Hospital News June 2014 Edition by Hospital News

Election coverage: Ontario votes

The latest in personalized cancer care

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Evidence Matters ...............................12

Approaches to cancer treatment, diagnosis and prevention. A look at medical imaging techniques for diagnosis, treatment and prevention of diseases. Pediatric programs and developments in the treatment of pediatric disorders including autism.

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Nursing Pulse .....................................19 Ethics .................................................. 21 From the CEO’s desk ......................... 24 Careers ............................................... 31

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In Brief

Canadian nurses poised for digital

Asthma treatment

The Asthma Society of Canada released the first-ever patient study of Severe Asthma in Canada. The study, Severe Asthma: The Canadian Patient Journey, takes an indepth look at the personal, social, medical and economic burden of Severe Asthma in Canada. Severe Asthma (SA), a more severe form of asthma and a greater threat to life, impacts the health and economic well-being of between 150,000 and 250,000 Canadians. Between 250 and 300 Canadians will die this year of asthma. Beyond personal costs, asthma is the leading cause of hospital admission in Canada. Between 2010 and 2011, direct and indirect costs associated with treating asthma topped more than $1-billion. Key Findings Include: • SA is generally poorly understood and diagnosed, and inconsistently managed by healthcare providers. Its severity is discounted by patients themselves, sometimes as a result of the stigma associated with the disease. • SA significantly reduces the personal, social, financial and health outcomes for many Canadians. SA has a noticeable impact on the Canadian economy. • Treatment of SA is hindered by availability of specialists, misdiagnoses and lack of patient understanding. • New treatment options are not wellH known by patients or physicians. ■

Lipid levels impact autism

In a ground-breaking York University study, researchers have found that abnormal levels of lipid molecules in the brain can affect the interaction between two key neural pathways in early prenatal brain development, which can trigger autism. And, environmental causes such as exposure to chemicals in some cosmetics and common over-the-counter medication can affect the levels of these lipids, according to the researchers. “We have found that the abnormal level of a lipid molecule called Prostaglandin E2 (PGE2) in the brain can affect the function of Wnt proteins. It is important because this can change the course of early embryonic development,” explains Professor Dorota Crawford in the Faculty of Health and a member of the York Autism Alliance Research Group. This is the first time research shows evidence for cross-talk between PGE2 and Wnt signalling in neuronal stem cells, according to the peer reviewed study published in Cell Communication and H Signaling. ■

health leadership An inaugural survey undertaken jointly by the Canadian Nurses Association (CNA) and Canada Health Infoway (Infoway) reveals that 83 per cent of Canadian nurses are comfortable using digital health tools in practice and approximately three-quarters feel digital health tools could improve continuity of care (78 per cent) and patient safety (72 per cent). “The vast majority of Canadian nurses recognize digital health as a key enabler to help deliver better patient care and

improved efficiency, yet 57 per cent say that the legacy systems and tools at their disposal are not adequate for their role,” said CNA President Barb Mildon. “The survey has provided valuable insight into how the health community can intensify the implementation of digital health tools, what strengths can be built upon, and what gaps we need to close.” While nurses recognize that digital health tools present a range of benefits for both themselves and their patients, there

are a number of factors impacting the full realization of digital health in nursing practice. Some of the barriers cited include the use of both paper and electronic systems to access patient information (61 per cent), having multiple log-ins to access different clinical systems (54 per cent) and inadequate types of tools and access for their roles. Those nurses currently using digital health tools use them mainly to enter and retrieve patient notes H (65 per cent). ■

Psychiatry for Ontario youth A first of its kind benchmarking survey was used to evaluate the state of inpatient psychiatry settings and services for youth at hospitals across Ontario, as published in the Journal of the Canadian Academy of Child and Adolescent Psychiatry. On average, the province’s services are comparable to other settings internationally, helping youth with the most severe and complex mental health problems, but also show similar signs of inconsistency across settings in the types and quality of inpatient care. “There is no rhyme or reason for these discrepancies throughout the province,” says Dr. Stephanie Greenham, co-author, psychologist and clinical researcher at the Children’s Hospital of Eastern Ontario (CHEO) and Clinical Professor with the School of Psychology at the University of Ottawa. “The planning and staffing of inpatient psychiatry units appears locally determined, but as the demand for mental health services skyrockets, youth and families’ needs would seem to be better met by adopting a more organized and systematic approach to inpatient care.” Twenty-five hospital-based programs specifically for children and youth requiring hospitalization for a mental health crisis responded to the first provincial benchmarking study of its kind to describe unit characteristics, services, and patient characteristics. Data were collected for a one year period, and included information from the Ontario Network of Child and Adolescent Inpatient Psychiatry Services (ONCAIPS) directory and the Ministry of Health and Long Term Care (MOHLTC) website. Respondents identified suicide risk as the most prevalent problem precipitating admission, while all settings admitted

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youth with mood, anxiety and psychotic disorders. Services were predominantly geared toward brief, acute crisis rather than longer term, planned treatment, and the majority of admissions were for adolescents rather than children. There were inequities across settings in access to psychiatry, availability of interdisciplinary staffing, criteria for who gets admitted and who does not, types of treatments provided, rates of involuntary admissions, and tracking of clinical outcomes. “The study findings confirm that inpatient services are an important and valuable

component in Ontario’s continuum of mental health services, particularly for children and adolescents with the most severe risks and problems,” says Dr. Joseph Persi, coauthor and psychologist at the North Bay Regional Health Centre in Sudbury and Adjunct Professor at Laurentian University. “The study leaves us with areas for improvement but also some unanswered questions. One of the most important of these questions, in light of surging admission rates, is ‘Are there ways that we can address problems earlier in a manner that reduces the H need for hospitalization?’” ■

Sleep problem in children

Clinical investigators at the Children’s Hospital of Eastern Ontario (CHEO) have developed a new screening tool to help diagnose obstructive sleep apnea in children. Their findings are published in Pediatric Pulmonology. Evidence suggests that adults with a large neck circumference are more likely to develop obstructive sleep apnea (OSA), especially males. As neck circumference varies by age and sex, there have been no reference ranges to diagnose pediatric OSA up until now. The new evidence-based diagnostic tool includes reference ranges – a new pediatric growth curve – to measure and track neck circumference for boys and girls between the ages of 6 and 17. “The gold standard test (for OSA) is still a sleep study and we would not replace that, but because the wait is so long,

we needed something quick and reliable to help bump kids up the priority list or to better understand who is at the highest risk for OSA,” says Dr. Sherri Katz, principal investigator at the CHEO Research Institute and assistant professor in the Faculty of Medicine at the University of Ottawa. “If left untreated, OSA sets kids up for cardiovascular disease, diabetes and other comorbid conditions down the line.” The research team discovered for children, a neck circumference measuring greater than the 95th percentile for age and sex is associated with increased risk of OSA. When examined by sex, the association was significant in males aged 12 or older, but not in females. The research team also looked at Body Mass Index (BMI), but did not find that it stands alone as a significant predictor of OSA in H this group. ■

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UPCOMING DEADLINES JULY 2014 ISSUE EDITORIAL JUNE 6 ADVERTISING: DISPLAY JUNE 20 CAREER JUNE 24 MONTHLY FOCUS: Cardiovascular Care/Respirology/ Diabetes/Gastroenterology: Developments in the prevention and treatment of vascular disease including cardiac surgery, diagnostic and interventional procedures. Advances in treatment for various respiratory disorders including asthma, allergies. Prevention, treatment and long term management of diabetes and other endocrine disorders. Advance in diagnosis and treatment of diseases of the gastrointestinal tract.

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Canadians not getting message about

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hough I am embarrassed to admit, in my young and foolish days you may have found me at a tanning salon. I was not a regular like many of my friends, but I did admire the sun-kissed look. I thought a tan made me look healthier, more vibrant. The serious tanners among my group of friends wore their tan lines like badges of honour. As a child, I received more than a few sunburns after long days outside with my friends, without sunscreen. A few of those sunburns were severe. If we only knew then what we know now – not only were the burns extremely painful, they also doubled my risk for melanoma later in life. In a special report on skin cancer released by the Canadian Cancer Society, it is estimated that children and adolescents who get five or more sunburns have double the risk of melanoma later in life. Like me, I think most thirty-somethings have doubled their risk. Skin cancer is one of the fastest rising cancers in Canada, despite being one of the most preventable. Overexposure to UV radiation causes about 90 per cent of melanoma cases. If most occurrences can be avoided by shielding ourselves from the sun, why aren’t we doing so? It is clear that Canadians are not getting the message. Is it because skin cancer is perceived as less serious or deadly than other forms of cancer? Or have we become complacent to the ozone/UV warnings that began nearly two decades ago?

Since these warnings began, two national surveys of Canadians’ sun exposure and protective behaviours have shown that Canadians are spending more time in the sun without adequate protection. In fact, significantly fewer Canadians reported wearing protective clothing and hats in 2006, compared to the decade earlier. Why are so few of us protecting ourselves from cancer-causing UV rays?

Children and adolescents who get five or more sunburns have double the risk of melanoma later in life Since the link between cancer and smoking was discovered, smoking rates have steadily decreased and continue to do so. In large part, due to successful public awareness campaigns about the risks of smoking and health promotion initiatives to help people quit smoking. If we can get people to stop smoking, likened to the strength of a heroin addiction, surely we can get people to put on hats and sunscreen. The occurrence and mortality rates for many types of cancer are going down. On the other hand, melanoma has increased significantly

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in both women and men. Though it is not as deadly as other types of cancer, the disease is a serious one – with approximately 1,050 Canadians expected to die from melanoma this year. Health care professionals have an important role to play in educating and raising awareness. It is time to start asking patients, “Do you wear sunscreen or protective clothing?” in the same way you would ask “Do you smoke?” Patients need to be informed about the risks and how easy it is to prevent. Even more importantly, health professionals need to stress the importance of ensuring children are protected from the sun. The tanning bed ban on those under 18 in Ontario is a good start, but we need to liken the application of sunscreen to a normal part of the day – like brushing one’s teeth. Perhaps we should start handing out sunscreen samples in health care facilities. There are always pharmaceutical samples on hand, why not sunscreen? An investment in education and awareness now will eventually lead to savings and decrease the $532-million economic burden of skin cancer. I cringe at the thought of the hours I spent sunbathing on a beach, or the times I exposed my skin to the harsh lights of a tanning bed. These days, I proudly sport my SPF 60 sunscreen and make putting on sunscreen a routine for my children. It’s like putting on their shoes – before we go outside we put on sunscreen. It’s that H simple. ■

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Advances in medical imaging By Natalie Chung-Sayers

esearchers at Sunnybrook Health Sciences Centre are perfecting a type of GPS navigation and roadmap for prostate cancer biopsies, by combining 3D MRI (multiparametric magnetic resonance imaging) and ultrasound to better guide the biopsy needle. Standard biopsies use ultrasound alone which limits visualization of the tumour. With what radiologist Dr. Masoom Haider calls the ‘smart biopsy, men undergo an image-navigated biopsy to the area of cancer only, resulting in far fewer biopsies for the patient, and more accurate assessment of the tumour. Studies conducted by Dr. Haider and Dr. Laurent Milot in Medical Imaging, and oncologists Drs. Laurence Klotz, Danny Vesprini, Andrew Loblaw and Robert Nam of Sunnybrook’s Odette Cancer Centre’s Genitourinary Cancer Care team show significant cancers can be found based on three to four needle biopsies or tissue samples using smart biopsy, compared to 12 needles with the standard procedure. “With a clearer view, we are also detecting tumours that were missed on first biopsy done the standard way.” The threedimensional view is made up of an MRI taken just before the procedure that is fused with ultrasound imaging recorded during the procedure. “MRI substantially improves our ability to identify and characterize tumours,” says Dr. Haider, chief of the Department of Medical Imaging at Sunnybrook, and a professor in the department of Medical Imaging at the University of Toronto, who helped refine the technologies to localize cancers with MRI. Sunnybrook’s Odette Cancer Centre is one of only a few centres in Canada conducting research with a large volume of navigated smart biopsies.

Ultrasound for faster breast cancer treatment tracking Knowing sooner helps better tailor treatment. That’s the premise behind new imaging research known as Quantitative Ultrasound being led by Dr. Gregory Czarnota. A radiation oncologist of the Odette Breast Cancer care team, Dr. Czarnota is using low-intensity ultrasound to detect cancer cell death from chemotherapy, in one to four weeks, in patients with locally advanced breast cancer. “A faster determination of how a cancer is responding means clinicians can modify to a course of more effective treatment, essentially individualizing treatment that much sooner for the patient,” says Dr. Czarnota, who is also the head of Radiation Oncology at the Odette, and a senior scientist at Sunnybrook Research Institute. Dr. Czarnota and his team use ultrasound as functional imaging to monitor tumour metabolic activity, applying special software to detect the absence or presence of cell death. This technology has been trialed with over 100 women with locally advanced breast cancer who had pre-surgery or neoadjuvant chemotherapy, a frequent treatment approach to shrink typically large breast tumours for better breast-conserving surgery. “The results proved that the technology works – that within one to four weeks www.hospitalnews.com

“These are exciting times," says Dr. Masoom Haider, Sunnybrook. "We are definitely doing leading-edge work in the area of imaging." Photo by: Dale Roddick we can demonstrate whether a specific chemotherapy was going to work,” says Dr. Czarnota. Cancer response to treatment is usually only known after months of treatment and is determined by MRI or CT (computed tomography). “We’re now at the stage where the technology is being expanded to potentially benefit other patients through more clinical trials in other centres,” he says.

Minimally invasive approach may replace liver biopsy What if patients could avoid a biopsy and undergo an equally telling but non-invasive test? That is the question posed by Dr. Laurent Milot, an abdominal radiologist in Medical Imaging at Sunnybrook, who collaborates with the Gastrointestinal and

Genitourinary Cancer Care teams at the Odette Cancer Centre. Dr. Milot is the first in the world to show in cancer that MRI with a newer contrast agent, gadofosveset trisodium, better characterizes whether or not an abnormality is cancer, compared to MRI with standard gadolinium contrast agent. “This technique could significantly benefit patients with spots on the liver that are highly suspicious of potential spread from colorectal cancer, especially as liver biopsy can be risky,” says Dr. Milot. His research published in the Journal of Magnetic Resonance Imaging shows that after 10 minutes, MRI with gadofosveset trisodium produces images with a distinct black hollow or leakage of contrast agent in cancer lesions, compared to images of pooling of contrast agent in benign ones.

He is using this technique in early clinical trials with patients and collaborating with Odette oncologists to use the data for vital surgical planning. To better characterize tumours, Dr. Milot, an affiliate scientist at Sunnybrook Research Institute who completed his Medical Imaging specialty at l’Université de Claude-Bernard Lyon 1 in France, is also researching the use of microscopic bubbles or microbubbles within blood vessels with contrast-enhanced ultrasound. Cancer lesions distinctly show rapid ‘wash out’ of microbubbles due to the abnormal vasculature of tumours, while benign lesions acH cumulate or retain them. ■ Natalie Chung-Sayers is a Communications Advisor at Sunnybrook Health Sciences Centre.

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Reducing radiation in cardiac imaging By Vincent Lamontagne

he University of Ottawa Heart Institute (UOHI) is setting the stage in what could become a revolution in medical imaging in Canada as it announces striking results in radiation reduction for the diagnosis of cardiovascular disease. As a result of an initiative that combines optimizing test protocols, state-of-the art equipment, and high-tech software, over 90 per cent of the Ottawa Heart Institute’s Nuclear Cardiology patients are currently receiving half the radiation dosage that they would normally get at most Canadian centres.

Each year, the University of Ottawa Heart Institute conducts nearly 5,000 nuclear cardiology (SPECT) scans, 1,500 PET scans and 1,500 CT angiograms Radiation reduction techniques have been achieved across all types of radiationbased cardiac imaging – nuclear, CT and PET. The Heart Institute is one of only a few centres in Canada with the in-house

expertise to evaluate and clinically apply such advances across these technologies. The American Society for Nuclear Cardiology has challenged the nuclear cardiology community to reduce radiation exposure below nine millisieverts (mSv) by 2014. The techniques being employed at the Heart Institute regularly reduce exposure to below five mSv, and often much less, putting the heart health centre well ahead of the game. UOHI clinicians are taking a much more critical look at who they are testing with methods using radiation and making decisions based upon risk and benefit which will only expose patients to radiation who need the test. These responsible practices, along with appropriate use of technology, can reduce radiation exposure by 50 per cent for patients undergoing cardiac imaging in Canada. The Ottawa Heart Institute uses a combination of powerful and effective tools that enable better diagnosis of cardiovascular disease. The cadmium zinc telluride camera system used for nuclear imaging is a significant innovation and was implemented by Dr. Glenn Wells, Medical Physicist, and Dr Terrence Ruddy in Nuclear Cardiology. The Heart Institute was one of the first centres in the world with this

Reducing radiation in cardiac imaging: Each year, the University of Ottawa Heart Institute conducts nearly 5,000 nuclear cardiology (SPECT) scans, 1,500 PET scans and 1,500 CT angiograms. Keeping radiation levels as low as possible is important for patient safety, and the Heart Institute is a North American leader in this area. technology in 2009, and it had a major impact on reducing radiation in SPECT perfusion scans, by far the most common cardiac imaging test. Software is another critical part of imaging, turning the scanner data into threedimensional pictures of what is found in a patient’s body. The Heart Institute has worked with commercial developers to evaluate and improve new advanced software packages scanners that maintain image quality while using smaller doses of radioactive isotopes.

Over the years, radiation with medical testing has become a concern for our society. Yet often we do not appreciate the significant benefits of highly accurate diagnostic information from techniques which may require very low amounts of medical radiation. Careful and appropriate selection of the right test for the right patient while balancing benefit and risk enables H optimal patient care. ■ Vincent Lamontagne is Senior Manager, Public Affairs at The University of Ottawa Heart Institute.

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New home screening program for liver disease in newborns By Lubna Ekramoddoullah

arents in British Columbia are being asked to check their newborn’s stool colour in an effort to detect early signs of a rare but fatal liver disease, as part of the Biliary Atresia Home Screening Program launched by Perinatal Services BC. When parents are discharged from the maternity unit, they are given a stool colour card that contains photos of normal and abnormal infant stool colours. Parents are asked to check their newborn’s stool colour against the colour card every day for the first month after birth. Biliary atresia is a liver disease resulting from blockage of the bile duct, which prevents bile from leaving the liver, resulting in damage and scarring that can lead to death by the age of two if not treated. The disease begins to affect newborns in the first month of life. While it is normal to see jaundice in the first few days after birth, some babies may have jaundice that lasts longer than two weeks as well as pale yellow, chalk white, or clay-coloured stools, an indication that very little or no bile is reaching the intestine. The preferred treatment is the Kasai procedure, a surgical method that reestablishes bile flow from the liver to the intestine by joining the two. The diseased bile duct is removed, and a small segment of the small intestine is attached to the liver at the spot where bile is expected to drain.

“We need to build awareness among parents and health care providers about the need to look at stool colour as a disease indicator” The effectiveness of this surgery depends on timing. If the Kasai procedure is performed in the first two months of life, it has an 80 per cent chance of success. But after three months, it drops to 20 per cent. If the procedure is unsuccessful, a liver transplant is required. That is why detecting biliary atresia early is so important. There is no single blood test for biliary atresia, so stool colour is the main tool for early detection. “We need to build awareness among parents and health care providers about the need to look at stool colour as a disease indicator,” says Dr. Richard Schreiber, Director, BC Pediatric Liver Transplant Program, BC Children's Hospital and Professor of Pediatrics, University of British Columbia. “Poor outcomes due to late diagnosis and surgery of infants three months of age or older remain a problem throughout Canada and elsewhere in the world.” The Biliary Atresia Home Screening Program is the first of its kind in Canada. The program is based on best practices in Taiwan as well as research conducted in BC and Quebec involving over 9,500 families. The stool colour card used in BC also www.hospitalnews.com

Natalie Williams’ biliary atresia was nearly missed. She now works to raise awareness. has a Quick Response code, so parents can use their smartphones to sign up for weekly text or email reminders to check their baby’s stool. The reminders are available in 12 languages. “BC is the first province in Canada to implement this unique type of home screening program,” says Kim Williams, Provincial Executive Director, Perinatal Services BC. “There are no blood tests or samples to collect, and it is family-centred—done at home by parents or other family members. Parents can feel empowered because they are taking a proactive role in identifying a life-threatening disease and improving the health of their newborns.” “As an infant, my biliary atresia was

nearly missed,” says Natalie Williams, a 16-year-old advocate from Vancouver Island. “My diagnosis was on the later side due to lack of awareness of medical professionals regarding both stool colour and prolonged jaundice. I am now 16-yearsold and had a successful Kasai procedure. However, very few children are as lucky. Through my Facebook page, I have seen far too many infants have poor outcomes primarily due to late diagnosis. This is why I feel the new screening program is very important as it can help diagnose an infant earlier and give them a better chance of the Kasai procedure being successful and ultimately a better chance of overall survival. The screening program is giving

parents the power and knowledge to help save their babies’ lives. I don’t think it gets much better than that.” Perinatal Services BC, an agency of the Provincial Health Services Authority, provides leadership, support, and coordination for the strategic planning of perinatal services in British Columbia in collaboration with regional health authorities and other key stakeholders. PSBC is the central source in BC for evidence-based perinatal information. Download biliary atresia reH sources from www.perinatalservices.bc. ■ Lubna Ekramoddoullah is a Communications Officer with Perinatal Services BC.

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Taking action against

chıldhood obesity

By Suzanne Gold

generation ago, “after school” was a time when most children looked forward to being outside, running around and playing until they were called inside for dinner. Flash forward to today, when school-aged children, teens and even toddlers spend most of their free time passively sitting in front of a screen. One in three Canadian children is now overweight or obese, and many of them are dealing with a variety of resulting serious health concerns. As a paediatric endocrinologist at The Hospital for Sick Children (SickKids), Dr. Jill Hamilton has noticed a gradual change in her patient population over the years, as more and more kids show up in her clinic with a condition that was previously known as an adult–onset disease. “Thirty years ago, Type 2 diabetes was not really a diagnosis in children,” she says. “The landscape is totally different now, and we need to address the changing needs of our patients who face potentially dire outcomes." Dr. Hamilton and her team recently launched the Centre for Healthy Active Kids at SickKids to take a more holistic approach in addressing the issue of childhood obesity. The Centre integrates a multidisciplinary team of health care providers offering clinical care, conducting research studies, and leading education in this emerging field. “It’s a complex path that we’ve taken to get to this point in childhood obesity, and it’s going to take a multi-faceted approach to get out,” says Hamilton, Director of the Centre for Healthy Active Kids and its clinical program, the SickKids Team Obesity Management Program (STOMP). “With the new Centre, we aim to prevent, understand and manage obesity and related disorders with the ultimate goal of improved health, wellness and quality of life for children and youth throughout their life course.” The Centre’s clinical activities began with the launch of STOMP in 2010. The program was the first of its kind in Canada, offering teens with complex obesity access to a team of health professionals, support groups and, for those who meet specific

The Centre for Healthy Active Kids at SickKids takes a more holistic approach in addressing the issue of childhood obesity. criteria, bariatric surgery. Throughout the two-year intensive curriculum, teens and their families are followed closely by paediatricians, a nurse practitioner, dietitians, an exercise therapist, a psychologist and a social worker. Open to patients aged 12 to 17, STOMP sees about 50 new patients per year.

Primary-care providers have historically received limited training on how to speak to families about weight–related issues in a way that is empathetic but also effective. STOMP’s latest clinical offering is its Early Years program, a collaboration with Toronto Public Health which serves children aged six months to six years. Launched in 2012, Early Years educates families about nutrition, meal planning and physical activity, and helps instil healthy habits for

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lifelong health. A unique component of the program is that it features home visits from a Public Health nurse, who can assess a family’s situation and help guide them to better habits at home and in their everyday lives. “Targeting our interventions to the earlychildhood period is critical,” says Dr. Catherine Birken, a paediatrician with STOMP who leads the Early Years program. “If we can identify unhealthy behaviour and risk factors early, we can provide the tools to help change kids’ habits before they become ingrained.” In addition to these clinical programs, the Centre for Healthy Active Kids is conducting a variety of research projects along the themes of healthy nutrition and physical activity, prevention and treatment of obesity and the physiology of body weight and associated health risks. Educational initiatives include the development of training opportunities for health-care professionals. Primary-care providers have historically received limited training on how to speak to families about weight–related issues in a way that is empathetic but also effective. This is something Dr. Hamilton and her team hope to change. Obesity is a complex issue that is influenced by individual, family, socioeconomic, genetic, physiological, environmental and policy factors. In some cases, it is the result of treatment, like steroids, for a medical condition. It could also stem from a brain tumour, like craniopharyngioma, or another serious illness. Nine-year-old Jan was diagnosed with craniopharyngioma in 2011. Early in his clinical care, he was referred to STOMP, since one of the common complications of the surgery required to remove the tumour is damage to the hypothalamus, an area of the brain involved in weight regulation. As a result, Jan faced a staggering 50 per cent risk of severe obesity. “When Jan was diagnosed, it seemed like obesity was almost certainly in his future, ” says his dad, Kenton Kroker.

“That was difficult, knowing the health risks and incapacity that can result.” Following Jan’s initial surgeries, the Kroker family began working with a STOMP dietitian and Dr. Hamilton to ensure that Jan’s weight would be carefully managed. At first, Jan was placed on a low glycemic index diet to prevent weight gain. When his tumour increased in size last year, and he required radiation therapy, his appetite decreased dramatically, and he needed further changes in his diet to prevent too much weight loss, his dietitian was there to help the family. While they had always strived to eat well, the family learned to incorporate Canada’s Food Guide into their meal planning. Jan’s dietitian offered them strategies to help them think of food differently and communicate with each other, as well as with teachers, friends and relatives, about Jan’s dietary needs. Today, Jan goes to school, plays baseball and maintains a healthy weight. He is wellversed in which foods he is able to eat, and looks forward to his weekly “treat days”, when he is able to indulge in favourite foods that are not part of his regular diet. “Trying to manage Jan’s health challenges around the dinner table was really hard, but that was made an awful lot easier by the STOMP team,” Kroker says. “The program answered the question of ‘what do I need to do?’ In a medical crisis, parents and kids lose agency really quickly. This was something we, and Jan, could take action on.” For information about the Centre for Healthy Active Kids, including tips and reliable educational resources for families, visit http://www.sickkids.ca/Centre-forHealthy-Active-Kids/index.html. For referral information for STOMP, visit http://www.sickkids.ca/STOMP/ Referral%20Information/Referral -InforH mation.html. ■ Suzanne Gold is a Senior Communications Specialist at The Hospital for Sick Children (SickKids). www.hospitalnews.com

Focus

ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

Speech and language therapy meets the 21st century By Maigen Bundy

he York Region Preschool Speech and Language Program (YRPSLP) offered through Markham Stouffville Hospital provides help for children from birth to Junior Kindergarten entry who have difficulty learning to communicate or to interact. The program focuses on the prevention, early identification and treatment of speech and language problems. With about one in 10 children in Ontario needing help developing normal speech and language skills, YRPSLP regularly pursues opportunities to reach parents and families through new and innovative formats. Several years ago, YRPSLP began offering parents/caregivers of children identified with a mild-to-severe articulation delay at their initial assessment, the opportunity to attend a two-hour, parent-only, evening workshop entitled, “Let’s Make Sounds.” The purpose of the workshop was to provide education about typical speech development and articulation delays, the adults’ role in therapy, and a home package tailored to their child’s articulation needs, so parents could start working with their child while waiting one to two months for their treatment sessions to begin. Attendance was high and the course was well-received. For some, this was their only intervention if their child had a mild articulation delay or would age-out of the system due to senior kindergarten entry at school.

For updates, resources and tips, visit www.childdevelopment programs.ca In 2011, parents were still being referred to the “Let’s Make Sounds” course and were agreeing to attend, but the actual attendance at the course began to drop. This caused the Child Development Programs staff to pause and reflect on the viability of this workshop. “Where were the parents?” wondered Susan Sheffield, director, Child Development Programs, Markham Stouffville Hospital. “Why were they agreeing to come and then not showing up? How were we going to ensure parents would still receive the intervention, particularly for those parents where this was the only intervention that they would receive, beyond an initial assessment.” Travel time, a long day of work, transportation issues, tired kids, tired spouses and parents, and the challenge of arranging childcare in the evening were real barriers being faced by parents trying to attend the workshop. “It became clear to our team that we needed a new solution, one that would take advantage of new technologies available and one that would fit with parents’ busy lifestyles,” Sheffield explains. Thanks to one-time funding from The Ministry of Children and Youth Services, the team worked to create an e-learning course based on the material covered in www.hospitalnews.com

Maigen Bundy visits the Child Development Programs website www.childdevelopmentprograms.ca, one of many new interactive resources for parents on the go. the face-to-face, “Let’s Make Sounds” parent education workshop. Three 30-minute education modules were developed for speech-language pathologists to recommend to parents, after their child had been seen for an initial assessment and articulation concerns were identified. YRPSLP also created four speech sound workbooks to accompany the course for parents to download and use after viewing the course. “This e-learning format allows parents to watch the course from the comfort of their own home, on their own schedule,” explains Sheffield. “It also affords families the luxury of both parents and other caregivers/family members being able to watch the course, whereas typically only one person was able to attend the face-to-face course due to child-minding duties.” The YRPSLP team knew more could be done to reach these families. The team continued to evaluate the e-learning course with speech-language pathologists, communicative disorders assistants, and, importantly, parents of children who had an initial speech-language pathology assessment within the program. With the financial support of other preschool speech and language programs, simplified speech sound workbooks were created to help parents apply their new knowledge within their day-to-day lives, online demonstration videos were upgraded, and the course became mobile-device friendly. For Marie Naro and her four-year-old daughter Mia, the online availability of the learning modules has made all the difference. “It can be a big struggle and stressful to balance work and appointments and caring for your child,” says Naro. Since her birth, Mia has visited several specialists, undergone multiple surgeries and continues to participate in ongoing treatment for health challenges related to talking, eating and feeding, as well as Congenital Vertical Talus, a disorder of the foot. Naro is one of the parents the YRPSLP team looks to for feedback and input into their programs. She participated in the face-to-face workshops, where she had the opportunity to meet other parents, some-

thing that Naro says allowed her to compare her experience to that of others, “to not feel alone and to get ideas.” Naro has also enjoyed accessing the online resources on her own time and says, “It is nice and refreshing when there’s an alternative available.” Mia began working with the YRPSLP team following her initial assessment at 15 months old and completed her therapy this April. She continues to succeed in her treatments and Naro is grateful to the YRPSLP team, especially “Miss Lauren” (speech-language pathologist Lauren Rossi) who she says is somebody she’ll never forget. “There are more good days than hard days,” Naro says. “You can see the happiness in Mia now.”

The e-learning course is now ready to be unveiled to preschool speech and language programs across Ontario. It will be password protected to ensure access to parents who have had a speech-language pathology assessment. For more information please email cdpfamilies@msh. on.ca. For updates, resources and tips, visit www.childdevelopmentprograms.ca, “like” Child Development Programs (cdpmsh) on Facebook and follow @ H childdevprogram on Twitter. ■ Maigen Bundy is a Speech-Language Pathologist for the York Region Preschool Speech and Language Program through Markham Stouffville Hospital.

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10 Focus

ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

The Mascoll and Cruz families along with Dr. Sharma displaying the Strands of Strength necklaces for babies Blake Mascoll and Tyler Cruz.

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HOSPITAL NEWS JUNE 2014

Growing stronger, one bead at a time By Julie Atkinson

ome of the tiny necklaces could easily fit around an adult’s wrist. The colourful beads tell a story of growth, healing and

of strength. This isn’t any regular child’s necklace purchased from a store. It is part of an innovative program designed to use beads to recognize milestones in a baby’s treatment. Staff in the Neonatal Intensive Care Unit (NICU) at Markham Stouffville Hospital are able to care for babies born as early as 30 weeks gestation. The majority of these tiny patients face a number of health challenges. The staff has embraced a number of initiatives designed to enhance the patient and family experience – and the most recent is the Strands of Strength initiative. The program is based on The Hospital for Sick Children's "Bravery Beads Program". This inspiring program began as an initiative between the Women's Auxiliary volunteers and the child life specialists at SickKids as a way for children to document their journey through treatment. Each baby admitted into the NICU receives a starter necklace with their name in beads. From that point, the family starts collecting beads for every treatment or milestone experienced. Upon discharge, each family is able to take their Strands of Strength home as a memory of their journey while in the NICU. “The Strands of Strength initiative has been a really positive addition to the culture within the NICU. It helps to strengthen the bond between nurses and families and also provides the opportunity to create connections with other hospitals throughout Ontario,” says Nancy Fletcher, executive vice president, clinical programs. “These beautiful necklaces become a visible, tangible reminder of just how far many of these babies have come.” Many infants are transferred among hospitals as they receive necessary treatment. Many of those partner hospitals

have similar bead programs and families can collect their beads as they move through the health care system and receive care and treatment. Markham Stouffville Hospital built upon the success of the SickKids model and adopted a similar legend and materials. “The florescent green beads mean IV start and the red beads mean transfusion,” says Cheryl Osborne, patient care manager of the NICU. “Often our nurses and physicians in the NICU are just as proud of the Strands of Strength as the families. For most of our babies, it means they are getting stronger as their necklace gets longer.” The program has been embraced by parents and family members. Looking back, Jen Mascoll is proud of the Strands of Strength that was created for her son Blake. He was born premature and spent five weeks in the NICU at Markham Stouffville Hospital. He required a number of procedures including a chest tube, an umbilical catheter, IVs and nasal feeding. "Strands of Strength helped us to focus on how far Blake had come. It reminded us how strong he was and helped us to get through those roller coaster days," says Mascoll. "Now that he is home, showing people his strand has made them realize how much he's been through and it will be something he can look at and be proud of when he gets older. A nice reminder of just how amazing he is." Osborne says she hopes the necklaces will continue to play an important role for the children and families, long after they have left the NICU. “It is our vision that as our little graduates grow, that they look back at their Strands of Strength and see how strong and brave they were and continue to be. It will be a source of inspiration for them in the years to come and will also H help inspire those around them.” ■ Julie Atkinson is a child life specialist at Markham Stouffville Hospital. www.hospitalnews.com

Focus 11

ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

The latest in personalized

cancer care By Natalie Chung-Sayers

ou feel invincible when youâ&#x20AC;&#x2122;re young and then all of a sudden, you have this wake-up call,â&#x20AC;? says Delaney Janhunen. Delaney was 36 when she was diagnosed with HER2-positive breast cancer. Three years later, the cancer had recurred in lymph nodes under her arm. Referred to Sunnybrookâ&#x20AC;&#x2122;s Odette Cancer Centre and medical oncologist, Dr. Sunil Verma, Delaney joined a global clinical trial at the Centre to examine the effectiveness of an antibody-drug conjugate, a new way to attach chemotherapy to targeted therapy. The approach harnesses the benefits of targeted therapy (aimed at cancer cells), and allows chemotherapy to be carried directly to cancer cells. Patients are living longer, thanks to earlier detection and better treatments. Treatments are more tailored for the individual, resulting in reduced side effects and improved quality of life. Care teams at the Odette Cancer Centre provide patients with advice on current standard treatment options, and is one of only a few centres in Canada with the expertise to provide the latest in tailored treatment research and clinical trials, including Stereotactic Body Radiotherapy (SBRT) multi-visceral laparoscopic surgery, and novel drug therapies, for example, designed to overcome cancer resistance or to directly target the key drivers of cancer cell growth.

â&#x20AC;&#x153;

Stereotactic Body Radiotherapy

SBRT is a newer technique that allows a very high dose of radiation to a focused area, over a few treatments. It used to treat some well-defined tumours of the lung, liver, bone/spine and brain, and is being investigated as potential primary treatment for prostate and kidney cancers. The goal of SBRT is to eradicate the treated tumour, making it another effective option for patients who cannot have, or choose not to have surgery. Dr. Patrick Cheung, radiation oncologist, Odette Thoracic and Genitourinary Cancer care teams, is also studying SBRT for patients like Louise McGarry, who have oligometastases (less than five tumours). In 2013, Louise, 47, had SBRT to treat a tumour in her lung and another lymph node tumour in her abdomen. Recalls Louise, â&#x20AC;&#x153;I thought â&#x20AC;&#x201C; since I had the choice of something less invasive especially with the added difficulty of where the tumour was, it was an easy decision â&#x20AC;&#x201C; letâ&#x20AC;&#x2122;s just do it!â&#x20AC;? She was diagnosed a year before with colorectal cancer, with a large tumour in the colon. The cancer had also spread to the liver, lung and lymph nodes behind the lining of the abdomen and abdominal organs. Treatment began with radiation therapy and oral chemotherapy to shrink the colon tumour. She underwent surgery to rewww.hospitalnews.com

Treatments are more tailored for the individual, resulting in reduced side effects and improved quality of life Dr. Sunil Verma is part of the team at the Odette working on the latest in tailored treatment research and clinical trials.

move it and the liver tumour. â&#x20AC;&#x153;Things happen for a reason,â&#x20AC;? she says. â&#x20AC;&#x153;You need to accept that you may never know what the reason is. This journeyâ&#x20AC;&#x2122;s been a blip in my life. I choose to fight and move forward. I know I have the strength and the support to deal with it.â&#x20AC;?

Multi-visceral Laparoscopic Resection

Ellen Skok, 88, had a novel surgical procedure called laparoscopic multivisceral resection for colon cancer. In most cancer centres, multivisceral resections with traditional incisions are already being performed and consist of removal of multiple organs altogether in order to resect a colon or rectal cancer completely. Sunnybrookâ&#x20AC;&#x2122;s Odette Cancer Centre is one of only a handful of centres worldwide, with the expertise to perform these multivisceral/multiple organs removals laparoscopically. â&#x20AC;&#x153;Without compromising oncologic principles of ensuring removal of the whole cancer, we can now offer this complex procedure to selected patients who can benefit from laparoscopic surgery despite a massive tumour invading other organs,â&#x20AC;? says Dr. Shady Ashamalla, a surgical oncologist of the Odette Gastrointestinal Cancer care team, who performed Ellenâ&#x20AC;&#x2122;s surgery, and who completed advanced training at the University of Toronto, in both Minimally Invasive Surgery and Surgical Oncology. Ellenâ&#x20AC;&#x2122;s procedure included laparoscopic removal of a large cancer in the colon and invading into adjacent tissues and organs, including abdominal muscles, and part of the liver and kidney. â&#x20AC;&#x153;There was no incision,â&#x20AC;? she says. â&#x20AC;?Two weeks after the surgery, I went out to have dinner, and people couldnâ&#x20AC;&#x2122;t believe it! My recovery was very rapid. I am able to do everything Iâ&#x20AC;&#x2122;ve always done: my own housework, laundry, and tidying my

apartment which is not large â&#x20AC;&#x201C; but not small either!â&#x20AC;?

Novel Targeted Therapies

Medical oncologists are exploring new approaches in immunotherapy for lung cancer and melanoma, targeting specific proteins so cancer cells cannot escape detection by the bodyâ&#x20AC;&#x2122;s immune system. Results of the Phase III clinical trial known as EMILIA, that Delaney Janhunen participated in, shows improved survival with significant reduced toxicity for women with ad-

vanced HER2 positive breast cancer. â&#x20AC;&#x153;The longer-term hope is that this framework will be used for other cancers and at earlier stages of disease,â&#x20AC;? says Dr. Verma, chair, Sunnybrook Odette breast medical oncology, and head, Breast Clinical Trials. Says Delaney, who now has no detectable cancer, â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m very blessed to be H maintaining close to a normal life.â&#x20AC;? â&#x2013; Natalie Chung-Sayers is a Communications Advisor at Sunnybrook Health Sciences Centre.

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JUNE 2014 HOSPITAL NEWS

12 Focus

ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

Options for hip replacement:

Evidence from CADTH's Rapid Response Service By Janice Mann

prostheses compared with metal-on-polyethylene prostheses. A second related rapid evidence review by CADTH looked more closely at the components and materials used for total hip replacement. This review recognized that there are several designs of hip implants available and different materials used for the implant components. Modular hip implants, unlike standard models, allow for the choice of different femoral neck lengths and femoral head sizes as well as modular acetabular cups.

anada’s health technology assessment (HTA) organizations provide Canadians with independent, evidence-based information on drugs and other health technologies. HTA allows decision-makers to balance the potential benefits of new drugs, devices, or procedures with the need to get the best value out of every health care dollar. CADTH – with its Rapid Response service – is a leader in providing timely, credible, and relevant evidence to support informed decision-making. Here is a round-up of recent rapid evidence reviews from CADTH focusing on hip replacement surgery from our Rapid Response service. Total hip replacement is a common orthopedic procedure for patients with degenerated hips and chronic pain. In 2009-2010 in Canada, 13,068 patients underwent the procedure. During total hip replacement, the head of the femur is removed and replaced with a prosthesis that has a protruding ball. The ball fits into an acetabular cup that is secured to the pelvis, and the cup may be lined to reduce friction and wear. Hip resurfacing arthroplasty is another option for treating patients with degenerative hip disease. During hip resurfacing, a metal cap is placed on the femoral head to cover damaged bone, and a metal shell is placed in the acetabulum. The cups, balls, and cup liners of hip prostheses used for total hip replacement are made of various combinations of metal, ceramic, or polyethylene. For metal-onpolyethylene hips, the ball is made of metal and the cup is lined with polyethylene. Metal-on-metal hips have a ball and cup both made of metal, with or without a metal liner. Metal-on-polyethylene hips – the gold standard – typically last 10 to 15 years or more, but wear and bone loss can

CADTH’s Rapid Response service looked at the evidence comparing total hip replacement with hip resurfacing, and comparing metalon-metal with metalon-polyethylene hip prostheses.

In 2009-2010 in Canada, 13,068 patients underwent hip replacement. be issues for younger, more active patients. Metal-on-metal hips tend to have better wear rates but may erode and gradually release metal ions into the bloodstream, which has been associated with high failure rates and surgical revisions. CADTH’s Rapid Response service looked at the evidence comparing total hip replacement with hip resurfacing, and comparing metal-on-metal with metal-onpolyethylene hip prostheses. The review showed no significant differences in mor-

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tality, dislocation, or deep hip joint infection between total hip replacement and hip resurfacing. When assessing bone preservation, wear rates, and functional outcomes, however, hip resurfacing performed better; but metal-on-metal hip resurfacing resulted in higher rates of revision, femoral neck fractures, and component loosening than total hip replacement. The evidence review also revealed a lack of both clinical and cost-effectiveness evidence on total hip replacement using metal-on-metal

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HOSPITAL NEWS JUNE 2014

This review found that ceramic-onpolyethylene implants do not appear to be more effective than metal-on-polyethylene implants for total hip replacement, but that ceramic-on-ceramic implants may require fewer revisions after five years than metalon-polyethylene implants. Modular stem implants may have lower early survival than standard implants but may be equal or better than standard implants over the long term. Large femoral head implants for total hip replacement are likely beneficial compared with standard-sized implants. A third rapid evidence review on hip replacement focused on the polyethylene liners of the acetabulum cups for metalon-polyethylene hip prostheses. Alternatives to regular polyethylene liners include cross-linked polyethylene and newly developed vitamin E-infused polyethylene liners. The CADTH rapid review compared the evidence on the different polyethylene liners and found that cross-linked polyethylene liners performed better than regular polyethylene liners, with reduced wear rate, bone loss, and need for revision. But there was no evidence comparing vitamin E-infused polyethylene liners with regular or cross-linked liners. This series of Rapid Response reviews from CADTH demonstrates just how complex decisions about health technologies can be. The initial question asked about the type of procedure to undertake, subsequent questions involved the type of hip prosthesis to use, then focused on what the prosthesis is made of, right down to the type of polyethylene lining the acetabulum cup! HTAs such as CADTH’s Rapid Response reports can’t answer all the questions that arise in the treatment of degenerative hip disease. But they can go a long way in providing the evidence pieces to the treatment puzzle. Clinicians, policymakers, patients, and others involved in making important decisions in healthcare in Canada can access our Rapid Response reports free of charge on our website anyH time at www.cadth.ca/RapidResponse. ■ Janice Mann BSc MD, is a Knowledge Mobilization at CADTH. www.hospitalnews.com

Focus 13

ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

Bone density testing is critical, because osteoporosis is often called the “silent thief” since bone loss does not have any symptoms, until a fracture occurs.

Osteoporosis program returns to Ontario By Giuseppe Tarulli ith more than half a million Ontarians affected by osteoporosis, a highly debilitating disease that causes bones to become thin and porous, it’s no wonder that standards of testing at digital imaging facilities and quality patient health management is a priority. The Ontario Association of Radiologists (OAR) is once again offering its Canadian Bone Mineral Densitometry (CBMD) Facility Accreditation Program and two continuing medical education (CME) programs this fall, aimed at radiologists and other physicians reading BMD and technologists providing BMD services, to meet this need. It’s an unfortunate reality that osteoporosis is a growing health problem for Canadians and remains a large burden on our health care system. Although both women and men can lose bone mass as they age, women lose bone at a

greater rate (from two to three per cent per year) as they approach menopause. In Canada, more than 80 per cent of all fractures after age 50 are caused by osteoporosis. The overall yearly cost to the Canadian health care system of treating osteoporosis and the fractures it causes was over $2.3 billion as of 2010. Fractures from osteoporosis cause pain and may lead to permanent deformities, risk of institutionalization, long-term disability or even death. They are more common than heart attack stroke and breast cancer combined. Hip fractures cause more illness, death and higher health care costs than other types of fractures. Bone density testing is critical, because osteoporosis is often called the “silent thief” since bone loss does not have any symptoms, until a fracture occurs. Unlike the majority of diagnostic imaging procedures, bone densitometry is not just performed to arrive at a diagnosis. It plays an

essential role in monitoring patients who are at risk of developing osteoporosis, or are being treated for high fracture risk. Because the technique is quantitative rather than qualitative, there is a relatively greater need to ensure that standards are met and proper quality control procedures in place. Equally, because the technique is only part of a clinical risk assessment, it is necessary for a reporting physician to demonstrate adequate knowledge of osteoporosis as a disease and not merely its radiological assessment. Before 2006, the quality of bone mineral density (BMD) services offered in Ontario was inconsistent. Canadian BMD training for physicians and technologists and quality control standard for BMD facilities were non-existent. Recognizing the need for quality control and standardization, Osteoporosis Canada (OC) on behalf of the Ontario Ministry of Health asked the OAR to develop a quality assurance proposal to sup-

New paediatric clinic addresses

constipation issues

By Akilah Dressekie

new paediatric clinic is helping provide relief to young patients. The paediatric constipation clinic recently opened at Rouge Valley Centenary’s (RVC) Galaxy 12 clinic in Scarborough. In total, 12 different paediatric specialty clinics are based at RVC. The clinic is the only one of its kind in the Greater Toronto Area that deals specifically with paediatric constipation issues, and provides the assessment and management of constipation for young patients, who range from infants to children up to 18 years of age. “Many people don’t realize that infants, children and adolescents can get constipated, or that having a bowel movement once every few days is not normal,” explains paediatric hospitalist Dr. Niraj Mistry, who leads the clinic. “This is a common, uncomfortable, and undertreated issue for many children. So our goal with www.hospitalnews.com

this clinic is to provide the highest quality of care for our patients, close to home.” Many children come to the emergency department complaining of severe stomach pains, which can be symptomatic of other issues. So having a physician who can recognize the symptoms, and understands the spectrum of care needed to deal with constipation, can help to provide young patients – and their parents – with the care and relief they need. In addition, the clinic can also identify behavioural and functional issues related to constipation that may also need addressing. The clinic works in partnership with RVC paediatric gastroenterologists Dr. Latifah Yeung, and Dr. Carol Dunro, whose expertise allows patients with more complicated issues to receive further specialized care. It operates using medical guidelines created by SickKids, allowing patients to receive the best available re-

Dr. Niraj Mistry, leads Rouge Valley's new paediatric constipation clinic. The clinic is the only one of its kind in the Greater Toronto Area. search knowledge and expertise. An essential part of the clinical practice guideline is community support, so having a paediatrician who follows these children closely while treating their constipation issues is essential to good outcomes. Patients can be referred to the clinic through their family physician/general practitioner, paediatrician, or emergency H department physician. ■ Akilah Dressekie is a Senior Communications Specialist at Rouge Valley Health System.

port BMD facility accreditation throughout Ontario, as part of the Ministry of Health’s Osteoporosis Strategy in Ontario. The OAR’s program evolved out of necessity and a commitment to ensure the highest standard of BMD examinations for Ontarians. It developed a two-pronged program – a facility quality control and quality assurance program and a CME component for medical specialists interpreting and technologists performing BMD services. The program resulted in a successful four-year pilot project, which demonstrated many significant benefits for the provision of important BMD services for the detection of bone loss and osteoporosis. Since the program began in March 2007, close to one-third of Ontario’s 300+ BMD units have been CBMD accredited. An evaluation of the OAR CBMD facility accreditation pilot project, with the involvement of U of T’s osteoporosis researchers, concluded that the program had a profound influence on improving the quality of scanning services provided by the participating sites between 2008 and 2010. Despite the program’s high level of success, it was put in jeopardy in March of 2012, when the Ministry of Health and Long Term care discontinued funding and reversed its commitment to providing accreditation as part of the province’s Osteoporosis Strategy. Recognizing the deep void that existed with the suspension of its program, the OAR’s board of directors unanimously agreed to re-develop the CBMD Facility Accreditation Program as an online program. Launching later this year, the program promises to continue to provide a thorough analysis of all the elements essential to providing a high-quality BMD service delivering the highest standard in quality patient care. The CBMD goal is to have every bone densitometry unit in Ontario accredited. All radiology clinics in Ontario are now required to be CBMD accredited by the College of Physicians & Surgeons of Ontario (CPSO). For more details and registration inforH mation, visit http://oarinfo.ca/cme. ■ Giuseppe Tarulli, MD, FRCPC is an interventional radiologist, Past President of the Ontario Association of Radiologists and Chair of the OAR CME Committee. JUNE 2014 HOSPITAL NEWS

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ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

Supporting development of children By Bobbi Greenberg

magine being a new immigrant to Canada and not understanding how the health care system works. Imagine knowing that there is something wrong with your baby and you donâ&#x20AC;&#x2122;t know what it is. Imagine going to see doctor after doctor in Canada and abroad â&#x20AC;&#x201C; travelling all the way to Indonesia â&#x20AC;&#x201C; your home country â&#x20AC;&#x201C; searching for answers to your childâ&#x20AC;&#x2122;s health condition and not getting one. Imagine having a child with a medical diagnosis that takes a long time to diagnose. And, imagine after months and months of not knowing â&#x20AC;&#x201C;finally receiving an answer â&#x20AC;&#x201C; your child has Rett Syndrome and you donâ&#x20AC;&#x2122;t know where to turn. One Community Care Access Patient is nine-year-old Gabrielle (Gabbie) who lives at home with her family in Mississauga. However, Gabbie is not a regular nine-year-old little girl. Gabbie has Rett Syndrome. Rett Syndrome is a rare neurodevelopmental condition affecting mostly females; it stunts growth, affects speech and coordination, and is characterized by repetitive hand movements. Children with Rett Syndrome display normal development until six or 18 months of age, when delay or regression occurs, which is typically when children are diagnosed. While Rett Syndrome is not degenerative, all children and adults living with the condition need fulltime assistance as they cannot stand, walk, feed, or toilet themselves. There is no cure.

Mississauga Halton CCAC Care Coordinator Rashmi Tailor pays a home visit to her patient nine-year-old Gabbie and mother Kusyati. Going back nine years, Gabbieâ&#x20AC;&#x2122;s mother, Kusyati intuitively felt that Gabbie was not progressing, reaching the same childhood milestones in the same way her other two children had when they were her age; but she did not know what was wrong. Finally, the answer came in the form of Gabbieâ&#x20AC;&#x2122;s diagnosis â&#x20AC;&#x201C; Rett Syndrome â&#x20AC;&#x201C; and that is when Kusyati contacted the Mississauga

Halton CCAC for looking for help. The Mississauga Halton CCAC supports families in care of infants, children or youth with complex medical and health care needs. Care coordinators such as Rashmi Tailor work with families to support development of the child, with their families maintaining the role of primary caregiver(s).

Support services â&#x20AC;&#x153;I love to help the community with the knowledge that I have so I can support them in their family life to make their life easier or better in any way possible. I am there to help them with health care related decisions. Continued on page 25

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 JUNE 2014

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Focus 15

Researchers identify new form of

inflammatory bowel disease By Caitlin McNamee-Lamb

nflammatory bowel disease (IBD), which affects more than 200,000 Canadians and is more common than multiple sclerosis and almost as prevalent as Type 1 diabetes and epilepsy, used to be known as a disease that typically developed in adolescents and young adults. However, over the past decade the medical community has seen a dramatic increase in the number of young children including infants diagnosed with a particularly severe form of the disease termed “very early onset IBD.” It is suspected that the onset of such severe IBD in especially young children may be explained by genetics. A new study led by The Hospital for Sick Children (SickKids) validates this suspicion. Researchers not only identified a gene that causes very early onset IBD, but they also uncovered a new form of the disease that has yet to be described in medical literature. The study is published in Gastroenterology. This research began with the genetic analysis of a single patient at SickKids. Dr. Yaron Avitzur, lead author of the paper, Staff Gastroenterologist and Medical Director of Intestinal Rehabilitation and Transplantation at SickKids, was caring for a baby who was born with extremely severe IBD. “The case was very unusual; not something I had ever seen before, and I couldn’t find a description of it anywhere. Diagnostic tests presented very unique features, so this really got the ball rolling to do a genetic analysis,” says Avitzur. The researchers identified a gene called TTC7A and through further investigation found that it was expressed in the bowel. “We determined that this gene is involved in a signalling network that is important in maintaining the healthy intestine. The protein it makes is supposed to bind to another protein that is very important for cell survival and proper orientation within the bowel,” says Dr. Aleixo Muise, principal investigator of the study, Co-Director of the IBD Centre and Staff Gastroenterologist and Scientist in Cell Biology at SickKids. “If this doesn’t happen, the result is a very serious intestinal disease.” After the gene was discovered in this single case, the research team connected with the interNational Early Onset Pediatric IBD Cohort Study (NEOPICS; www. NEOPICS.org) and were soon able to find four other patients with mutation in the same gene – two in Germany and two in Iran (both sibling pairs). • The IBD Centre at SickKids provides care to over 800 families with an estimated 2,000 clinic visits per year. • IBD cases represent 1,500 inpatient days per year and 300 emergency department visits per year. www.hospitalnews.com

NEOPICS is an international research group that was started by Muise in 2012. It is devoted to discovering all the genes that cause very early onset IBD to ultimately develop new treatments for all young children with IBD. “When you identify a mutation in a single patient, you can’t be fully certain that it is the causative gene, but when you have five patients with mutations in the same gene, we are much more confident that defects in this gene do, in fact, cause disease,” says Muise. “The fact that we were able to find four other patients so quickly tells me that there are more patients out there,” says Avitzur. The discovery of this gene and the description of this new form of the disease will help clinicians identify and diagnose this disease in young children around the world. The international team of investigators termed the new disease TTC7A-deficiency. Previous SickKids research into the genetic causes of very early onset IBD demonstrated that children with a different gene mutation could be treated, and cured, with a bone marrow transplant. This current study identifies a different genetic defect, and Muise explains that because this newly-identified gene is expressed in the bowel, a bone marrow transplant would not be effective for patients with this genetic alteration. “This is a prime example of the value of individualized medicine. There are unique genetic causes for what on the surface appears to be the same disease, but genetic analysis tells us that there are specific differences that will affect the way we can treat these patients,” says Muise. “A bone marrow transplant isn’t the answer for patients with the TTC7A-deficiency, but the good news is that we now know this, and are already screening existing drugs that may be able to treat this defect” This study speaks to the strength of SickKids collaborative research. “The ongoing communication between the scientists and clinicians gives us the ability to make discoveries that go from the bedside to the lab and back to bedside,” says Avitzur. “Ultimately, we are impacting children’s health, not only in Canada, but around the world.” The study demonstrates one genetic cause for one form of infantile IBD, but researchers believe that this growing knowledge on the genetic factors behind infantile IBD will not only help treat young patients, but may also provide insight into the cause of IBD in adolescents and adults. The paper was supported by CIHR, Leona M. and Harry B. Helmsley Charitable H Trust and SickKids Foundation. ■

From left: Dr Yaron Avitvur and Dr Aleixo Muise have identified a new form of IBD and the gene that causes it.

Caitlin McNamee-Lamb works in communications at The Hospital for Sick Children. JUNE 2014 HOSPITAL NEWS

16 Focus

It’s time to start using the M-word Cover story

By Tania Haas

n many ways, Marion Albaum of Toronto, 38, is your typical Canadian mom. She cheers at her son’s minor league hockey games and creates brightly coloured cakes for her daughter’s sleepover parties. Photos of anniversary dinners and birthdays plaster her Facebook page. Not pictured are the nights she spends in hospital with a feeding tube and hovering team of nurses and doctors nearby. Marion suffers from fibromyalgia and Crohn’s disease. Independently, these two conditions are debilitating. Combined, the pain can be blinding and all encompassing. Marion’s treatment history includes opioids and other prescription drugs. But when her dependence on opioids proved too destructive – she started to shake and sweat if her dose wasn’t constantly increased – her doctor suggested cannabis. Like the more than 40,000 Canadians who are legally entitled to take cannabis for ailments, and thousands more doing it under the table, Marion swears marijuana is a lifesaver. She says the herb has helped her skirt a major addiction because it’s safer and less toxic than her other pharmaceutical options. She says it makes her a functional parent, wife and friend again. Luckily for Marion, her doctor was open to considering cannabis in the context of an overall treatment strategy. Many clinicians in Canada are not comfortable discussing cannabis with patients, let alone prescribing it. Health care providers are hesitant to consider medical cannabis for a variety of reasons: conflicting information about cannabinoids in medical literature; irregular concentrations of THC (the psychoactive ingredient) or CBD (the non-psychoactive ingredient) in dosages; taking accountability for prescribing an illegal substance; the potential use of cannabis for recreational purposes; and the harm that smoking cannabis can cause. For these and other reasons, many physicians deny the medical cannabis conversation with their patients. And that’s a disservice to all, say medical cannabis advocates across the country. “These aren’t hippies getting high. These are desperate people who find life can be livable again thanks to medical cannabis. To ignore the medical properties of the plant is shortsighted,” says Dr. Arnold Shoichet, a general practitioner in B.C. and director of the medical program at the Medicinal Cannabis Resource Centre (MCRCI), a private clinic based in Vancouver. “This is a very stigmatized substance. Many physicians and associations don’t accept that there is a potential benefit to this plant. If physicians are denying access then they need to be considering how that will place their patients, especially in endof-life situations and treatments not responding to traditional medications,” says Lynda Balneaves, PhD, RN, acting associate director at the School of Nursing at the University of British Columbia. Medical cannabis advocates like Dr. Shoichet and Ms. Balneaves say they understand physician hesitancy, but to say there is not supportive evidence is incorHOSPITAL NEWS JUNE 2014

CanniMed products undergo 281 points of quality control before they are ever put on the market. This ensures products are consistent and safe. Credit: CanniMed Ltd. rect. Evidence of its benefits are seen everyday when severely ill or disabled patients are able to function again. Clinicians and researchers from McGill, Dalhousie and UBC tell Hospital News the short-term solution to the current schism in the medical community includes more funding for clinical research and increased medical education of the existing research.

This is a very stigmatized substance. Many physicians and associations don’t accept that there is a potential benefit to this plant.

Under the newest regulations, physicians and nurse practitioners are the gatekeepers to legal cannabis. “It is not sitting well with many physicians that they are now effectively prescribing a product for which they have little control – or knowledge to guide them – on the dose, concentration, and variety of cannabinoids,” says Dr. Colleen O’Connell, assistant professor at Dalhousie Faculty of Medicine and the research chief at the Stan Cassidy Centre for Rehabilitation in Fredericton, New Brunswick. That leaves patients like Kristin Nelson of Toronto, 33, unhappy and scared of

getting hooked on prescription drugs. She asked her doctor for medical cannabis to help with severe insomnia after her first pregnancy. Her doctor refused and prescribed benzodiazepine instead. Now Kristin can’t sleep without it. “I think the biggest thing for me is how easily the docs will prescribe a habit-forming pharmaceutical over medical marijuana,” says Nelson who would still like to try medical cannabis. She is waiting to be assessed by a private clinic. Recent studies show that physicians have disproportionate concerns about the addictive, psychiatric, respiratory and other health hazards of marijuana compared to what is indicated in the scientific literature. When compared to other drugs or substances like cocaine, heroin, tobacco and alcohol, marijuana ranks low in terms of dependence. “As a physician who has had the opportunity to research medical marijuana, I have a greater comfort with the products available than an average physician. When I support a patient’s prescription, that includes monitoring for effect and outcomes as well as non-pharmacologic approaches to symptom management,” says Dr. O’Connell. While doctors like Drs. Shoichet and O’Connell base their decisions to use medical cannabis on clinical and anecdotal evidence, they do so knowing that they don’t have the support of the major regulatory colleges or the Canadian Medical Association.

“What we need is this drug to be tested just as vigorously as any other new drug that comes out on the market, and for the federal government to step up to the plate and provide the funding to do those studies,” says Dr. Louis Hugo Francescutti, president, CMA. “If the evidence is there, then I don’t think the profession would have any problems getting behind it. Doctors are not very keen to prescribe with a blindfold on.” Dr. Mark Ware says it’s time to take the blindfold off and quit standing at the sidelines. Dr. Ware, a practising pain physician at the McGill University Health Centre, researches the safety and effectiveness of medicines derived from cannabis (cannabinoids). He hopes to enhance research and medical education through the nonprofit Canadian Consortium for the Investigation of Cannabinoids (CCIC). “Bottom line, physicians and clinicians need to engage in this process so we can help shape it, so it can be what we want it to be,” says Dr. Ware. “We need to figure out together what is the best way to provide it to suitable patients at a reasonable cost with good quality control and sensible balance between risk and benefit.” He says one way to increase research is to demand support from the newly licensed medical cannabis distributors. “They are now the ‘new pharmaceutical industry’, so I believe they have an obligation to fund research,” says Dr. Ware. “It may be difficult to see multiple large scale phase 3 clinical trials in the next five to 10 www.hospitalnews.com

Cover Story 17

Photo, CanniMed Ltd.

years. But we are operating with limited evidence and growing clinical need. They can fund helpful studies now.” At least one medical cannabis producer has stepped up to the challenge with a study focused on osteoarthritis. Prairie Plant Systems announced in May 2014 that Health Canada has formally approved a clinical trial application for a randomized, double blind, placebo controlled, proof-of-concept, crossover clinical trial of vapourized cannabis in adults with painful osteoarthritis of the knee. This clinical trial is the first to be registered with Health Canada after the transition to the new Marihuana for Medical Purposes Regulations (MMPR). Dr. O’Connell would like to see studies identify which cannabinoids, and in what concentration are beneficial for what conditions. “Physicians and nurse practitioners are hesitant, as unlike any other medication, there is no basis on which to inform on dose and concentration,” Dr. O’Connell says. Other areas needing further study include testing clean delivery systems where the dosing is easier to control and determining the upper limits if there are any. Clinicians also need more guidance on understanding how the Endocannabinoid System functions and how to better screen patients for therapeutic use. “We don’t know all the risks yet, and we are working on it. But every day, we prescribe federally approved pharmaceuticals that have significant risks, including www.hospitalnews.com

death,” says Dr. Shoichet. “There’s never been a death attributed to the use of cannabis and that can’t be said for any other drug I’ve prescribed.” Studies have already shown a reasonable proof of concept, says Dr. Ware. Cannabis helps patients with nausea, spasticity, mood disorders, and appetite loss to name a few. Whether that evidence base is sufficient for a professional is often a matter of medical judgment. Western University’s Dr. Richard McLachlan, professor of neurology, is currently investigating the usage of marijuana among epilepsy patients and recording their observed benefits and any adverse effects. He turned to research after more of his patients were asking for him to help them obtain it legally. “In the 19th century, cannabis was one of the few treatments for epilepsy thought to be effective. There are a number of studies of animal models of epilepsy done before 1980, which give support to the possible use of cannabinoids to control seizures and some that indicated it might make seizures worse. There are few studies after 1980 and none in patients because, as far as I can tell, authorities made it too difficult to carry out such research,” says Dr. McLachlan. Under Health Canada’s current restrictions, there’s a lot of experimentation – just like with other types of medications. “Some strains made me paranoid or didn’t help with the pain,” says Marion. “Once I find the right strain with the right combination of cannabinoids, I buy as much as I can.” “I was a bit apprehensive at first,” says Gloria Kabele, 60, of White Rock, B.C. who was diagnosed with multiple sclerosis at 42 years old. She says it helps her with sleep problems but not the spasticity. “My doctor was supportive and completed the referral form I needed,” says Kabele. “My neurologist was not as supportive.” A handful of physicians and medical entrepreneurs in Canada are hoping hesitant health care providers, like Gloria’s neurologist, will refer patients to them, rather than closing the door on cannabis treatment entirely. Specialty clinics like the Cannabinoid Medical Clinic, which is set to open this summer in north Toronto. The clinic’s physicians will see patients on a referral basis to evaluate them for suitability for cannabinoid therapy in its various forms. “We will work closely with the CCIC to ensure that we are providing proper screening, proper guidance, and follow up after one or two weeks, and then again after three months. The goal is to attain the desired outcome: increased mobility, return to work or reduced opioid usage,” says Dr. Danial Schecter, a Georgian Bay, Ontario based general practitioner and co-founder of the clinic. Dr. Schecter, and others in this burgeoning field, say he is filling a much-needed void. Until cannabinoid knowledge is integrated into general medicine, clinicians can make patient referrals to experts like him. From a harm-reduction perspective, it’s the best approach since patients are using the substance regardless. He says the clinic’s strategy includes establishing the standard of care in cannabinoid medicine and increasing medical education. “We will send letters back to the referral physician so they will understand who we choose, which products we recommend and which side effects to expect,” says Dr.

Schecter. “Hopefully, after they send four or five patients, they will get more comfortable prescribing for pain therapy or palliative care.” Dr. Schecter would like to see cannabinoid integrated in general medicine just like opioid and cholesterol treatment. His goal is to help further the notion that medical cannabis be considered a viable alternative to established treatments. Another specialty clinic is the MCRCI, which has been in practice in British Columbia since 2010. It’s a private organization that accepts applications from patients anywhere in Canada (in person or via telemedicine) and charges a fee to cover operating costs. If the patient’s health needs are in line with medical requirements, the centre helps the patient access the medical cannabis. MCRCI has plans to open more clinics in Halifax, Montreal, Calgary and Edmonton in the coming years.

“Every day, we prescribe federally approved pharmaceuticals that have significant risks, including death,” says Dr. Shoichet. “There’s never been a death attributed to the use of cannabis and that can’t be said for any other drug I’ve prescribed.” Dr. Shoichet works to foster awareness for cannabinoid therapy among those professionals who are more reluctant or less informed. He does this through MCRCI. He also founded Practitioners for Medicinal Cannabis (PMC) a network of specialists and general practitioners committed to fostering professional awareness of all aspects of cannabis in patient care. He says the first step to more knowledge is repealing prohibition – if only for the scientific and medical communities. When it’s legal, he says, scientific understanding will accelerate. Price inflation is another challenge facing Canadian patients. The cost of growing cannabis is around one or two dollars a gram. The current market cost is around

six or 12 dollars a gram – which puts it out of the budget of many. Under the initial regulations, patients were allowed to grow their own plants or have someone else grow it for them, which was a more economical option for many. But now only licensed distributors can grow. Clinicians say the product is now safer, standardized, and independently tested in lab for mold, residue or pesticides. But the price is certainly a negative factor for many patients. Marion spends around $70 every three weeks. It’s not covered by her insurance. “There are a lot of other out-of-pocket expenses like my feeding tube supplies. The cost adds up. It would be nice if it were covered,” says Marion. Another inconvenience is access. When her supply runs out, she can’t just drive up to the nearest pharmacy. She has to wait for a licensed distributor to deliver, which can take days. What’s needed, says another medical researcher, is a shift in perspective. “I’ve seen doctors jokingly refer to it as reefer madness. The humor disrespects the serious medicine that it is,” says Balneaves who is the principal investigator of a cannabis access regulations study. “And this humor transfers over to funding bodies.” Balneaves wants more human-level studies with the whole plant and better education for physicians and nurse practitioners. Marion continues to smoke her medicine but is considering a vaporizer. When it’s time for a dose, her children know that she needs privacy. She doesn’t like promoting the use of it. It is, after all, still a street drug, and not even endorsed by Health Canada. An estimated 1.5 million Canadians have a criminal record for using, selling or growing marijuana. “The role of this drug in society, be it medical, recreational or criminal will only be determined by allowing unbiased research to find the answer,” says Dr. McLachlan. So behind closed doors, Marion inhales. Her pain subsides, if only for a while. And in those pain-free moments she can return H to being a normal mom again. ■ Tania Haas is a freelance journalist. www.taniahaas.com Cover photo courtesy of CanniMed Ltd.

Photo, CanniMed Ltd.

The trichomes on the surface of medical marijuana are visible when viewed under a microscope. This is the area of the plant where medically active cannabinoids are produced. JUNE 2014 HOSPITAL NEWS

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ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

Paediatric Services at Windsor Regional Hospital By Ron Foster

he history of Paediatric Services has been evolving over the last many decades in Windsor/Essex, the service being located at three different hospital facilities until a mandated site was recommended by a Steering Committee Report in a 1998 by the Health Services Restructuring Commission stating that all Women’s and Children’s Services were to be located at the Met Campus of Windsor Regional Hospital. Once construction had been completed, expanding the square footage required to accommodate Paediatric Services, it relocated in 2005, opening a 33-bed inpatient unit and a vibrant outpatient unit. A wide variety of children with diagnoses ranging from medical, surgical, oncology to mental health issues are assessed and cared for with some of the most common diagnoses being neonatal jaundice, bronchiolitis, asthma and gastroenteritis. The multidisciplinary team of professionals including registered nurses, paediatricians and other specialists, social workers, respiratory therapists, physiotherapists, occupational therapists, child life specialists, other allied health professionals and dedicated volunteers, all providing a progressive treatment plan toward wellness. Outpatient services make up more than 85 per cent of total paediatric volumes, focused on the day-to-day needs such as surgery, medical day care, oncology satellite unit, asthma, cystic fibrosis, hemophilia and metabolic clinics. Outpatient surgery is performed on children from newborns up to their eighteenth birthday. The most common surgeries are tonsillectomies, adenoidectomies, myringotomies, hernia repairs and dental surgery. A unique feature within the program is a visual concept known as Surgical Safari, a pre-op tour with the child and parents to help reduce the anxieties of having to undergo surgery. When Paediatric Services re-located to Windsor Regional Hospital, a new progressive view of service had been planned which included the addition of Child Life Services, a team of specialists who assist to reduce stress and anxiety that is often associated with hospital visits. They provide music therapy, art therapy and therapeutic play opportunities to assist with preparation for procedures. Using cloth dolls, medical play kits and real medical equipment, children are able to play through their experiences, expressing emotions and relieving misconceptions. Through these avenues, children are provided with a sense of normalcy and control within an unfamiliar environment. Families support and participate as it helps with their level of anxiety as well. In 2007, the service began functioning as a Clinical Teaching Unit (CTU), part of the Southwestern Ontario Medical Education Network (SWOMEN) which was an extension of the Schulich School of Medicine and Dentistry at the University of Western Ontario and now with a direct relationship with the Schulich School at the University of Windsor. A realization evolved with children arriving at emergency departments that showed the hospital was not child friendly. HOSPITAL NEWS JUNE 2014

Child Life Services, provides a team of specialists who assist to reduce stress and anxiety that is often associated with hospital visits. Sick and frightened children endure the same long wait times and share crowded waiting rooms with sick adults. Embracing the Windsor Regional Hospital vision of Outstanding Care – No Exceptions, the team got to work to create a system where sick children can access specialized Paediatric care in a timely manner. The ini-

tiation of an Emergency Medical Paediatric Program (EMPP) is a first step towards meeting the goal. Children who present in the emergency department with respiratory or gastrointestinal problems, dehydration and/or fever are triaged and sent directly from the ER to Paediatric Services. There, a Paediatrician assesses the child within 30

minutes of their arrival on the Paediatric Unit. Following assessment, the child is treated and released and/or admitted to Paediatric Short Stay Unit for observation or to the Paediatric inpatient unit for further treatment and investigations. The EMPP operates Monday through Friday from 0900h to 1600h with a long term goal to offer the service to families on a 24/7 basis and to expand the scope to include children triaged as CTAS 2 with identified conditions. Through the trial, 348 children were seen through the program with up to 75 per cent of the children assessed, treated and discharged home within four hours. The remaining 25 per cent were admitted to Paediatric Short Stay or the Paediatric Inpatient unit for further treatment and observation. As Windsor/Essex plans for a single site acute care hospital for the future, one of the objectives is to research and educate ourselves and the community about what Paediatric Services should consist of in the next decade and beyond to continue to H serve children requiring hospital care. ■ Ron Foster is Vice President, Public Affairs, Communications and Philanthropy at Windsor Regional Hospital.

New tool helps diagnose lung cancer without surgery By Lauren Pelley

racing for a potential cancer diagnosis is scary enough. Knowing you have to undergo surgery to gain that diagnosis makes it even worse. At St. Joe’s, a special diagnostic tool is now in use to help patients with potential lung cancer avoid surgery, get answers faster, and begin treatment sooner if needed. It’s called an EBUS – or Endo-Bronchial Ultrasound. “The EBUS machine allows us to biopsy lymph nodes from within the airway,” says Dr. Chris Compeau, Chief of Surgery at St. Joe’s. The EBUS uses an ultrasound probe and a needle to do the work, he explains. “It’s less invasive,” adds respiratory therapist Kyle Davies. “So there’s less risk for infection, and less risk of extra complications.” Having an EBUS at our disposal is a big boost for patient care at St. Joe’s. Lung cancer remains a serious problem, notes Dr. Compeau, adding it’s the number one cancer killer in both men and women in Ontario over the age of 50. “(The EBUS) is something that we recognize is going to enhance the care to our patients,” he says. We can also thank many of our patients for helping bring this tool to the Health Centre. Over 70 patients

Respiratory Therapist Kyle Davies (far left) and Dr. Chris Compeau (far right) use the EBUS device on a patient at St. Joseph's Health Centre, Toronto. helped raise $265,000 last year to purchase the device. They worked in conjunction with the St. Joseph’s Health Centre Foundation and our thoracic team comprised of Dr. Compeau, Dr. Maurice Blitz, Dr. Michael Ko, and many dedicated respirologists and staff. “This success shows what we can do when we partner with our staff and physicians to improve care for our patients, and how meaningful it is for grateful patients to say thank you by

making a gift to St. Joe's,” notes Maria Dyck, Foundation President. “It really has been an eye-opening experience to me to see how incredibly generous our donors have been – our patients and their families,” adds Dr. Compeau. “I think it speaks to their gratitude for St. Joe’s for what the H Health Centre has provided them.” ■ Lauren Pelley is a Junior Associate in the communications department at St. Joseph’s Health Centre, Toronto. www.hospitalnews.com

Nursing Pulse 19

Inspired lives By Daniel Punch

diagnosis of cancer is traumatic for individuals and their families. Imagine a scenario in which both parents get crushing news they will face the fight of their lives, at the same time. The Ryalls live with this reality, and have found inspiration in their children. Amanda Ellard-Ryall’s voice wavers as she and her husband, Francis, discuss the “gift” of cancer. “I do see cancer as a gift, because I can say I know the extra freckles on my kids’ faces. I see the changes in their eyes. I see the added colour.” She pauses, swallows, and then continues, her voice jumping an octave. “It’s not that I want everyone to get cancer, but sometimes…you have to look at (what) it does give you. Because it does make you stand still for that moment, it does make you breathe, and in that breath, you see the things you’ve never seen before.” It’s impossible not to feel inspired after a conversation with these irrepressible Windsor-based RNs standing brave in the face of overwhelming challenges. Francis was diagnosed with bowel cancer in 2011, which later spread to his liver. Three years, three surgeries and three rounds of chemotherapy later, his prognosis is not good. In 2013, Amanda was stunned to learn she had breast cancer. She’s since had a double mastectomy and been through chemo. While the outlook is hopeful, she’s not out of the woods yet. The couple must now juggle their illnesses, a growing stack of bills, and four kids under the age of 10. Yet they remain upbeat. Buoyed by a loving family and a supportive community, they have a remarkable perspective on the illness that forever altered their lives. “I’m sad this disease has gotten ahold of me. But that said, it doesn’t define who I am,” Francis says. “My wife and children have much more to do with that.” Friends call them the calm and the storm, with Francis’ laid-back, steady nature balancing perfectly with Amanda’s type-A assertiveness. They’ve always had plenty in common. They’re both RNs, both teachers (at St. Clair College), and both Irish. Amanda immigrated to Canada as a young nanny, and Francis was born in Saskatchewan to first-generation Irish parents. The pair met in Windsor two decades ago, wed in Ireland, and then moved to Texas, where she practised on a neonatal helicopter team and he in an emergency department. They eventually worked their way back to Windsor, where Amanda returned to school and Francis landed a job across the border at the Henry Ford Hospital in Michigan. They struggled for eight years to get pregnant, spending a fortune on costly fertility treatments with no success. Nine years ago, they jumped at the opportunity to adopt Molly from an international student at the University of Windsor. “She changed everything for us,” Amanda says. “It…was love at first sight.” Two years later, Amanda gave birth to www.hospitalnews.com

twin boys. And in 2008, just as she was starting her master’s degree, the couple was surprised by news they were expecting again. The newly whole, six-member Ryall family was settling into life when they were rocked by news that Francis had a tumour in his large intestine. “Your whole world crashes in that one moment,” Amanda remembers. Francis could no longer work, Amanda was still in school, and life wasn’t about to slow down with four young kids at home. Still, they managed to keep their heads above water.

It’s not that I want everyone to get cancer, but sometimes… you have to look at (what) it does give you.

Amanda found work at the WindsorEssex County Health Unit (WECHU) and served as Francis’ unofficial nurse. With Amanda’s diagnosis in 2013, the couple that did everything together was forced to take on their most difficult journey side-by-side. After spending two years taking care of Francis, an exhausted Amanda reluctantly let her husband return the favour. “For a woman, it’s hard to have no hair, it’s hard to lose breasts, it’s hard to look different

and try to be the same mom,” she says. It was also difficult explaining matters of life, death and cancer to their kids. Amanda remembers the moment last year when Molly, now nine, realized her dad probably won’t be around when she grows up. Their seven-year-old twin boys, Killian and Quinn, think it’s “cool” that mom is bald. And when Amanda told five-yearold Kiera about mommy’s cancer, their youngest gave her mom a big hug and said: “You’re the best mommy ever…can I have blueberries on my pancakes?” The Ryalls have been humbled by the support of the nursing community during these trying times. Francis still can’t work, and although Amanda has finished chemo and returns to work in June, expenses are mounting. “I just can’t imagine worrying about finances (in their situation),” says Dana Boyd, Amanda’s colleague at WECHU, and a member of the executive for the Windsor-Essex chapter of the Registered Nurses’ Association of Ontario (RNAO). “We know, as nurses, that you’re supposed to reduce your stress to promote healing.” Boyd and the Windsor-Essex chapter raised about $5,500 at a pasta fundraiser in March, and many of Amanda’s WECHU colleagues gifted their sick days to her in a bid to supplement her disability income. Support has also come from the community-at-large. Two events over the winter raised more than $15,000. Friends and neighbours donated Christmas presents, shoveled their driveway during a particularly difficult winter season, and stopped by to drop off dinners. “It’s heartwarming, it’s overwhelming, it’s soul-saving,” says Fran-

cis. “Our community has stepped up and wrapped a blanket around us.” The future remains uncertain for the Ryalls. Francis is likely facing his fourth round of chemo, after a recent scan revealed several new tumours. Yet the news hasn’t slowed them down. They continue to live their lives to the fullest, determined to make memories with their children. “It’s better to live every day until you die, instead of dying every day until you die,” Francis says. “Do everything in your ability and do what you want, and what I want to do is get up in the morning and cook (my family) breakfast.” While cancer can seem to be “ticking like a time bomb,” Amanda is spurred by the words of her father, a Sgt.- Maj. in the British Royal Air Force. “Live by the belly,” and “press on regardless,” he would say. Together, the calm and the storm press on, ready for bad weather, but always lookH ing toward the sun. ■ Daniel Punch is editorial assistant for the Registered Nurses’ Association of Ontario (RNAO), the professional association representing registered nurses in Ontario. For more information, visit www.RNAO.ca

Donations to the Ryall family can be made through TD Canada Trust, Transit #38702, Institution #004, Account #6063429

Reduced-rate RNAO membership lets you sample our professional offerings at a special low rate of $50 + HST. Try the award-winning Registered Nurse Journal, the Canadian Nurse a publication of the Canadian Nurses Association, essential email updates, educational resources, group rate savings on home and auto insurance, advocacy that speaks out for nursing.…and more. Yes, even at this low rate, you will receive memberships to the Canadian Nurses Association, the International Council of Nurses and also be eligible for professional liability protection (PLP) through the Canadian Nurses Protective Society (CNPS). We know you’ll love being part of the RNAO family enough to sign on again in November 2014.

For details and to sign up: www.RNAO.ca/tryRNAO or call 1-800-268-7199

For $50 (+ HST = $56.50), membership is available to lapsed and new members through to October 31, 2014.

JUNE 2014 HOSPITAL NEWS

20 Focus

ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

Tool being developed to help prevent

patient-on-staff violence By Era Mae Ferron new tool is being created in Ontario to assess workplace environments within mental health facilities to help prevent patient-on-staff violence. The Public Services Health & Safety Association (PSHSA) has partnered with the Ontario Shores Centre for Mental Health Sciences, a health-care facility, and the Institute for Work & Health (IWH), a research organization, to create and pilot the Clinical Practice Assessment Tool (CPAT). This self-report survey asks caregivers to asses work environment factors associated with the prevention of patienton-staff violence in mental health care units or facilities.

Why the tool is necessary Workplace violence when employees are abused threatened or assaulted in circumstances related to their job is a fact of life in Ontario’s health care facilities. Research shows health care professionals are at higher risk of workplace violence than other service providers such as police officers, prison guards and bank personnel. Patient-on-staff violence in health care is particularly a problem in mental health units and facilities. Ontario’s Workplace Safety and Insurance Board reported in 2012 that violence accounted for 37 per cent of lost-time injuries in psychiatric hospitals. Other research shows that psychiatric nurses report the highest rates of violent events among all nurses. Indeed, a study of psychiatric departments in Minnesota found a two-fold greater risk of violent events compared to nurses in other departments. Patient-on-staff violence is not limited to nurses within mental health-care facilities. In one study of physiotherapists working in mental health care, 51 per cent reported being assaulted at work during their career, and 24 per cent reported being assaulted in the previous year. Victims of workplace violence may suffer from minor, sustained or life-endangering injuries. Beyond physical pain, many victims live with debilitating residual emotional and psychological effects, such as post-traumatic stress disorder. In addition, staff victimization has negative repercussions for an organization’s delivery of quality care, including decreased staff productivity, impaired job performance and increased errors. Contrary to what some believe, patienton-staff violence is not “part of the job” in health care and, in particular, mental health care. Many organizations, such as the Canadian Nurses Association and Canadian Federation of Nurses Union, promote “zero tolerance” of any type of violence. Actions at all levels – organizational to individual – must be taken to effectively address patient-on-staff violence at work. To that end, health care organizations HOSPITAL NEWS JUNE 2014

Figure A. Timeline of focus groups with sample size need scientifically credible tools to assess the conditions of their clinical environments to make appropriate and effective changes that will protect staff from violence at the hands of patients.

How the tool was developed This is where the development of the Clinical Practice Assessment Tool comes in. Through a self-report survey, CPAT asks caregivers in mental health care units or facilities to assess work environment factors that may prevent patient-on-staff violence. The survey as it was initially conceived asked questions in seven areas: 1. Leadership commitment 2. Support for violence prevention programs 3. Environmental supports for staff safety 4. Staff development 5. Client (i.e., patient) admission/transfer and assessment for violence and aggression risk 6. Client engagement

7. Client care and communication The partners developing the tool conducted five focus groups between September 2013 and April 2014 (see figure A) with experts in workplace violence and frontline staff from Ontario Shores. The aim was to get their feedback on the tool. Through the feedback, the partners learned the following: (1) Several questions implied that staff members were to blame for violent patients. (2) Several questions were ambiguous or not relevant to patient-on-staff violence. (3) Questions were missing about the effectiveness of education and training programs, interdisciplinary teamwork, the debriefing process and whether or not staff felt safe. (4) The client care and communication section was not relevant. These findings resulted in revisions to the CPAT for caregivers. Overall, the experts and staff taking part in the focus groups felt that the CPAT for caregivers is an important tool that can help keep staff safe in mental health care units

and facilities, with the potential for the tool to be used in other health care sectors as well. The caregiver CPAT is now ready for further testing in the workplace to ensure its validity and reliability. Hospitals and health care professionals strive to provide patients with the highest quality care. Quality care is not just limited to clinical indicators; it also includes the quality of the work environment. If health care professionals are not safe at work, they cannot do their jobs successfully, ultimately affecting the care patients receive. CPAT has the potential to be an effective tool that health care leaders can use to provide staff H with healthy and safe work environments. ■ Era Mae Ferron, RN, PhD is a project coordinator at the Institute for Work & Health in Toronto and a member of the research team developing the Clinical Practice Assessment Tool. To keep up on IWH research, go to www.iwh.on.ca/ e-alerts

Planting seeds, improving breast care By Dahlia Reich

he planting of tiny seeds is sprouting some big results for breast care patients at St. Joseph’s Hospital in London. The radioactive seeds, which have very low radioactivity, are reducing the wait for breast cancer surgery. Before breast care patients undergo surgery for a biopsy or to remove a tumor, a radiologist locates the tumor so that the surgeon knows exactly where to operate, explains Dr. Anat Kornecki, Medical Director, Breast Imaging, St. Joseph’s Breast Care Program. “Traditionally, this has been done by marking the spot with a wire that is inserted into the breast. Patients must have the wire localization done the same day as the surgery or the afternoon prior and surgeries have to be carefully scheduled around this procedure.” In the fall, the Breast Care Program began trialing the use of radioactive seeds called I-125 seeds. These tiny seeds, no bigger than a caraway seed, replace the wire. The amount of radiation absorbed by each patient from the radioactive seeds is less than what is in

The use of tiny radioactive seeds, called I-125 seeds, by the Breast Care Program team at St. Joseph's Hospital in London replace the use of a wire to mark the spot of a tumour so that the surgeon knows exactly where to operate. This photo is of unused, unsterilized seeds. their environment (e.g. soil, atmosphere). “The tiny capsules contain a small amount of radioactive material and can be implanted up to two weeks in advance of the surgery,” says breast surgeon Dr.

Leslie Scott. “This allows for greater flexibility in scheduling surgeries and therefore increased access for breast cancer patients. During the operation, the surgeon locates the seed using a hand held probe.” With the success of the pilot, the seeds are now being used by five of the six breast surgeons and about 85 per cent of patients undergoing a biopsy or breast cancer surgery. It’s hoped use of the seeds will be expanded further. At the same time, St. Joseph’s has begun using a “digital specimen radiography system” in the operating room, says Dr. Kornecki. The system is a type of digital x-ray machine used to image the specimen to see whether the edges of the biopsy are visibly clear of the cancer. With the system located in the operating room, specimens can now be imaged on the spot, eliminating the need to bring them to radiology. This also enhances efficiency and contributes to improved access and shorter H wait times for patients. ■ Dahlia Reich works in Communications & Public Affairs at St. Joseph's Health Care, London. www.hospitalnews.com

Ethics 21

Should there be an age cut-off for publicly-funded chemotherapy? By Jonathan Breslin, PhD

n late April of this year Kimm Fletcher, 41 year-old mother of two from Milton, passed away after a battle with glioblastoma multiforme, a particularly aggressive form of brain cancer. Ms. Fletcher made headlines last fall for being the most recent heart-wrenching story of an Ontario citizen who tried (unsuccessfully) to petition the Ontario government to cover the cost of her chemotherapy. These stories are becoming more common because many new chemotherapeutic drugs are extremely expensive. According to the Ontario Ministry of Health and Long Term Careâ&#x20AC;&#x2122;s Committee to Evaluate Drugs (CED), Avastin, the treatment that was the subject of Ms. Fletcherâ&#x20AC;&#x2122;s petition, costs $35,000 per patient for nine cycles of treatment. Torisel, a treatment for metastatic kidney cancer, costs $5,000 per month per patient. Vidaza, a treatment for myelodysplastic syndrome, can cost up to $60,000 for a full 10 cycles of treatment per patient. What these numbers donâ&#x20AC;&#x2122;t include are the additional costs associated with cancer treatments: other medications to treat symptoms, hospital visits, home care, and so on.

cer Drugs (OSCCD), which provides recommendations to the CED. Perhaps an easier way to make these decisions would be to have an age cut-off, beyond which nobody would be entitled to coverage for expensive chemotherapy. This was suggested in a recent news story by Dr. Karol Sikora, a British cancer specialist and former head of the cancer program at the World Health Organization. While he denied that there should be a rigid cut-off, he did suggest that age

should be taken into consideration when making funding decisions about expensive chemotherapies. The problem with the proposal is that there is no way to â&#x20AC;&#x153;take age into considerationâ&#x20AC;? without it becoming arbitrary and discriminatory. It sounds reasonable at the extremes: if given a choice between expensive chemotherapy for a 90 year-old and expensive chemotherapy for a 10 year-old, most people would prefer that the drugs be given to the 10 year-old. But this is an

artificial choice that in no way reflects the reality of drug funding decisions. The choice becomes much more difficult when comparing people closer in age because age alone becomes less and less relevant as a criterion to determine potential benefit when we move away from the extremes. What matters ethically is that there is sufficient potential benefit to justify the cost of the treatment; and age, on its own, has no direct bearing on potential benefit in H the vast majority of cases. â&#x2013;

â&#x20AC;&#x153; Focus on the things you can do, not ZKDW \RX FDQĂ&#x2013;W DQG \RX ZLOO Ă&#x;QG just like I did, that life is fantastic.â&#x20AC;? â&#x20AC;&#x201C; Danny McCoy

If the Ministry of Health had to cover the cost of all chemotherapies for every cancer patient in the province it would eat up a large a portion of the health care budget. A recent study published in CMAJ Open looked at the costs of treatment in Ontario within the first year of diagnosis for seven major cancers diagnosed between 1997 and 2007. Costs included chemotherapy, radiotherapy, cancer-related surgery, home care, and other admissions to hospital. The study found that the mean costs per patient during the study period have doubled for breast and colorectal cancers and nearly tripled for melanoma. If the Ministry of Health had to cover the cost of all chemotherapies for every cancer patient in the province it would eat up a large a portion of the health care budget. Enter the ethical issue of rationing: if the government canâ&#x20AC;&#x2122;t pay for every patientâ&#x20AC;&#x2122;s cancer treatment, who should be covered and how should those decisions be made? The process in Ontario is that the CED, an independent expert advisory committee comprised of various clinicians, an economist, and patient representatives, makes recommendations to the Executive Officer about which drugs should be covered. The CED examines all the available evidence related to a particular drug (impact on survival, quality of life, and side effects) and makes a judgment about whether the drug provides sufficient value for money. Information about the CED, including its membership and recommendations, are publicly available on the Ministry of Healthâ&#x20AC;&#x2122;s website. In 2013 a more specialized committee was developed to evaluate cancer drugs, called the Ontario Steering Committee on Canwww.hospitalnews.com

Danny McCoy was rendered a paraplegic in a terrible car accident at the age of 43. Before the accident he was an avid sailor. After the accident, Danny became one of the top ranked competitive disabled sailors in the world. Heâ&#x20AC;&#x2122;s also the founder of the Disabled Sailing Association of Ontario and one of the sportâ&#x20AC;&#x2122;s foremost international ambassadors. Thomson, Rogers is a proud supporter of The Disabled Sailing Association of Ontario. We are honoured to have represented Danny McCoy in his lawsuit and to count Danny as a friend and one of the many everyday heroes we have been able to help.

YOUR ADVANTAGE, in and out of the courtroom

416-868-3100 | 1-888-223-0448 www.thomsonrogers.com JUNE 2014 HOSPITAL NEWS

22 Ontario Votes

Like so many families throughout Ontario, my own has had to rely on our public health care system and I’ve been awed by the compassion and care we received from the nurses, doctors and other health care professionals on the front line. I am very grateful. And I am resolved to ensure future generations can count on this same high quality of care. Nothing threatens our publicly funded health care system more than Ontario’s debt. For too long, politicians have pretended we can keep spending money we don’t have and it will never impact the quality of care we receive. The larger Ontario’s debt becomes, the more money we are forced to pay in interest and the less money is left to hire nurses, purchase MRIs or afford cutting-edge medication that Ontario patients need. That is why our Million Jobs Plan is committed to balancing Ontario’s budget while protecting health care funding, and protecting the number of nurses and doctors providing frontline care. By balancing the budget and creating more jobs we will put our front-line health care services on a stable, sustainable footing so that our children and grandchildren will have access to the same health care system that we count on today. Each new job we create will, in turn, provide additional revenue that helps us hire more nurses, invest in new medical equipment and improve patient care. I have also long believed that decisions affecting your family’s care are best made by health care professionals, not anonymous health care bureaucrats who have never seen a patient. We think your nurses, doctors, community care organizations and hospitals know best what care is needed. Our plan will also put a new focus on treating chronic diseases as the leading health challenge of our time. Diabetes, heart disease or Alzheimer’s cannot be treated by a single trip to the hospital. Instead, we will ensure all of the doctors and nurses caring for people with serious chronic conditions work together on long-term comprehensive plans guided by compassion and common sense. We will also move health closer to home by expanding access to home care and long-term care for seniors or people suffering from long-term illnesses. We want seniors to live healthy and fulfilled lives and that includes allowing them to stay in their own homes as long as they can. Additionally, we will update the scope of practice for pharmacists, nurse practitioners and other professionals. This will allow treatment where it is most convenient and beneficial for patients. Our plan will make mental health care a priority. For too long mental health has been an afterthought in our health care system. A mental illness is as much a health care issue as an illness anywhere else in the body. We will take the fragmented services now offered and replace them with a comprehensive approach to help some of our most vulnerable citizens. And our plan will help keep our children active. Children should get at least 45 minutes of physical activity every weekday, whether through schoolbased activities or after-school sports. Active kids are healthier, happier and do better in schools. Active healthy kids also usually become active healthy adults which will reduce the strain on our health care system. Ontario’s world class health care system was built on a foundation of looking to the future while making smart, responsible choices today. I want to ensure the high-quality publicly funded health care system that was there for our parents and is there for us, will also be there for our children. That’s what our Million Jobs Plan will do. Sincerely,

Dear health care workers on the front lines: I am writing today to thank you for your incredible dedication to the people of Ontario. Without your hard work, passion and talents, there would be no one to care for our loved ones when they are ill and at their most disadvantaged. Our system has, no doubt, improved in the past decade but I and the Green Party of Ontario believe we can support you further in your mission to improve the quality of life for all Ontarians. Our current infrastructure is not meeting the needs of patients. Hospitals in the Scarborough area have operating rooms that were built in the 50s. Without appropriate investments, these operating rooms cannot be renovated and equipped with the technologies demanded by today’s advanced procedures. Rather than shunting money towards brand new brick and mortar structures, the Green Party of Ontario advocates that we revitalize the hospitals that we currently have in order to provide patients with the advanced procedures they require in their own communities. Similarly, we need to invest in the front line workers that staff these hospitals. There are hospitals across Ontario that are not functioning at full capacity. They are closing emergency rooms, operating rooms and beds due to staffing shortages. If we want to tackle wait times for important diagnostic investigations and procedures, we need to staff our hospitals appropriately. Ontario has a wealth of underemployed and highly trained nurses, physicians and allied health professionals that should be put to better use. The Green Party of Ontario wants to increase health care staffing to increase the efficiency of our health care system. While we can improve upon our existing hospitals, we do need to create a significant number of nursing home beds in the next 10 years. Many patients that occupy beds in expensive ($1000+) acute care hospital beds no longer require acute medical or surgical care. The elderly and disabled are often stranded because their families cannot safely care for them at home and there are no available public nursing home or rehab beds. They exist in a purgatory devoid of the comforts of home and the appropriate rehab they require to convalesce appropriately. Over time, they develop complications related to their prolonged hospital stays (e.g. nosocomial infections, DVTs and PEs, pressure ulcers) which can lead to both increased morbidity and mortality. The Green Party of Ontario supports the doubling of nursing home beds in the next 10 years. These beds will allow our elderly to convalesce while freeing up acute care beds for those waiting for admission to a medical or surgical bed. While we prepare for a dramatic increase in our elderly, we also need to implement strategies that will promote health and prevent illness. The Green Party of Ontario proposes a Guaranteed Annual Income to eradicate poverty in Ontario. By offering people a livable wage from the outset, our poor will be able to afford food, shelter, childcare and an education. They will raise themselves out of poverty and bring with them, successive generations. As their socioeconomic status rises, the risk of obesity, medical and mental health conditions, addictions and crime/abuse fall. The moral and financial rewards will be outstanding. The Green Party of Ontario believes that a better health care system is on the horizon and with your help, we can make that happen sooner rather than later. Sincerely, Mike Schreiner Leader of the Green Party of Ontario Ontario Green Party Candidate – Guelph

Christine Elliott Deputy Leader, Ontario PC Party Ontario PC Critic for Health and Long-Term Care Ontario PC Candidate- Whitby-Oshawa

HOSPITAL NEWS JUNE 2014

www.hospitalnews.com

Ontario Votes 23

The Ontario Liberal Party is the only party with a plan for health care. We’re ensuring families get the right care, in the right place, at the right time to create a sustainable system for generations to come. Since 2003, Ontario Liberals have worked with our health care partners to build a quality health care system for all. We understand the critical role our hospitals and health care professionals play each day in the lives of Ontarians. That’s why we have hired 20,500 more nurses and 4,910 new doctors, while increasing hospital funding by more than 50 percent. By working together, Ontario now has the shortest surgical wait times in Canada and 2.1 million more Ontarians have a family doctor. These achievements are a testament to the dedicated, passionate, and hard-working health care professionals across Ontario. We know there is much more to do and we will continue to build on the gains we have made by working together. If re-elected, we will provide a primary care guarantee to every Ontarian, invest $270 million more in home and community care, provide better mental health supports, and develop a strategy to help more patients receive their end-of-life care at home. Our health care professionals are the foundation of our health care system and we value the tremendous contribution they make to our province each day. That’s why our plan will also increase wages for Personal Support Workers and expand the roles and responsibilities of nurses. Our publicly funded hospitals are centres of excellence and provide high quality, timely care to Ontarians when they need it most. Our plan will invest over $11.4 billion in hospital expansions over the next 10 years, while continuing to bring down wait times in key areas of health services. We are also committed to capping parking fees for those who must visit our hospitals frequently. We are determined to make Ontario the healthiest place in North America to grow up and grow old. Unfortunately, the NDP and the PCs rejected all of these measures when they said no to the Liberal Plan and voted against the budget. The Hudak PC proposal to slash 100,000 jobs would put Ontario’s economy at risk and plunge the province back into a recession. Fewer people at work will result in less money invested back into the economy, leading to thousands of layoffs of highly-skilled workers and would undermine the progress made in health care. Andrea Horwath’s NDP put Ontario’s economic recovery from the last recession at risk when they chose not to support the 2014 Liberal Budget, which would have made important investments in health care. Instead of backing record investments in health care, Horwath sided with Tim Hudak’s cuts. That’s not what Ontario Liberals stand for. On June 12th, Ontarians have a clear choice between building the province up with a strong Liberal plan or dividing this province through cuts to our most valued services. As long as I am Premier, health providers in Ontario will be treated as respected partners in fulfilling our most important role of government. Looking at everything we have already accomplished together, I have no doubt that health care’s best days – indeed, our province’s best days – lie ahead.

Health care has always been a key priority for the NDP, across Canada, and remains so today. Ontario’s NDP has a plan to focus on the fundamentals and deliver relief to Ontario’s families looking for change that makes sense on health care. A health care issue that comes up in large and small communities across the province is home care. The Ontario NDP understands that the bulk of home care is delivered by family members, many of whom are struggling with financial and emotional stress from caring for aging parents and their own children. Our Caregiver Tax Credit will offer these families relief. Under our practical plan, anyone caring for a dependent at home will be able to claim $1,275 annually. This tax credit, which will help keep families together while saving on costly long-term care, is fully refundable, not income-based and supplements credits or supports that families receive through other programs. Our guarantee that every Ontarian will have access to home care within five days of approval will provide patients with quality care in comfort and dignity. Combined with our plan to create 1,400 additional long-term care beds, this will eliminate the long-term care crisis. Of course, home care is not the only issue I hear about. For many Ontarians, a visit to the ER is their first point of contact with the health care system when something changes in their health. No one should spend anxious hours in ERs just to find out if their loved one is going to be okay. The Liberals promised to reduce wait times but once again, failed to deliver. Ontarians can trust an NDP government to keep our promise to cut ER wait times in half with solutions that make sense. We will hire 250 nurse practitioners to ease ER wait times. St. Michael’s Hospital in Toronto has successfully introduced its Fast Track program and nurse practitioners each treat about 350 patients per month – dropping ER wait times by half. As well, since many people go to the ER because they don’t have access to a primary care practitioner, our plan to create 50 new 24-hour family health clinics will relieve pressure on hospitals. To address the rural-urban health care gap, an NDP government will attract as many as 250 new physicians to underserviced rural communities with a medical school debt-forgiveness program, which will forgive up to $20,000 of debt per year of service. These practical, fully costed measures will ensure that families have access to quality care, when and where they need it. The Liberals failed to deliver on just three promises from the last budget and cannot be trusted to deliver this time. Ontario’s families know that the NDP can be trusted to deliver on our commitments. The NDP’s solutions that invest in people’s priorities not scandal and waste make sense. Sincerely, Monique Taylor NDP Candidate – Hamilton Mountain

Kathleen Wynne Leader of the Ontario Liberal Party

www.hospitalnews.com

JUNE 2014 HOSPITAL NEWS

24 From the CEO's Desk

Individual commitment to a group effort By Karim Mamdani

he time before and after we enter into a new fiscal year is, traditionally, a very hectic time for everyone at Ontario Shores Centre for Mental Health Sciences (Ontario Shores) and, likely, for everyone working in acute and specialty care hospitals across Canada. As a new year approaches, inevitably the hospitalâ&#x20AC;&#x2122;s focus centers around financial reporting, progress against our Strategic Plan and the completion of existing projects before turning attention to new projects along with preparation and planning for the 12 months ahead. The elevated pace has become customary for the months of March and April as individuals across the organization do their part to position Ontario Shores for future success. Itâ&#x20AC;&#x2122;s this time of year which helps me appreciate the team we have become here at Ontario Shores. We all contribute individually through our roles and responsibilities at the hospital, but as a collective we are determined to achieve our Strategic Plan and positively impact the lives of people living with mental illness and their loved ones. Commitment is defined as dedication to a cause. For us that cause is our patients, our Strategic Plan, and Ontario Shores. This commitment, this singularity of purpose taps enormous potential within each

of us. We share a common direction, we share a passion in the fulfillment of our purpose, we come together as a team, and we dig deeply to achieve our common purpose. Vince Lombardi, the late great football coach of the storied Green Bay Packers, once said; â&#x20AC;&#x153;Individual commitment to a group effort â&#x20AC;&#x201C; that is what makes a team work, a company work, a society work, a civilization work.â&#x20AC;? I cherish that quote. I share it often and use it as a mantra of sorts in my role as President and CEO at Ontario Shores. Now, feeding and maintaining that â&#x20AC;&#x2DC;individual commitment to a group effortâ&#x20AC;&#x2122; can be a distinct challenge. However, I feel in healthcare we are blessed with endless opportunities to inspire and recognize the efforts of individuals who are essential to any team accomplishments we hope to achieve. Each day the walls of hospitals are filled with success stories. Daily routines make these successes appear to be less obvious some days, but, regardless, they are always there. Patients receiving exemplary care, family experiences embedded in respect and staff members contributing to change which positively impacts care are all successes worth celebrating. Finding time and opportunity to celebrate is also imperative. Whether it is a

Karim Mamdani is President and CEO at Ontario Shores for Mental Health Sciences. formal presentation or a simple pat on the back for a job well done, there are multiple moments each day where opportunity to offer recognition to those contributing to a greater goal are presented. As leaders, maintaining a culture of teamwork and celebration is not limited to our specific hospitals or organizations. We have much to be proud of in Ontarioâ&#x20AC;&#x2122;s health care system. Yet there is still much to be done, especially in the area of chronic disease management. We know that one in five people struggle with a mental health issue and we also know the system can be difficult for patients and their families to navigate. These are undisputed facts that need to change. Regardless of our organizational roles

within healthcare, together we have the ability to strengthen relationships, leverage expertise and build a system which offers exemplary care and access to our communities. This can be achieved by each of us being relentless in our pursuit of both organizational and sector goals, thus displaying a determination and commitment which inspires others. By bringing the patient experience as central to our work, improving transitions between organizations and by introducing new and innovative models H we can improve our health care system. â&#x2013; Karim Mamdani is President and CEO at Ontario Shores for Mental Health Sciences.

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Focus 25

ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

Start the conversation because

moments matter By Helen Reilly

or kids escaping school routine, the summer offers endless possibilities of things to do, people to see and places to go. For children with life-limiting illness, the expectations of that same day are no less exciting, but they’re different. Emily’s House is Toronto’s first children’s hospice and only the sixth one in Canada offering hospice palliative care to children who will not recover from illness. The hospice officially opened in July 2013 with provincial funding for six beds and space to support care and respite for up to 10 children. Located in Toronto’s east end, the hospice offers specialized care in addition to support for children and adults in the community through the Phillip Aziz Centre. Unlike her classmates, topping nineyear-old Grace’s list of things to do during her winter break was a return visit to Emily’s House. As Captain of The Healing Cycle Ride’s Kids4Kids team, she and fellow youth cyclists visited the construction zone which was to be Emily’s House a year-and-a-half earlier to donate a cheque representing funds raised during the ride. She was eager to see the finished project. While many of us may avoid talking about the subject of death with our children, let alone each other, the topic is not actually a taboo one for many young people; it’s not even unique since many schools and athletic teams have rallied around children and families whose lives have been impacted by childhood illnesses. Perhaps the best proof that children readily embrace the topic of conversation is that Emily’s House has a Youth Advisory Council – kids supporting other kids with life-limiting illness. There’s a poignant les-

son in that children understand and embrace the possibility that while there may be no way to prevent death, there is an opportunity to improve quality of life for people with life-limiting illness. The day Grace visited was Rapunzel Day! A young client was proud to show off her golden locks fashioned from gold ribbon strands lovingly attached to a hairband with the assistance of a therapist. The colourful space and custom furniture designed to accommodate wheelal devices is chairs and medical drenched with natural light streaming in through the treess and the wall of windows no doubt incorporated in architectural design for this very reason. The hospice nd offers comfort and care for children and lti-discifor families. A multi-disciplinary team of medical professionals and therapists, chaplains and volunteers offers medical, spiritual, emotional and practical care to families through music and play therapy as well as bereavement support. “The Healing Cycle Foundation recognizes the essential need to support hospice palliative care programs throughout Ontario. We are working year-round to raise awareness and funds to support programming so that families have access to palliative care when they need it,” says Heather Campbell, president and CEO, The Healing Cycle Foundation.

The Healing Cycle Foundation is a volunteer-driven foundation raising funds and awareness for hospice palliative care in Ontario. This year marks the foundation’s 10th anniversary and a milestone for the organization, as it surpasses $2 million raised for hospice palliative care programs in Ontario Riders range in age from infancy (in ride-along accessories) to 75 years of age and come from all walks of life. They come from the bed as patients to the bedside, as physicia physicians, therapists, pat nurses, patients and fammem ily members to cycle 10K, 25K, 50, 75K and 100K bi bike routes in su support of palli liative care proggrams throughou Ontario. out The Foundation tion’s goal is to suppo hospice palsupport c liative care programs compas that compassionately provide quality endend-of-life support for patients and their families through hospice outreach services as well as fundraising consultation for hospices to encourage them to maximize their own fundraising capacity. Hospices entering teams in the annual ride retain nearly all funds raised by their hospice team. In addition, they have the opportunity to qualify for grants up to $10,000. To date, grants have been used to fund needs such as equipment, staffing, a food program, landscaping, bereavement programs and art programs. Through its support of hospices, the

Supporting the development of children at home Continued from page 14 I feel that you get the best gains when you are proactive vs. reactive,” she says. For the past five years, Rashmi has worked closely with Kusyati to understand Gabbie’s needs, help the family understand Ontario’s ‘complex health care system, and connect the family to a wide range of community resources and services. Rashmi has wrapped the circle of care around Gabbie and her family. She has arranged for the necessary supports for Gabbie to live safely at home. Rashmi anticipated the family’s needs in caring for Gabbie. She was able to source the necessary medical equipment through Easter Seals and the provincial assistive devices program that the family needed, such as a walker (Gabbie is not able to stand on her own), a bath chair, stroller, as well as lifts for the family van and the home entrance. Rashmi also arranged for personal support workers to help with Gabbie’s bathing, dressing and eating as she is unable to eat, bathe, or toilet herself. Taking care of a child with high care needs is not easy. To manage Gabbie’s

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care Kusyati works the night shift, so that she is able to care for Gabbie during the day. Gabbie’s older sister also helps to care for her sister. Rashmi is very in tune with this family’s needs – connecting the family with resources and funding locally and provincially. “I connected Kusyati to resources in the community. I was able to get her enhanced respite care through the Ministry of Community and Social Services,” explains Rashmi. Kusyati explains, “I’m very pleased with Rashmi. I tell her my problems and issues and she is a good listener. I need someone to talk to and she is the perfect person to talk to. She works to pull all the resources together. I had no supports before.” Rashmi has been involved in several school case conferences with the family, service providers and school staff to ensure that Gabbie would get the help she needed to attend school. Today, Gabbie attends school in a special needs class, getting to school in a specially-equipped wheelchair bus, which picks her up in the morning and

returns her home at the end of the day. While in school, Gabbie is assisted by a specialized Educational Assistant. She also receives occupational therapy to improve her balance and develop fine motor skills, and physiotherapy to help her with movement and mobility. Gabbie’s care is not easy. She requires care 24/7. It takes 45 minutes to one hour just to feed her. She has daily seizures and is exhausted afterwards. Her condition is alleviated by a number of medications and her family’s love, devotion and care. Despite her health condition, she is a happy child. Although she cannot talk, she communicates through body language and sounds. She loves to be hugged, tickled, sung and spoken to. Gabbie continues to make progress and with the care and services of the Mississauga Halton CCAC she is able to remain at home, where she is nurH tured and loved. ■ Bobbi Greenberg works in communications at the Mississauga Halton CCAC.

foundation’s long range goal is to improve access to hospice palliative care. Currently, only three in 10 Canadians have access to timely palliative care when they need it. “Although, hospices often operate on shoe-string budgets, the value of the hospice palliative care experience for patients and their families is priceless,” says Heather Campbell, President and CEO, The Healing Cycle Foundation. “It’s not an easy task to capture what we do, why we do it and who we do it for, but we ultimately agreed that in honour of the 10th annual ride, the best words to capture our work were “Making Moments Matter,” says Heather with a sense of satisfaction that reveals her own dedication as the organization’s full-time volunteer President and CEO. In 2013, more than 500 riders participated to support hospices, loved ones and their own personal palliative care journeys raising over $300,000. “This year’s ride will be bigger and better because we are celebrating 10 years and marking the milestone for our second million dollars for palliative care in Ontario,” she beams. The petite mother of three children does nothing in a small way. For the first time in 10 years, having recruited a highly qualified crew of 70 volunteers, she will participate in the ride for the very first time. Her goal is to cross the finish line in time to host the finish line celebration featuring live music, entertainment and prizes. While everyone’s journey is different, the destination remains the same for each and every one of us. We each have our own reasons for riding and for supporting the availability of palliative care services in local hospices. Regardless of our age, it is only through the recognition that quality of life is as important as quantity of life that we are “Making Moments Matter.” To learn more about The Healing Cycle Foundation, donate, volunteer or register an individual or team, visit thehealingcyH clefoundation.ca ■ Helen Reilly is a volunteer at The Healing Cycle Foundation.

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26 Focus

ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

New prostate cancer treatment By Michael Giardino

magine a world in which prostate cancer could be treated in just a one-day outpatient procedure. With current technologies, including advanced screening and diagnostic tools, this world is increasingly becoming a reality for some patients diagnosed with certain types of cancers. Prostate cancer is one of them. The last 30 years have seen a big increase in awareness and screening for prostate cancer. The number of men who are cured of the disease when it is found early has increased. In general, it is a slowgrowing disease that often appears later in life. But if it’s not monitored, tumours can grow and cause problems. Dr. John Trachtenberg, the lead clinician of a Phase I trial testing a device to help manage prostate cancer, is hoping the technology he’s working on will bring much needed change to the field. “One of the biggest problems with current prostate cancer treatment is that it is too severe for the type of disease prostate cancer is today,” he says. “In Western countries where regular screening takes place, about 60 to 80 per cent of patients are found to have low-volume, low-grade disease with low risk. In many cases systemic therapies like chemotherapy are simply not needed.” Trachtenberg mentions various North American trials that have all come to the same conclusion regarding treatment. A

HOSPITAL NEWS JUNE 2014

randomized controlled trial called PIVOT conducted between 1994 and 2002 studied 731 patients who either underwent radical prostatectomy (removal of the prostate gland) or had nothing done and were closely observed instead. After 12 years, there was no observable difference in the disease-specific survival rate.

“One of the biggest problems with current prostate cancer treatment is that it is too severe for the type of disease prostate cancer is today.” “Studies like PIVOT have shown that while there’s not a big difference in survival, there is a difference in the side effects,” says Trachtenberg. “Eighty per cent of men become impotent and 20 per cent suffer incontinence after treatment – and these are only the most common side effects.” His hope was to develop a treatment with fewer side effects that would still work well. “To do this, we brought to-

gether a variety of newer treatments and discoveries of the day into a treatment option,” he says. “MRI imaging can show you where the tumour is and can give you an idea of how aggressive it is.” A concept Trachtenberg and his team use is the “index lesion”, which is the largest and most noticeable site of tumour seen by multiple sequences of an MRI. “MRI allows you to see the largest tumour. Usually there are four or five tumours of variable sizes, but there’s always a larger one. About 85 per cent of local tumour growth comes from this tumour or index lesion and if found early enough and treated, could stop the disease from growing further and maybe stop it from spreading to other parts of the body, just like a colonoscopy does today.” Once the tumour is found with imaging and diagnostic tools, Trachtenberg uses a state-of-the-art robotic device that delivers heat to remove the index lesion in a therapy called focal ablation. “Once a biopsy has been done to prove that the tumour is the site of highly proliferated cancer cells, it is then ablated and coagulated completely,” he says. “By using magnetic resonance phase shift you can see within one degree centigrade the area that you are coagulating versus the area that you need to preserve. “Right next to the tumour are often the nerves that control erection and con-

tinence, and the urethra. We can avoid those areas by differentiating between the heat in the tumour that is being coagulated and the normal temperature of the functional sites next to it.” He believes this is a big advantage. In collaboration with Dr. Aaron Fenster, Trachtenberg and his team have treated over 50 patients. “We have seen that not a single person has had any significant side effects,” he says. “There have been no reports of impotence or incontinence three weeks after treatment. Because the laser is placed by a series of needles through the perineum there is often bruising and mild painful urination for some time, but compared to other options this is mild.” Trachtenberg’s approach is simple. “It is true that when we are only treating the most aggressive portion of the tumour, we are leaving some tumour tissue behind,” he says. “We believe the small tumours that aren’t seen by MRI are not important because they are very slow growing. If you live to be 200 years old it might be important. But for most people who are found to have these tumours in their early 60s, it doesn’t seem significant. I’d argue that quality of life is much more important to H these patients.” ■ Michael Giardino is a Communications Officer at the Ontario Institute for Cancer Research.

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Focus 27

ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

Photo, Sandra Tavares

The Paediatric Oncology Group of Ontario (POGO) located at Credit Valley Hospital provides care closer to home for kids who have been diagnosed with cancer.

Bringing care closer to home for kids with cancer By Priya Ramsingh

hen you have a child facing an illness, close to home is where you want to be. That’s why the POGO (Paediatric Oncology Group of Ontario) clinic located at Credit Valley Hospital provides care closer to home for kids who have been diagnosed with cancer. The largest satellite of seven in Ontario, the POGO clinic started at Credit Valley Hospital in 2003. It provides cancer treatments for kids who have been referred by SickKids and live in Mississauga, Brampton, Oakville, Caledon and surrounding areas. “All of the children are on a treatment plan which entails several visits monthly, weekly and sometimes daily,” says Lena Lloyd, Paediatric Clinical Educator. “Before the POGO satellite at Credit Valley Hospital, families were making frequent trips to downtown Toronto to visit SickKids. By reducing the travel time, we can ease some of the stress for children and their families by providing care in their own community.” The clinic works closely with the paediatric inpatient unit at Credit Valley Hospital and provides off-hours services for POGO patients. If kids become ill and need to be admitted to the hospital, they can be assessed directly through the paediatric inpatient unit instead of having to go through the ER. “This 24/7 service for POGO patients helps ease the anxiety for families because they are already familiar with the team at the paediatric inpatient unit,” says Lloyd. “This kind of comfort is a welcome relief for kids who are going through a difficult ordeal.” In addition to clinical treatments such as chemotherapy and blood transfusions, the POGO clinic provides therapies and supports to children and their families as they continue with a complicated and emotional period of their lives. The Camp Oochigeas In-Hospital Program, or simply “Camp Ooch” as it’s affecwww.hospitalnews.com

tionately known, brings the fun of camp right to the kids at the POGO clinic. A privately-funded, volunteer-based organization, Camp Ooch provides kids affected by cancer with a unique opportunity for growth through challenging, fun, and enriching experiences. Each Monday morning, camp counsellors from Ooch arrive at the POGO clinic armed with crafts, activities, songs and games so kids can play, be creative and connect with other kids going through a similar experience. There’s also a teen mentoring program where teens can support one another by bonding through leisure activities. “Teens are already facing a lot of growth changes,” says Anna Geraldes, Program Coor-

dinator, Paediatric Oncology Group of Ontario (POGO). “In addition to their illness, they struggle with body image and emotional issues and they need someone who can identify with what they’re experiencing.” Six registered nurses who are all oncology certified currently provide care to over 200 children from 18 months to 18 yearsold. There is also a child life specialist on site who works with the children to help normalize their experiences. The clinic acH commodates over 2500 visits per year. ■ Priya Ramsingh is a senior communications advisor at Trillium Health Partners.

Child Life Specialist works with a patient at the POGO clinic

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28 Focus

ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

Improving children’s healthcare By Elaine Orrbine

ealth promotion and health care delivery are complex issues. All children, youth and their families must have access to a health care system supported by quality standards of care and evidence-based practice that will appropriately position this vulnerable population for optimal transition to adulthood. Many believe that the absence of collaboration among child and youth health care organizations and networks can lead to inefficient use of limited resources and little real change in the goal to improve timely access to healthcare for all children and youth. The Canadian Association of Paediatric Health Centres (CAPHC) is committed to improving healthcare for Canada’s children and youth by supporting the work and addressing the challenges of health care professionals and their respective organizations across the country. CAPHC’s work is facilitated through multiple national Communities of Practice (CoPs) lead by many child and youth health care providers and leaders from coast to coast. Over the past several years CAPHC has established the following ‘Core Programs’Advancing paediatric empirical decision support and national benchmarking – Across the continuum of care;- Established in 2005, CAPHC’s Canadian Paediatric Decision Support Network (CPDSN) is a national data sharing and benchmarking program that utilizes a collaborative and networking model to broaden the scope of understanding and analysis of paediatric health care services in Canada; Building on CAPHC’s long-standing partnership with the Canadian Institute of Health Information (CIHI), our collective goal is to advance a national agenda in pursuit of access to better data, relevant and timely information in response to the changing needs of our child and youth community of practice. Developing, implementing and evaluating national paediatric practice guidelines, tools and standards in priority areas of children’s healthcare; CAPHC’s goal is to improve health care quality, safety and efficiency through a positive and dynamic collaboration to share ideas and experiences regarding the development, implementation and evaluation of national paediatric practice guidelines. Over the last two years, four Communities of Practice (CoPs) have been established in the following areas: Transition from Paediatric to Adult Care; Management of Medically Complex Children through the Continuum of Care; Sepsis Screening; and the Management of Acute Procedural Pain. Other areas of national paediatric practice guideline development include: Interfacility Critical Care Transport of Maternal, Neonatal and Paediatric Patients in collaboration with Accreditation Canada; and Treatment with Inhaled Nitric Oxide in the Neonatal & Paediatric populations. Advancing quality of life for children and youth with disabilities – Paediatric Rehabilitation Reporting System (PRRS) In February 2014, an agreement in principle was reached between CAPHC and the Canadian Institute for Health Information (CIHI) regarding the creation of a Paediatric Rehabilitation Reporting System (PPRS). In partnership with CIHI HOSPITAL NEWS JUNE 2014

and many rehabilitation/health care organizations across Canada, the goal of this national program is to create a high quality national database that includes functional/developmental outcomes and service delivery data on infants, children and youth who access rehabilitation services to improve their functioning, activity and participation; promote reliable and consistent data capture, reporting and facilitate benchmarking across Canada; and to create, inform and operationalize the collection of meaningful data from rehabilitation centres for collation, knowledge translation to support service improvement. Ongoing development of tools & resources – A National Screening Tool Kit for Children & Youth Identified and Potentially Affected by Fetal Alcohol Spectrum Disorder (FASD) – This was developed with the support and partnership of the Public Health Agency of Canada (PHAC) and the leadership of CAPHC’s National FASD Steering Committee. The Tool Kit includes screening tools applicable to a variety of populations, implemen-

All children, youth and their families must have access to a health care system supported by quality standards of care and evidencebased practice tation settings, sectors and jurisdictions: • Meconium Testing – in the neonatal population; • Neurobehavioral Screening Tool (NST) • Maternal History Guide – Pre-natal exposure for at-risk women, and •Youth Probation Officer Tool – Youth Justice System. CAPHC Paediatric Trigger Tool (CPTT) – The CPTT is the first validated, comprehensive trigger tool available to detect adverse events in children hospitalized in acute care facilities. CAPHC Conversations (blog) was

created to actively engage with the child and youth health care community across the country to share thoughts and activities that are making a difference to the health and well-being of our children, youth and families. CAPHC Conversations is an effective vehicle to initiate a discussion on priority topics of the day and of most interest and relevance to our child and youth health care community. A comprehensive catalogue/repository and video library of all CAPHC webinars has been created and made available on CAPHC’s Knowledge Exchange Network (KEN). CAPHC’s Knowledge Exchange Network is an online community, focused on sharing and developing knowledge in child and youth health service delivery. The CAPHC-KEN seeks to engage practitioners, patients, families, researchers and other stakeholders in a common, interactive knowledge exchange H community. ■ Elaine Orrbine is President and CEO, CAPHC.

6 epic natural wonders of the world By Louise Cheng

n today’s modern world, new lists from the ‘Natural Wonders of the World’ to the ‘New Seven Wonders of the World’ have cropped up with choices including The Great Barrier Reef, Machu Picchu, The Taj Mahal and more. Whilst there will never be a definitive list agreed by everyone, here are a few more worth seeing.

Red Beach, Panjin, China Prepare to be visually amazed at the vision of red before you. Although not strictly a ‘beach’ as such, Red Beach is actually the biggest wetland and reed marsh in the world. It is an ecosystem home to over 260 species of bird and 399 forms of wildlife. The seaweed starts growing around April/May and starts off as a green colour. The colour eventually transforms to a vibrant red as seen around the autumn period.

The Marble Cathedral, Patagonia, Chile See the surreal looking mineral formations at General Carrera Lake in Chile, the second largest freshwater lake in South America. Take a boat trip and see The Marble Cathedral which has evolved from many years of erosion resulting in

stunning marble walls and distinctive shapes. The water of the lake is beautifully turquoise and adds to the surreal nature of the surroundings.

Bamboo Forest, Sagano, Japan Wind through the beautiful bamboo forest in Sagano on a picturesque path by foot or by bicycle. The bamboo forest is particularly inviting on a day filled with sunshine and evokes a charmed atmosphere with not just the visuals, but also the sounds of the forest itself. Bamboo is a useful resource in Japan and can be stronger than steel.

Rainbow Mountains, Danxia, China More fitting in a dream landscape, the Rainbow Mountains in China are a geological sensation set in Zhangye Danxia Landform Geological Park. From shades of orange, yellow to blues and reds the Rainbow Mountains are a sight to behold. The natural formations have been formed over thousands of years and the park has been designated a UNESCO World Heritage site since 2010.

Lake Retba, Senegal, Africa Visit Lake Retba in Senegal and see

just how pink the lake is. Located in the north of the Cap Vert Peninsula of Senegal, Lake Retba is at its pinkest during the dry season between November and June. The state of the waters is caused by the algae producing a red pigment which turns the lake a wonderfully pink hue. The manner of how pink the lake can get depends on the salt content if the lake, with a high content changing it to a deeper shade of red.

Perito Moreno Glacier, Patagonia, Argentina An awe inspiring glacier which is actually still growing in size! Perito Moreno Glacier is one of the biggest glaciers of the Southern Patagonian Ice Field and it is located in Los Glaciares National Park. The peninsula offers breath taking views of almost 4km of walkways and don’t worry about slipping over on the ice as visitors are given ice cleats to wear. One of the best experiences is seeing the sight of large blocks of ice breaking away from the impressive glacier and hearing the erupH tions from it. ■ Louise Cheng is Marketing Manager at Holidays Please. This column appeared on www.aluxurytravelblog. com and is reprinted with permission. www.hospitalnews.com

Healthcare Technology 29

Website targets health professionals working with newcomer families C

hildren and youth new to Canada do not enjoy the same health status as their Canadian-born peers. That’s why the Canadian Paediatric Society wants to ensure that physicians, nurses, hospital administrators and others caring for immigrant and refugee kids have what they need to provide the best possible care. Caring for Kids New to Canada (kidsnewtocanada.ca) is a free bilingual website for health professionals working with newcomer children and youth. It features evidence-based information on how to assess and screen patients, evaluate and manage medical conditions, advocate for immigrant and refugee health, and much more. The first Canadian website of its kind, Caring for Kids New to Canada will also help health professionals and hospital administrators develop policy that promotes better care for newcomers. “Health care providers across this country care for immigrant and refugee children and youth every day,” says Dr. Tony Barozzino, the website’s co-editor-in-chief and Director of Community Outreach and Ambulatory Services at St. Michael's Hospital in Toronto. “The increased mobility of individuals around the globe and the sheer

www.hospitalnews.com

d size of Canada – where local resources and expertise can vary widely – make Caring forr Kids New to Canada invaluable and timelyy in its introduction.” Co-editor Dr. Chuck Hui said thee site fills a gap in paediatric-specificc information. “Although there are some resources forr health care practitioners in Canada, theyy tend to be regional, specific to particularr groups, and adult-focused,” says Dr. Hui,, a paediatric infectious diseases specialist att the Children’s Hospital of Eastern Ontarioo in Ottawa. “This guide is a direct responsee h to needs identified by key stakeholders with input from content experts from across thee country and multiple disciplines.” h Development of the website – which was funded through a grant from Citizen-d ship and Immigration Canada – involved a 22-member editorial board with repre-sentatives from paediatrics, family medi-cine and nursing, as well as an extensivee network of expert peer reviewers and otherr contributors. The result is a resource thatt addresses many of the most common ques-tions faced by health care providers whilee providing in-depth information in areass that are important to providing appropri-H ate and complete care. ■

kidsnewtocanada.ca

JUNE 2014 HOSPITAL NEWS

30 Focus

ONCOLOGY/MEDICAL IMAGING/PAEDIATRICS

Nephrologist Dr. Kishan Mahabir (right) with a patient.

Patient engagement using

mobile technology By Puneet Seth

atient engagement and mobile health technology (or mHealth) are expressions that have permeated discussion and debate within health care organizations. The combination of the two has been touted as having the potential to advance the safety and quality of health care delivery, while simultaneously reducing costs and increasing accessibility. According to a recent PwC report, nearly 80 per cent of the 2,500 Canadians surveyed reported that they would be comfortable using a virtual monitoring service for a chronic condition. This begs the question – where is mobile patient engagement in the frontlines of healthcare in Canada today? At the Regional Kidney Wellness Centre in Brampton, Ontario, a nephrologist has already taken the bold step of being a pioneer by bringing such technology to his practice. Using an intuitive and innovative platform called InputHealth, Dr. Kishan Mahabir has been reaching out to his patients to better their care. By developing a simple yet effective ‘mobile blood pressure engagement tool’ on the platform, he aims to engage patients with mHealth technology. At the end of each visit with a patient, he quickly schedules an automated digital questionnaire (on his web browser) to HOSPITAL NEWS JUNE 2014

A screenshot of the mobile blood pressure engagement tool. go out to the patient’s phone or email address (with consent). The interactive questionnaire reminds them about things such as how to check their blood pressure properly and to take their meds, in addition to allowing them to submit their readings to him. “I have customized the tool to enhance my practice. I can monitor a patient’s response to therapy in between clinic visits and adjust

therapy at intervals that I deem important,” explains Dr. Mahabir. The digital questionnaires can be scheduled to go out however often the patient is comfortable with being engaged, with no extra effort on the part of the physician. With the platform being HIPAA-compliant and interoperable between any mobile or desktop operating system, safety and usability concerns are laid to rest. The information returns to the patient’s health record, and is automatically aggregated and presented in a user-friendly visual report. So what have the patients thought thus far? “Every patient I have approached has been keen on utilizing the program. The patients truly see my interest and understand the importance of blood pressure monitoring at home. They have become more vested in their own health.” Chronic kidney disease (or CKD), much like diabetes, has all the elements to make it a poster-child for mobile patient engagement. The condition is often life-long, there is often a long-term relationship developed with the treating clinician, the condition can be life-altering (or life-ending) if it progresses, and most importantly, there can be good outcomes if it is well controlled. However, unlike diabetes, CKD has not gotten the same attention from the mobile developer market, whereas there is a gamut of apps and

digital services for diabetes. As a result, patients with such conditions have traditionally been left with fewer resources to empower or educate themselves. “Our blood pressure tool is only the tip of the iceberg as we test waters with our patients”, Dr. Mahabir explains. “We are actively working towards incorporating validated questionnaires directed towards patients with chronic kidney diseases using mHealth. Going a step further, we can educate patients by sending patient specific education modules that we create based on their diagnoses. This will truly revolutionize not only the patient experience, but allow treating nephrologists to have data that is powerful and transformative.” Similarly, InputHealth has been successfully applied to a variety of clinical settings across Canada, from cardiactransplant clinics in Vancouver, BC to rehabilitation centres in Southern Ontario. Powerful mobile technologies that involve patients do exist and are ready to meet the demands at the frontline of our burdened health care system – what is needed now is for clinicians take the next step and bring H it into their practices. ■ Dr. Puneet Seth is a practicing hospitalist in southern Ontario, and is Vice President, Operations of InputHealth Systems. www.hospitalnews.com

Natural Path 31

Nutritional and lifestyle needs of children By Christopher Knee

ttention Deficit Hyperactivity Disorder (ADHD) is the most common mental health disorder in children, where it is estimated to occur in about five to 12 per cent of school-aged kids. It is a chronic condition that can continue well into adolescence and adulthood. According to the Centre for ADHD Awareness Canada (CADDAC), it can have negative effects on a number of areas of â&#x20AC;&#x2DC;executive functioningâ&#x20AC;&#x2122;, such as planning, memory, attention, and ability to focus. There can be a wide variety of symptoms of ADHD depending on the child, their family history, their environment at home and at school, and much more. According to the organization CHADD (Children and Adults with AttentionDeficit/Hyperactivity Disorder), treatment usually includes a number of approaches, such as parent training, behavioral strategies, education, and medication (when necessary). Typically ADHD has thought to be caused mostly by genetics; however scientists and other researchers are beginning to look at other factors that might modify the condition, such as the dietary and nutritional status of children with ADHD. â&#x20AC;&#x153;Medications can be effective in man-

aging ADHD symptoms for some children, but do not work for everyone. There is a high demand for research into other causes of ADHD and treatment options, and parents and the public are beginning to ask more about the safety of medications and natural treatment alternatives,â&#x20AC;? says Kieran Cooley, naturopathic doctor and associate director of research at the Canadian College of Naturopathic Medicine (CCNM) in Toronto. â&#x20AC;&#x153;ADHD is a neurobiological disorder; many of the chemicals used by our brains for proper functioning are produced and supported by nutrients that we must get from our diet,â&#x20AC;? Cooley adds. According to Cooley, there is some early scientific evidence to suggest that nutrients such as zinc, magnesium, and vitamin B6, may be deficient in children with ADHD, and may be associated with the severity of ADHD symptoms. Itâ&#x20AC;&#x2122;s not clear however, whether children with ADHD also may require higher than normal intake of these nutrients to optimize neurological function and development. The research department at the College has designed a fairly simple yet well-controlled trial to really see whether these nutrients are associated with or can improve symptoms of ADHD in children. Most

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parents know that diet is important, however kids can be picky eaters, and there is not a lot of solid research on specific nutrient supplements to show significant benefits. In this study, researchers are actually able to compare blood levels of the nutrients and correlate the findings to the children who took the nutrient tablet and may have had improved symptoms. The ADHD Nutrient Research Study, which has ongoing recruitment and enrolment, is comparing a chewable nutrient tablet to placebo (a tablet containing no nutrients), over 10 weeks in children aged 6 to 12 years with ADHD. Parents are required to go to CCNM for two 60-minute visits, where they are asked to complete two questionnaires and the child gives a small blood test. There is no cost to participate and a $50 honorarium is awarded at the completion of the study. The study has received funding from the SickKids Foundation and is a collaboration between investigators at CCNM, the University of Toronto, and Torontoâ&#x20AC;&#x2122;s Centre for Addictions and Mental Health (CAMH). This research fits alongside a growing body of investigations into the impacts of diet, nutrition and nutrients in a wide variety of childhood and mental health disorders. While still in early stages, a

number of long-term longitudinal studies are looking at key factors in supporting healthy development through childhood, many of which include dietary and lifestyle components. Leslie Solomonian, naturopathic doctor and assistant professor at CCNM, is currently evaluating the impact of a family-centered group program for wellness education, called â&#x20AC;&#x2DC;Healthy Families, Healthy Kidsâ&#x20AC;&#x2122;. The program focuses on educating families (children and parents) on positive behavior change in a high quality encounter with a naturopathic doctor outside of the traditional â&#x20AC;&#x2DC;doctorâ&#x20AC;&#x2122;s officeâ&#x20AC;&#x2122; setting. The goal of the program is to help instill the knowledge, skills and motivation to support development and maintenance of healthy habits and health-promoting behaviours. The target population is families with at least one child under the age of six in the city of Toronto and involves six two-hour evening sessions spread out over a number of weeks and is currently taking place at CCNM as well as a number of Ontario H Early Years Centres around Toronto. â&#x2013; Christopher Knee is a naturopathic doctor and research coordinator at CCNM.

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