search paid off.

“A young physician at Queen’s University in Kingston presented a paper at a conference of the American Psychiatric Association about the growing use of internet-assisted CBT,” Dr. Gratzer explains. “We were astonished at how much work has been done in this area –not just with depression and anxiety, but for people with physical conditions –chronic pain, for instance. We learned some people actually do better with online CBT than with individual or group therapy.” Continued on page 27

Personalizing dementia care By Mary Schulz

y 2040, the number of Canadians with dementia, including Alzheimer’s disease, will increase from 747,000 today, to 1.4 million. While most Canadians with dementia prefer to remain in their own homes for as long as possible, the reality is that 57 per cent of seniors living in a residential care home have a diagnosis of dementia and 70 per cent of all individuals diagnosed with dementia will die in a long-term care home.

Changing the culture of care In 2008, the Alzheimer Society of Canada decided it was time to start changing the conversation about long-term care. Rather than focusing on the number of beds and their cost, we asked: “How can we work with others to improve the experience of long-term care for people living with dementia? How can we make the transition to long-term care less frightening for their families? And, how can we support staff to provide care that centres on the needs of people with dementia and their families rather than those of the home?” These questions are at the root of the Alzheimer Society’s culture change work to advance person-centred care in the way

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people with dementia and their families and long-term care staff work together and support each other. In 2011, we developed Guidelines for Care: Person-centred care of people with dementia living in care homes, which helped us understand what we know theoretically about person-centred care, but not necessarily how to put this approach into practice. To address this gap, we asked long-term care representatives and experts in personcentred care to help us select six homes that are known to be practicing personcentred care and that reflect the diversity of Canada’s long-term care sector. These include: Delta View Life Enrichment Centres (British Columbia); Sherbrooke Community Centre (Saskatchewan); Fenelon Court and Union Villa Long-Term Care Home (Ontario); Donald Berman Maimonides Geriatric Centre (Quebec); and Northwood Care Halifax (Nova Scotia).

Positive changes are happening They are just a sampling of homes in Canada embracing person-centred care. The good news is that more and more longterm care homes are learning about person-centred care and using this approach to better meet the complex and unique needs of their residents with dementia. In the homes we visited, they’re committed to trying different methods, seeing what works and adjusting their practices. In these homes we were also able to uncover seven common key elements driving and sustaining a culture change towards person-centred care. These are called PC P.E.A.R.L.S.™ • Person and family engagement • Care • Processes • Environment • Activity and recreation • Leadership • Staffing The Alzheimer Society has developed a set of information sheets describing each element with key principles and strategies that long-term care and other health professionals can use to adopt a person-

centred care approach in the practice of dementia care. Understanding the lifelong values, wishes and personality of each individual opens the door to creative approaches that can make each day the best day possible for people with dementia, no matter the stage of their disease. Homes practicing person-centred care recognize that family members are integral members of the care team because they provide important information to help guide the care of the person with dementia. For example, a resident might resist staff when they try to give him a shower early in the day. The family can point out that their father or husband was never a morning person. By changing the time of the day for showering, the resident might be more comfortable, calm and happier. Staff may have an easier time if he doesn’t push them away. Families feel reassured that their father or husband is more content while he gets the physical care he needs. Even though it means accommodating many different schedules, this change in care can benefit everyone.

A step in the right direction At the core of culture change is shifting our way of thinking. A diagnosis of dementia doesn’t automatically mean life is over for people with the disease. They can still live meaningfully in an environment that respects them as whole individuals, emphasizes autonomy, dignity and choice, while promoting their strengths and abilities. The Alzheimer Society of Canada encourages long-term care homes to put PC P.E.A.R.L.S. into practice to improve the experience of people with dementia, caregivers and staff. Our ultimate goal is to make person-centred care the norm rather than the exception in Canada. Many longterm care homes already share our vision. To download PC P.E.A.R.L.S™, Guidelines for Care, or to learn more about culture change, visit www.alzheimer.ca/cultuH rechange. ■ Mary Schulz is Director of Education, Alzheimer Society of Canada.

Spotting the signs of dementia Research conducted by the Alzheimer Society of Canada shows that 50 per cent of Canadians believe memory loss is the only sign of dementia. A quarter couldn’t name any warning sign. Recognizing the warning signs is vitally important for getting diagnosed and getting the right medical attention, help and support. Whether you think you might be experiencing symptoms or are concerned for someone else, take 10 minutes to learn these 10 signs: • Memory loss affecting day-today abilities–forgetting things often or struggling to retain new information. • Trouble performing familiar tasks forgetting how to prepare a meal or get dressed. • Problems with language–forgetting words or substituting words that don’t fit the context. • Disorientation in time and space– not knowing what day of the week it is or getting lost in familiar places. • Impaired judgment–not recognizing a medical problem that needs attention or wearing light clothing on a cold day. • Problems with abstract thinking– not understanding what numbers signify on a calculator or how they’re used. • Misplacing objects–putting things in strange places, like an iron in the freezer or a wristwatch in the sugar bowl. • Changes in mood and behaviour– exhibiting severe mood swings from being easy-going to quicktempered. • Changes in personality–behaving out of character such as feeling paranoid or threatened. • Loss of initiative–losing interest in friends, family and favourite activities. www.hospitalnews.com

GERONTOLOGY/PALLIATIVE CARE/HOME CARE/RURAL AND REMOTE

Focus 27

Online program improves access to mental health services

Continued from page 26

Internet-assisted CBT, or iCBT for short, is gaining in popularity around the world, but has yet to catch on in a big way in North America’s public sector. Here’s how it works: Using the same modules as face-to-face versions (but adapted for email), TSH’s team – two Registered Nurses, one Psychology Associate and one Social Worker – emails one module per week to outpatient clients, who can complete the modules on their own time, emailing the completed modules by the end of the week. The therapist then blocks off time to review the work. “This is when the therapy kicks in,” Faiza explains. “The therapist provides feedback, encouragement, acknowledgement, explores coping skills and suggests ways to do things better – just as they would in a group session. “There’s no impact on staffing, no cost attached to this. It’s one way of getting help to those who might otherwise fall through the cracks.” It’s not just mental health clients who can benefit from online therapy. Dr. Gratzer envisions its use for other patients. “As people go through what is perhaps the most trying moment of their lives – fighting cancer, for instance – if they have mood and anxiety symptoms, they could be given an iPad and go through some of the exercises while getting their

www.hospitalnews.com

chemotherapy. How perfect is that?” adds Dr. Gratzer. “We can now offer evidencebased therapy that goes beyond the traditional ‘bricks and mortar’ approach.”

Internet-assisted cognitive behavioural therapy, or iCBT for short, is gaining in popularity around the world, but has yet to catch on in a big way in North America’s public sector.

The research project aims to enrol at least 40 outpatient clients to participate in iCBT. For one client, it’s an excellent opportunity to access therapy without the inconvenience of physically attending group or individual therapy. “This is something new, and it sounds really interesting,” the client says. “I am so busy with classes at college that it would be hard for me to come in during the day, so I would H like to try this.” ■ Cindy Woods is Senior Communications Officer at The Scarborough Hospital.

David Kosinec, TSH Psychological Associate (left) and Faiza Khalid-Khan, TSH Patient Care Manager (right) display the new online iCBT program that provides improved access to Mental Health services for clients.

APRIL 2014 HOSPITAL NEWS

28 Focus

GERONTOLOGY/PALLIATIVE CARE/HOME CA ARE/HOME CARE/RURAL CARE/RURAL AND REMOTE

Home care: A fine balance By Robin Crombie

ome care may not be new, but with increasing professionalization of the sector, it has evolved, revealing fresh challenges and opportunities. Though home care providers share a commitment to quality healthcare with their counterparts in hospitals, their work reality is distinctly different. “In home care, nothing is a given,” says VHA Home HealthCare (VHA) CEO and President, Carol Annett, “a quick consult with a colleague is not just down the hall, nor is the physical arrangement of each home necessarily conducive to care. In no other health setting does the relationship between patient and caregiver have the potential to play such a decisive role in the successful outcome of care.” Recognizing the fine balance of clinical expertise and strong interpersonal skills required for this unique approach to care means that home health care organizations must help their staff develop both of these skill sets if they hope to provide the best home healthcare possible. For VHA – a not-for-profit agency that has served Ontarians for nearly 90 years – achieving this equilibrium has become an organizational passion and is the driving force behind its Best Practice Spotlight Organization (BPSO®) program application and candidacy. Funded by the Ministry of Health and Long-Term Care, BPSO® is a rigorous three-year program, combining clinical experience and evidence-based research to implement and evaluate the Registered Nurses Association of Ontario’s (RNAO) best practice guidelines. Candidate organizations must select clinical

Home care workers balance clinical expertise with strong interpersonal skills to deliver spectacular care in the community. topics specific to their work and for VHA natural best practice guidelines (BPGs) to focus on included: assessment and management of pressure ulcers, prevention of falls, end of life care, assessment and management of pain, and client and familycentred care. “BPSO® is a great opportunity to develop and support practice quality and patient safety improvements across the organization,” says Bea Mudge, Vice President Best Practices, Research and Education and VHA’s Chief Nursing Executive. “We’re building individual expertise through the role of champions and team knowledge through interdisciplinary collaboration. This isn’t just about improving nursing – we’re applying these standards and guidelines to rehabilitation and personal support

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HOSPITAL NEWS APRIL 2014

services too.” Though their roles are different, the goal is the same: to provide a consistent, evidence-based quality of care at home and in the community. Mudge notes this approach results in more consistent care, better client outcomes and ultimately clients who are more satisfied with their care. “More importantly,” she adds, “measurement and outcome assessment from VHA’s candidacy will hopefully help shape home care best practices overall.”

Just as hospitals continue to work on measuring and improving patient experience, home care organizations are also honing in on client and family wants and needs to improve how they feel about the care they receive. Just as hospitals continue to work on measuring and improving patient experience, home care organizations are also honing in on client and family wants and needs to improve how they feel about the care they receive. One of the most successful strategies, notes Joy Klopp, VHA’s Director of Contracts, Quality and Risk Management has been Changing the Conversation, a collaboration between Toronto Central CCAC and its contracted Service Provider Agencies. “It’s a flexible approach to care that stresses simple yet important elements – not rushing, active listening, a positive demeanor – and translates these into a set of simple questions,” says Klopp. “It gives clients and family members the chance to talk about their concerns and priorities and encourages them to be in the driver’s seat when it comes to their care. It also empowers our staff and service providers to really get to know and respond to what matters most to our clients.” With evaluations showing an improvement in client satisfaction, this is clearly an important step in enhancing the client experience. But the shift from client-centred

care to a client-driven model means home care organizations must not only survey clients and family members after receiving care, but also engage them before any new program, service or communication vehicle is developed. A client-driven culture ensures the client and family voice are the foundation of all aspects of the organization’s planning, operation and services. With this in mind, VHA began Client and Family Voice in 2013 – an ongoing initiative that seeks out opportunities to partner with clients and families to ensure their needs, wants and priorities are understood and addressed at every level of service. “Whether it’s determining important qualities to look for when recruiting staff, how VHA deals with compliments and complaints, or what information they’d like to see on our website,” says Barbara Cawley VP of Client Services and Client and Family Voice lead, “we want to know what our clients and their family members think. Healthcare has had a reputation for taking a ‘we know best’ kind of attitude. Client and Family Voice really views clients and family members as the true experts in their care.” Though it’s still early days for the initiative, Cawley is enthusiastic about the potential: “We’ve gleaned a lot from Holland Bloorview Kids Rehabilitation Hospital who are trailblazers in this area.What’s exciting is using their knowledge and experience as a springboard to developing a framework unique to home healthcare.” By investing in initiatives that highlight both clinical and client experience best practices, organizations like VHA are carving out a new role for themselves within the health care continuum. At a time when historic demographic shifts, economic constraints and changing attitudes to life quality are rocking the health system, this commitment to clinical best practices and bedside manner excellence are absolute necessities – especially as home healthcare’s role becomes utterly inH dispensable. ■ Robin Crombie is a Communications Consultant in Toronto. www.hospitalnews.com

Health Technology 29

Bedside videoconferencing facilitates patient transfer By Michelle Halsey

olland Bloorview Kids Rehabilitation Hospital recently had a unique opportunity to facilitate the transfer of a client by demonstrating care through a remote communication model they call “bedside videoconferencing.” The virtual knowledge exchange took place with health care providers in the client’s hometown of Thunder Bay where they had never before received a pediatric ventilator-dependent patient. Zoey Faith Lamarche came to Holland Bloorview as a client at eight months of age. She had a complex diagnosis and was considered a medically fragile technology dependent (MFTD) client requiring round the clock care. Zoey Faith’s parents, Amanda Mintenko and Mathew Lamarche, were committed to learning how to care for their daughter so they could take her home to live in Thunder Bay where son Liam was anxiously awaiting their return. “I was really scared at first because we thought Holland Bloorview was a longterm stay facility but the hospital had a high level of communication with us and included us in all decision-making,” Amanda says. “They made me feel more like a mom.” The Holland Bloorview team created a transition plan based on the family’s needs and then worked with health care providers in Thunder Bay to facilitate the transfer. Through the innovative use of Ontario Telemedicine Network’s (OTN) videoconferencing, members in the circle of care in Toronto and Thunder Bay were able to attend family team meetings during Zoey Faith’s entire stay. The videoconferencing was also used to train respiratory therapists and nurses in Thunder Bay on Zoey Faith’s care to reduce the possibility of surprises upon transfer. Robert Gangnon, a respiratory therapist at Holland Bloorview helped coordinate multiple videoconferencing sessions for www.hospitalnews.com

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Zoe’s transfer was made possible by bedside videoconferencing. the team in Thunder Bay. “The technology was amazing,” says Robert. “I could easily zoom in with the camera and move it around to show detailed equipment examples by myself as I was explaining specifics.” Amanda and Mathew were trained on all aspects of Zoey Faith’s care by the Holland Bloorview team and then participated in a month of “care-by-parent” at the hospital. During the care-by-parent period that is intended to simulate the future experience at home, Amanda and Mathew provided all care for Zoey Faith with the ability to call a nurse if needed. Equipped with this experience, Amanda and Mathew were then able to help train the remote team in Thunder Bay via videoconferencing on things like tracheostomy care and daily physiotherapy activities. Maryanne Fellin, a clinical resource leader at Holland Bloorview, was pleased that the parents could demonstrate their comfort level with care and also act as teachers for the Thunder Bay team. Continued on page 31

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30 Health Technology

Blood test can predict

Alzheimer’s disease A

blood test that can predict with 90 per cent accuracy if a healthy person will develop mild cognitive impairment (MCI) or Alzheimer’s disease (AD) within three years has been discovered and validated by researchers at Georgetown and six other institutions. The study team explains in the April issue of Nature Medicine how they discovered and then validated a set of 10 lipid biomarkers in the blood that predict both conditions. The discovery heralds the possible development of earlier treatment options for Alzheimer’s, when therapy could be more effective at slowing or even preventing onset of the disease. “Our novel blood test offers the potential to identify people at risk for progressive cognitive decline and can change how patients, their families and treating physicians plan for and manage the disorder,” says the study’s corresponding author, Dr. Howard J. Federoff, executive vice president of health sciences at Georgetown University Medical Center.

There is currently no cure or effective treatment for Alzheimer’s disease, which, according to the World Health Organization, is expected to double every 20 years worldwide – from 35.6 million individuals in 2010 to 115.4 million by 2050. Federoff, also a professor of neurology, explains there have been many efforts to develop drugs to slow or reverse the progression of Alzheimer’s disease, but all of them have failed. He says one reason may be the drugs were evaluated too late in the disease process. “The preclinical state of the disease offers a window of opportunity for timely disease-modifying intervention, and biomarkers defining this asymptomatic period are critical for successful development and application of these therapeutics,” says Federoff.

'Major Step Forward' “The lipid panel was able to distinguish with 90 per cent accuracy these two distinct groups – cognitively normal participants who would progress to MCI or AD within two to three years, and those who

From left, Georgetown researchers Dr. Howard J. Federoff; Amrita K. Cheema, associate professor of oncology and co-director of GUMC's metabolomics shared resource; and Dr. Massimo S. Fiandaca, associate professor of neurology, are among the co-inventors of a blood test that can predict with 90 percent accuracy if a healthy person will develop mild cognitive impairment (MCI) or Alzheimer’s disease within three years. would remain normal in the near future,” says Federoff, who also serves as executive dean of the School of Medicine. Researchers say the panel reveals changes in the breakdown of neural cell membranes resulting in 10 identifiable lipids, or metabolites, circulating in the blood. In particular, two of the 10 metabolites have strong links to the neuropathology of Alzheimer’s.

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“We consider our results a major step toward the commercialization of a preclinical disease biomarker test that could be useful for large-scale screening to identify at-risk individuals,” Federoff concludes. “We’re intending to design a clinical trial where we’ll use this panel to identify people at high risk for Alzheimer’s to test a therapeutic agent that might delay or prevent H the emergence of the disease.” ■

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Careers 31

video-conferencing Continued from page 29 â&#x20AC;&#x153;Having the family show Zoey Faithâ&#x20AC;&#x2122;s care right at the bedside helped the Thunder Bay team visualize what they would need to do,â&#x20AC;? Maryanne explains. â&#x20AC;&#x153;It also allowed the Thunder Bay team to get to know the family, see how Zoey Faith would react in a real setting and then have a discussion during the videoconference.â&#x20AC;?

As respiratory therapists, we do education for community nurses and itâ&#x20AC;&#x2122;s tough to get on everyoneâ&#x20AC;&#x2122;s schedule. Videoconferencing could lend itself perfectly for training these kinds of groups. This was the first time that Holland Bloorview had used the OTN videoconferencing technology and the team is excited about future applications. â&#x20AC;&#x153;As respiratory therapists, we do education for community nurses and itâ&#x20AC;&#x2122;s tough to get on everyoneâ&#x20AC;&#x2122;s schedule,â&#x20AC;? says Robert. â&#x20AC;&#x153;This technology could lend itself perfectly for training these kinds of groups.â&#x20AC;?

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Earlier this year, Amanda and Mathew made the journey to Thunder Bay ahead of Zoey Faith to get everything set up at home. Due to an unforeseen delay, Zoey Faithâ&#x20AC;&#x2122;s transfer took place three weeks later. A respiratory therapist and nurse from Holland Bloorview accompanied Zoey Faith on the flight home by medical transport and provided a comprehensive handover of care to the Thunder Bay team. Zoey Faithâ&#x20AC;&#x2122;s family greeted her upon arrival and was thrilled to be reunited. Amanda reports that Zoey Faithâ&#x20AC;&#x2122;s older brother Liam is now enjoying his little sister. â&#x20AC;&#x153;It was a long hard process but we got through it,â&#x20AC;? Amanda says. â&#x20AC;&#x153;If it wasnâ&#x20AC;&#x2122;t for Holland Bloorview we wouldnâ&#x20AC;&#x2122;t have been able to bring Zoey Faith home.â&#x20AC;? The team at Holland Bloorview was pleased to have the opportunity to work with the team in Thunder Bay in such a unique remote communication model. â&#x20AC;&#x153;It was a bittersweet transition,â&#x20AC;? Maryanne says. â&#x20AC;&#x153;We were sad to see Zoey Faith leave, but we felt like we found a really innovative solution and implemented it well to H get this little girl home.â&#x20AC;? â&#x2013; Michelle Halsey is a Senior Communications Associate at Holland Bloorview Kids Rehabilitation Hospital.

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