Hospital News August 2013 Edition by Hospital News

Alberta Health Services responds to flooding disaster FOCUS IN THIS ISSUE

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS

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Emergency and trauma delivery systems and emergency preparedness issues facing hospitals. Advances in critical care medicine.

AUG 2013 | VOLUME 26 ISSUE 8 | www.hospitalnews.com

Code Orange at North Bay General Hospital INSIDE Legal ...................................................15 Nursing Pulse .....................................22 From the CEO's desk..........................26 Care Giving .........................................30

Preparing for a disaster The Canadian Red Cross Emergency Response Unit in training

By Jamie Cuthbertson

s a member of the Canadian Red Cross Public Affairs team, I had the opportunity to visit the Red Cross Emergency Response Unit (ERU) during a training exercise in June. I was in awe of the amount of work and training that is involved. A team of about 40 highly skilled medical and non-medical experts spend one week on a training exercise where they learn to assemble the field hospital in conditions that simulate an actual deployment. The ERU, supported by the Government of Canada, is the first of its kind in North America. Itâ&#x20AC;&#x2122;s a mobile hospital prepared for rapid deployment with teams that depart within 24-48 hours following a disaster or conflict. The ERU is designed to be operational within 12 hours of arrival on site and selfsufficient for one month. The hospital, complete with an operating theatre and emergency wards, can provide in-patient care and surgical services for up to 300 patients a day.

Working as a team, Red Cross delegates determine a plan for treating mock patients during a simulation exercise. The Red Cross aims to train at least 300 delegates including surgeons, pediatricians, radiation technologists, laboratory technologists, OB/GYNs, nurses, psychosocial support workers, community health

workers, anesthetists, and midwives. It also includes experts in medical logistics, communications, administration and technical support. Once trained, the team can be deployed

Photo by Johan Hallberg-Campbell

with the ERU in times of disaster or conflict when the existing health system or infrastructure has been damaged or overwhelmed. Continued on page 6

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In Brief

Neighbourhood Pharmacy supports Premiers' efforts to strengthen sustainable healthcare Canada's Premiers spoke about their continuing work to improve Canada's healthcare system. The Canadian Association of Chain Drug Stores (CACDS) is a supportive partner in the Premiers efforts to manage healthcare costs, while ensuring access to high quality care. Canada's Premiers also spoke about the need to expand access to services, and enhance the quality of care by taking a closer look at the themes of appropriateness of care and seniors care. Canada's neighborhood pharmacies applaud this focus. "CACDS looks forward to ongoing work with Canada's Premiers as they consider key initiatives that can strengthen the healthcare system while reducing costs. For instance, the pharmacy community is in discussions with various governments on our proposed plan that could save governments across Canada between $8.5 billion and $11 billion over the next three years - a much larger amount than isolated changes can deliver - while at the same time significantly enhancing the quality of the patient experience in Canada," said Denise Carpenter, President and CEO of CACDS. Neighbourhood pharmacy's proposal (9000 Points of Care: Improving Access to Affordable Healthcare) addresses the appropriateness of care and access to care through a combination of initiatives including; expanded scope of practice for pharmacists; improved accessibility of health services through the pharmacy; and, building appropriate infrastructure to help Canadians manage chronic diseases H and prevent adverse drug reactions. ■

What's next for health care? The national organizations representing the majority of Canada's health-care providers — the Canadian Nurses Association (CNA), the Canadian Medical Association (CMA) and the Health Action Lobby (HEAL) — applaud the pan-Canadian collaborative approach of the healthcare innovation working group (HCIWG). Continued progress will require a multiyear commitment from providers and governments together. Leaders from the three provider groups met with premiers Brad Wall and Robert

Ghiz in Niagara-on-the-Lake in July during the Council of the Federation's summer meetings. On the agenda was a report on the completion of the second phase of the HCIWG. Providers are there to affirm the continued need for this important panCanadian collaboration to address the quality, safety and sustainability of Canada's health system. CNA, CMA and HEAL are all involved with the HCIWG, formed by the Council of the Federation in January 2012 and co-

chaired by Saskatchewan's Premier Brad Wall and Prince Edward Island's Premier Robert Ghiz. The HCIWG is tasked with identifying and increasing the acceptance of shared health system initiatives. Progress has been made since last summer's release of the group's initial report, From Innovation to Action. The provider groups are working with decision-makers to develop a clear vision for the HCIWG and to ensure that the momentum and commitment by H premiers continues. ■

Canadian Pharmacists Association reacts to Council of the Federation's announcements on health care The Canadian Pharmacists Association (CPhA) recently reacted favourably to the health care-related announcements made by the Council of the Federation (CoF) at the conclusion of its annual summer meetings. The Council of the Federation is the body comprised of Canada's 13 provincial and territorial Premiers. In January 2012, the CoF created the Health Care Innovation Working Group (HCIWG), Chaired by Premiers Wall (SK) and Ghiz (PEI) tasked with developing a panCanadian approach to specific health care reform topics. The CoF made a number of announcements of relevance to the pharmacy sector. Specifically, it stated:

• Agreements have been reached with suppliers to lower the price of 10 brand name drugs, with another 17 expected. Together, these agreements are expected to result in savings of $60-$70 million. • Premiers tasked the Health Care Innovation Working Group to "increase the important role that paramedics and pharmacists (emphasis added) can play in the provision of front line services", within a teambased model framework. • Premiers Wall and Ghiz will be stepping down as Co-Chairs of the HCIWG, to be replaced by Premiers Wynne (Ontario), Redford (Alberta), and Pasloski (Yukon).

Premier Pasloski's involvement is key in that he is Canada's first pharmacist premier. "We are very pleased that premiers have committed to continuing to look at ways in which pharmacists can play an even stronger role in the delivery of health care to Canadians," stated Sherry Peister, President of CPhA. "CPhA, its provincial associations, and other pharmacy stakeholders look forward to continuing our joint work with provincial and territorial governments in this regard. We are also happy to see Premier Pasloski's leadership added to the Health Care Innovation Working Group table ", H she added. ■

World Hepatitis Alliance calls for urgent action to address disease killing as many as HIV/AIDS On World Hepatitis Day on July 28th, the World Hepatitis Alliance called for urgent attention to be given to recent figures showing that although viral hepatitis kills as many as HIV/AIDS, in the great majority of countries. The Global Burden of Disease study released last year in the Lancet shows that viral hepatitis was responsible for almost 1.45 million deaths in 2010, the same as

HIV/AIDS and significantly more than TB or Malaria. Despite this enormous annual death toll, leaders in global health consistently leave it off their agendas. Currently, diseases receive attention and funding depending on their global priority. However the global priority list does not necessarily reflect the real burden of disease. This has led to responses that are disproportionate to disease impact, and

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has left some diseases tragically under-resourced. Viral hepatitis is a clear example; despite its huge burden there is little global pressure to address it. Consequently, the majority of governments have failed to dedicate resources to viral hepatitis, even in countries where prevalence is up to 20 per cent. The World Hepatitis Alliance is a

non-governmental umbrella organisation with 165 member patient groups in 66 countries. Representing 500 million people living with viral hepatitis worldwide, the Alliance strives to support and promote patient voices, to raise the profile of viral hepatitis and to establish comprehensive hepatitis strategies in all counH tries. ■

National and international research teams to study the impact of environmental factors on human health and disease The Honourable Leona Aglukkaq, Minister of Health, recently announced that nine teams of researchers have received funding to examine how environmental factors can alter the expression of our DNA and potentially affect our health. The research teams are being funded by the Government of Canada in partnership with Genome BC, Fonds de recherche du QuébecSanté (FRQS) and the Japan Science & Technology Agency. In October 2012, Minister Aglukkaq

announced the funding committed to support the teams through the Canadian Epigenetics, Environment and Health Research Consortium (CEEHRC), a national initiative designed to position Canada as a leader in the field of epigenetics and health. Total funding for all nine teams is $21.8M over five years. The teams were selected by a rigorous peer-review panel of international experts. They include six Canadian teams and three teams composed of Canadian H and Japanese researchers. ■ www.hospitalnews.com

News

Printing new joints with a 3D printer: advancing regenerative medicine for canadians By Jyll Weinberg-Martin

magine the day when doctors repair damaged, diseased or arthritic joints with new ones – not made of titanium or plastic – but with a patient’s very own tissue. Driven by new research, that day is swiftly approaching. Scientists at Mount Sinai Hospital’s Centre for Regenerative Medicine and Musculoskeletal Research, including Dr. Rita Kandel, are pioneering an entirely new frontier in Canada: the use of threedimensional printing to construct replacement parts that mimic the patient’s own joint. This powerful technology creates objects by laying down many successive micro-layers of material. In biomedicine, 3D printing can help generate a part of the human body that is an accurate replicate of a patient’s own structure. With a rapidly growing population of older adults in Canada, these innovations couldn’t be timelier. Joint replacements – such as artificial knees and hips – are increasingly common and are often essential for people with failing joints. However, despite being built of advanced materials, current replacement parts aren't as durable as the original joints, as they: • Are most commonly made of metal and plastic • May require cementing to bone • Can deteriorate and come loose • Usually need replacing after 10 to 20 years For the past few years, Dr. Kandel, a scientist at Mount Sinai’s Lunenfeld-Tanenbaum Research Institute, together with fellow Lunenfeld-Tanenbaum researchers Drs. Marc Grynpas and Andras Nagy, have been studying the use of stem cells in joint replacement, working with bioengineers, orthopaedic surgeons, veterinary surgeons, bone biologists and stem cell biologists to create replacement joints from a patient’s own tissues. Dr. Kandel has also been working closely with Drs. Robert Pilliar and Ehsan Toyserkani of the Universities of Toronto and Waterloo, respectively, to construct highly personalized joints with the help of a three-dimensional printing machine. “This is a real meeting of minds,” ex-

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Mt. Sinai Researcher Dr. Rita Kandel is helping to pioneer joint replacement technology using a 3D printer. plains Dr. Kandel, who is also Chief of Pathology and Laboratory Medicine at Mount Sinai Hospital. “Dr. Toyserkani uses 3D printing to literally construct the joint using biodegradable material. We then take that joint and use the patient’s stem cells to grow actual tissue (cartilage, etc.) on it. The original damaged joint will be replaced by a joint made entirely of the patient’s own tissues. It’s quite extraordinary.” These ‘bio-replacements’ stand to overcome many of the current limitations of traditional replacements, and could be

used to repair joint tissues damaged by disease or injury, and could also play an important role in intervertebral disc, or even bone replacements. “The joint is a very complex structure of specific shapes and all components have to work together to create the painless movement we experience when we move our knees and elbows,” says Dr. Kandel. “Now, with 3D printing, we can tailor precisely the implant to the missing structure in a patient’s body. This work is a shining example of personalized medicine, because the tissues

that comprise these joints are those of the exact patient who will receive the replacement,” she adds. The team hopes to be testing this innovation in humans in the next few years. “The implementation of these technologies is not far off from clinical care,” notes Dr. Kandel. From printer to bench to bedside…it’s H all in a few year’s work at Mount Sinai. ■ Jyll Weinberg-Martin is a Communications Specialist at Mount Sinai Hospital.

AUGUST 2013 HOSPITAL NEWS

Editorial

UPCOMING DEADLINES SEPTEMBER: 2013 ISSUE EDITORIAL AUGUST 2 ADVERTISING: DISPLAY AUG. 23 | CAREER AUG. 27 MONTHLY FOCUS: Patient Safety/Research/ Infection Control: Developments in patient safety practices. An overview of current research initiatives. Innovations in the prevention and treatment of drug-resistant bacteria and control of infectious diseases, including HIV/AIDS and hepatitis. Advances in the measurement of patient outcomes and program metrics.

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Recovering from disaster – the healthcare response It seems that every time we turn on the news we are bombarded with details about the latest catastrophic event. Internationally, stories like the Boston Marathon bombings, Hurricane Sandy, the factory collapse in Bangladesh and the most recent earthquakes in China overwhelm us with images of devastation, suffering and human tragedy. Although we are empathetic, we can also somehow remain detached from these occurrences because of our geographical distance. But when it’s no longer happening ‘over there’ but in our own backyards, it’s a different story. This summer Canada has faced at least two major disasters as we witnessed Quebec’s Lac Mégantic train disaster and the Alberta floods. As I write this column, the emergency relief efforts are ongoing and although these communities are returning to some state of calm and order, they will never be the same. Many questions have been raised and remain unanswered as to how these types of calamities can be avoided and I’m sure as time goes on we will have new resources and prevention measures to target some of these occurrences, but the truth is that mother nature and human nature will continue to challenge us in new and different ways. In July we also witnessed massive flooding in areas of downtown Toronto that were unprecedented. Images of flooding in the Don Valley with GO train commuters having to be evacuated by boat were equally dazzling and frightening. Thankfully there were few casualties but these extreme scenarios remind us that we need to be prepared for situations well beyond our normal scope of imagining. How do we prepare for these disasters and how do we respond to them when they are occurring? These questions are a major challenge for everyone in the emergency response and health-care fields.

One of the biggest players in relief and disaster response in the country is the Canadian Red Cross, which is part of one of the largest humanitarian networks in the world. They help vulnerable communities in Canada affected by emergencies and disasters and work in partnership with first responders, emergency managers and public officials to support their response activities. They were front-line and centre on the scene in both Alberta and Lac Mégantic.

How to prepare for these disasters and how do we respond to them when they are occuring? But they are also at work before a disaster happens planning for the unexpected. One of their areas of focus is training their volunteer base. In this issue we look at the rigorous and extensive training that they provide for their volunteers and medical personnel before they dispatch them to respond to a crisis situation. The mock hospital, emergency department, operating rooms and housing for medical staff are all carefully planned and need to be executed under the harshest and most chaotic conditions. In times of crisis, a level head, a calm and dedicated team and a detailed plan, carefully executed, are critical to success. And after the initial relief efforts comes the cleanup and restoration. The Canadian Red Cross recently outlined how it will use generous donor dollars to help affected Albertans transition from the relief to the recovery phase following the devastating floods. To-date, generous individuals, organizations and companies have donated more than $25.3 million to their flood relief efforts. They have also collected some $5

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million in support for Lac Mégantic, and these funds will make it possible to provide direct assistance to those affected by the disaster. In this issue we also look at the emergency response of Alberta Health Services (AHS) which coordinated the massive medical relief efforts and also a great deal of the general clean-up operations in the province. They dispatched volunteers that stepped into action performing all kinds of functions, above and beyond the call of duty in the areas most affected by the disaster. “I had the opportunity to meet the compassionate and committed health professionals who are providing care, comfort and support,” said AHS President and CEO, Dr. Chris Eagle, in a statement that was sent to staff, physicians and volunteers during the height of the flood response in June. “In Canmore, I was pleased to tour the hospital alongside Premier Alison Redford and members of her Cabinet. The staff were in good humour, and doing a remarkable job. Everyone – from emergency department physicians and obstetricians, to nurses and other health care staff – was intently focused on their patients, in addition to cleaning and repairing their hospital.” Thanks to their hard work, organization and teamwork, the hospital in Canmore was well on its way to recovery, just days after it was almost completely surrounded by flood waters. “With the emergency now subsiding somewhat in most communities, our focus is shifting to recovery. The situation is no less urgent,” said Eagle. “Thousands of people have yet to return home, where they will face the physical task of cleanup and restoration, and the mental challenges of dealing with what they’ve been through and what is yet to come. This is a marathon, not a sprint – we will be there to help them with their health needs every step of H the way.” ■

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A new facility, a new perspective:

A new beginning St. Joseph’s Health Care London celebrates the grand opening of Southwest Centre for Forensic Mental Health Care By Renée Sweeney

his building fights stigma. When we can all come together and create such a space it allows us to all understand. We can have no doubt that these illnesses deserve our very best.” Those powerful words, spoken by former forensic patient Brett Batten, resonated in the hearts of all those in attendance at the grand opening ceremony of St. Joseph’s Health Care London’s (St. Joseph’s) new facility in Central Elgin-Southwest Centre for Forensic Mental Health Care (Southwest Centre) on June 14. The room was silent as Brett shared his story with dignitaries, community members, and care providers during the day’s formal program. His words are both a testament to the excellent care he received from St. Joseph’s and an affirmation of what the new Southwest Centre means for the future of forensic mental health care throughout the region. The new purpose-built facility houses 89 beds and offers comprehensive inpatient and outpatient services for those with a mental illness who have come into contact with the criminal justice system. 233,640 square feet of contemporary, therapeutic space will facilitate the recovery process for patients and help provide them with the skills to return to full and successful living back in their home communities. Throughout the day nearly 1,000 people came to see the new facility and take a guided tour, providing visitors with a unique opportunity to learn about the building’s innovative design and the Forensic Psychiatry Program. The formal opening ceremony, attended by about 300 people, was led by former El-

“

From left to right: Deb Matthews, Brett Batten, Kathleen Wynne and Dr. Gillian Kernaghan gather outside of the new Southwest Centre for a photo after the ceremony. www.hospitalnews.com

Former patients Brett (left) and Bill raise the flag at the Southwest Centre grand opening ceremony on June 14. gin MPP Steve Peters with participation of several dignitaries, including Premier Kathleen Wynne. “It’s a centre that’s designed not just to treat mental health issues but to promote healing and recovery so patients can successfully return to their communities,” said the Premier during her speech. “The centre represents a new perspective on patient care, one that’s driven by compassion respect and hope.” Dr. Gillian Kergnahan, St. Joseph’s President and CEO, commented on the

journey that made this day a reality. “This vision has been studied, started, stopped, re-shaped and re-started for more than 30 years,” she said. “Now, together, we can truly say, this is the time for mental health care and today marks a major destination point on this journey.” But it was Brett who put it best. Knowing first-hand what this facility will mean for the future, his powerful and candid words brought perspective and purpose to opening and the audience to their feet in a standing ovation.

“When I see this building I am convinced that the individuals who will pass through here will be cared for on many levels. I hope these surroundings remind them that they are not abandoned or forgotten. When I see this building I know my community cares about mental illness. When I see this building I know society H has compassion.” ■ Renée Sweeney is a Communication Consultant at St. Joseph's Health Care London.

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,ĞĂƚŚĞƌ ŚĂƐ ƉůĂǇĞĚ Ă ŬĞǇ ƌŽůĞ ŝŶ ƚŚĞ ĚĞǀĞůŽƉŵĞŶƚ ŽĨ ,/ZK ͛Ɛ ƌĂƟ ŶŐ ŵĞƚŚŽĚŽůŽŐŝĞƐ͕ ĂƐ ǁĞůů ĂƐ ďƵŝůĚŝŶŐ ƚŚĞ ĐĂƉĂĐŝƚǇ ĂŶĚ ĞǆƉĞƌƟ ƐĞ ŽĨ ƚŚĞ /ŶƐƵƌĂŶĐĞ KƉĞƌĂƟ ŽŶƐ ĚĞƉĂƌƚŵĞŶƚ͘ ,Ğƌ ĞǆƉĞƌŝĞŶĐĞ ǁŝůů ĞŶƐƵƌĞ ,/ZK ͛Ɛ /ŶƐƵƌĂŶĐĞ KƉĞƌĂƟ ŽŶƐ ĚĞƉĂƌƚŵĞŶƚ ĐŽŶƟ ŶƵĞƐ ŝƚƐ ƚƌĂĚŝƟ ŽŶ ŽĨ ƐƉĞĐŝĂůŝǌĞĚ ŬŶŽǁůĞĚŐĞ͕ Į ŶĂŶĐŝĂů ƐƚĞǁĂƌĚƐŚŝƉ ĂŶĚ ƌĞƐƉŽŶƐŝǀĞ ĐůŝĞŶƚ ƐĞƌǀŝĐĞ͘ ,/ZK ǁŽƌŬƐ ŝŶ ƉĂƌƚŶĞƌƐŚŝƉ ǁŝƚŚ ŚĞĂůƚŚĐĂƌĞ ŽƌŐĂŶŝǌĂƟ ŽŶƐ ĂĐƌŽƐƐ ĂŶĂĚĂ ƚŽ ƉƌŽǀŝĚĞ ŝŶŶŽǀĂƟ ǀĞ ŝŶƐƵƌĂŶĐĞ ĂŶĚ ƌŝƐŬ ŵĂŶĂŐĞŵĞŶƚ ƐŽůƵƟ ŽŶƐ ƐƵƉƉŽƌƟ ŶŐ ƐĂĨĞƚǇ͕ ƐƚĂďŝůŝƚǇ ĂŶĚ ĐŽůůĂďŽƌĂƟ ŽŶ ŝŶ ŚĞĂůƚŚĐĂƌĞ͘ Ɛ Ă ƌĞĐŝƉƌŽĐĂů͕ ĂŶǇ ƉƌŽĮ ƚ͕ Žƌ ĞǆĐĞƐƐ ƐƵƌƉůƵƐ͕ ŝƐ ƌĞƚƵƌŶĞĚ ƚŽ ƚŚĞ ŵĞŵďĞƌͲ ŽǁŶĞƌƐ͘ ^ŝŶĐĞ ϭϵϴϳ͕ ,/ZK ŚĂƐ ƌĞƚƵƌŶĞĚ ŽǀĞƌ Ψϵϭ ŵŝůůŝŽŶ ƚŽ ŝƚƐ ƐƵďƐĐƌŝďĞƌƐ Ͳ ĨƵŶĚƐ ƚŚĂƚ ŚĂǀĞ ďĞĞŶ ƌĞͲŝŶǀĞƐƚĞĚ ŝŶ ƉƌŽŐƌĂŵƐ ƚŚĂƚ ŝŵƉƌŽǀĞ ƉĂƟ ĞŶƚ ĐĂƌĞ ĂŶĚ ŽƵƚĐŽŵĞƐ͘

AUGUST 2013 HOSPITAL NEWS

Focus

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

Preparing for a disaster Continued from page 1

ERUs like this are critical because they help fill the gap in the immediate aftermath of an emergency when a country’s existing systems can be temporarily overloaded or absent altogether. Prior to deployment, all delegates go through a week-long intensive training program that includes some classroom sessions and a simulation exercise that mimics a disaster or conflict environment. As part of the simulation, the delegates learn to put up the tents that they sleep and work in, get acquainted with the medical equipment and supplies available to them and ‘treat’ volunteers who act as patients. It is a life-like simulation that exposes delegates to challenges they may come across in the field and the types of injuries/diseases they may be faced with. The training also includes a mass casualty simulation exercise. As a Red Cross staff person, I volunteered to participate in the simulation by playing the role of a patient. The response from the ERU delegates during the mass casualty simulation was amazing. Within minutes they were triaging patients based on different levels of injuries and assigning medical and non-medical staff to various tasks to ensure patients were taken care of. The team worked to treat all patients and handled all of the plot twists we threw at them with ease. As would be expected in any mass casualty, there were some challenges in communicating and organizing everyone inside the hospital, but the team was able to identify these challenges and learn new solutions in a debriefing exercise following the simulation. Even though all of the patients knew it was a simulation it was overwhelming to be a part of such a chaotic scene. While my mock injury was non-life threatening, I was quickly treated by a nurse and then taken to a psychosocial support worker who helped calm me. The care that the support worker took

Photo by Johan Hallberg-Campbell

The operating room where Red Cross delegates trained to treat mock patients during the week-long training program. to ensure my well-being was comforting despite the chaos that surrounded me. The simulation left me wondering how it would feel for patients in a real-life situation, and the comfort they must take in knowing that the Red Cross is there for them. To date, the Canadian Red Cross ERU has been deployed to Haiti during the cholera outbreak, and some delegates on the team have deployed to Sierra Leone and Mozambique during cholera outbreaks. Most recently, a surgical team was also deployed to South Sudan to provide additional capacity to a hospital treating war wounded patients. For further information about the ERU or how to become an ERU delegate, please visit the Red Cross website at H www.redcross.ca ■ Jamie Cuthbertson is a Communications Coordinator at the Canadian Red Cross.

Photo by Johan Hallberg-Campbell

During the week-long training program, Red Cross delegates are exposed to many of the challenges they may come across in a disaster or conflict environment.

Canadian Red Cross emergency response unit training can make a difference The Canadian Red Cross is one of the most active non-profit organizations in Canada and responds to a variety of emergency situations both in the country and abroad. From relief for emergencies and disasters to providing support for a range of programs that help people gain vital emergency preparedness skills, the Canadian Red Cross offers an essential layer of support during times of need to individuals who have had to cope with the devastating impact of major, life-altering events. When disasters and other incidents, including armed conflict, break out in a community, it can negatively affect the lives of the most vulnerable people in an area. One of the most important ways that the Red Cross works to provide relief after emergencies and disasters is with Emergency Response Units (ERUs). ERUs can provide efficient and quality HOSPITAL NEWS AUGUST 2013

medical assistance in the aftermath of an emergency and support the long-term health needs of people impacted by it. ERUs are comprised of highly trained and qualified medical professionals, social workers and midwives, as well as technicians and support staff who can ensure that the care provided to individuals is timely, standardized and effective. The Canadian Red Cross has two health ERUs available for deployment in the event of an emergency - one is a field hospital and the other is a field clinic, or Basic Health Care Unit. These ERUs can be sent worldwide within 48 hours of a major incident and can operate for up to four months. Each ERU includes between 10 and 20 staff members, and after being set up in an area, may assist up to 300 individuals each day. http:// www.redcross.ca ■ H www.hospitalnews.com

News

Education 2.0: what’s happening in Bridgepoint’s new learning lab By Jennifer Specht

Educators at work on the simulation mannequin, from left to right, Steve Hall, Kate Pettapiece and Carla Gibson.

n observation room and a high-tech, gender switching mannequin programmed to have various medical issues sounds like something out of a sci-fi film, but it all exists in Bridgepoint Hospital’s new Learning Lab. “With state-of-the-art technology now available to us, the possible uses are endless,” notes Nurse Educator Carla Gibson. “We can use the simulation mannequin to train specific skills or to observe interac-

tions of an interprofessional team during programmed simulations.” Bridgepoint is the only rehabilitation and complex care hospital to have a simulation mannequin onsite for training. Our nurse and allied health education specialists are in the process of learning how to optimize the use of the mannequin to enH hance Bridgepoint’s learning potential. ■ Jennifer Specht is a Communications Specialist at Bridgepoint Health in Toronto.

North York General Launches Scotiabank

language services kiosk By Amanda Monaghan

orth York General, with the philanthropic support of Scotiabank, launched its Language Services Kiosk in June to better serve its diverse community of over 400,000 residents in North Toronto and beyond. For the past 45 years, North York General has been a beacon to all residents of North York in need of the highest quality medical care. Our hospital's mission to provide exceptional health care to our diverse communities is enabled by our newly developed diversity framework which allows us to focus on four components of diversity: cultural competence, spiritual and religious competence, organizational integration and accessibility. The health needs of each patient and family we serve are influenced by their unique cultural practices and traditions. More than 54 per cent of residents living in the catchment area of North York General do not use French or English as their first language. As part of the diversity framework, and through the support of Scotiabank, North York General now offers the Scotiabank Language Services Kiosk. Visitors, patients and family members to the hospital will have access to the kiosk upon arrival. The touch screen kiosk will provide information about the clinical areas in the Hospital, along with directions to those areas in the top seven languages spoken by our patients and families (English, French, Cantonese, Mandarin, Russian, Korean, Persian, and Farsi). Equipped with a printer, the kiosk can provide a printed copy of the information as well as directions to the departments, helping to guide the patients and visitors to their destination. This is one of the many ways that North York General is putting patients first in everything we do. The Scotiabank Language Services Kiosk aligns with our Patient and FamilyCentred Care initiatives, and our approach to the planning, delivery and evaluation of health care partnerships among patients, H families and health care providers. ■ Amanda Monaghan is Communications Coordinator at North York General Hospital. www.hospitalnews.com

From left: Dorothy Wong, Diversity Services Coordinator; Sheila Baker, Volunteer Services; Terry Pursell, President & CEO, North York General Foundation; Dr. Tim Rutledge, President & CEO, North York General; Sandra Smith, VP People Services & Organizational Development; Gareth Dean, PC Support Specialist; Carmel Pulo, Planning Services Coordinator; Luu Nghi, Patient Advisor; and Louise D’Orsay, Stewardship Officer, North York General Foundation.

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AUGUST 2013 HOSPITAL NEWS

Focus

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

Progressive Mobility Program at St. Joseph’s Taking one step at time towards better health By Michelle Tadique

rogressive mobility in critical care is a growing trend in health care worldwide, which aims to keeps patients moving through exercise during their Intensive Care Unit (ICU) stay. St. Joseph’s Health Centre’s ICU team has developed its own Progressive Mobility program to improve the overall function of their patients, to give them the best chance for optimal quality of life once they are discharged. “Through the program we are helping patients to keep their muscles moving, so that when they are ready to go to the ward, they are in a much better physical and mental state because they’ve had some activity,” says Julie Ninnis, Patient Care Manager of the ICU at St. Joe’s. “When I was training as a critical care nurse, the methodology in caring for ICU patients was to keep them sedated, asleep, with the lights off, in a very quiet atmosphere. Yes, these patients do need to rest, but a growing number of studies now are finding that progressive mobility will not harm patients – and will actually help them in the long run,” she says. Keeping patients sedated and inactive increases their risk of delirium and disorientation and can ultimately lengthen a patient’s stay in the ICU, Ninnis explains. The ICU team, including nurses, a physiotherapist, respiratory therapists, ICU assistants, physicians and a pharmacist; collaboratively determine how patients can safely start a mobility program. “Mobility starts with passive movements when the patient is in bed,” says Pat Glover, the physiotherapist in St. Joe’s ICU. “It’s all about maintaining that range of motion and joint movement – and when the patients cannot do it themselves we can do it for them,” she says. Rosie Goulart, an ICU registered nurse,

Pat Glover, St. Joe's ICU physiotherapist, supports patient Bill McDow using the passive-to-active arm and leg exerciser. says the team helps patients do a variety of activities like stretches, sitting up in bed or dangling their feet at the bedside – all great starting points that lead patients to gain the strength they need. Eventually patients can walk around the unit if they are able to. ICU staff also work with families, to get

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HOSPITAL NEWS AUGUST 2013

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them involved in their loved one’s exercise program – helping them do their stretches or walking with them around the unit. “These exercises help patients get better faster and it adds so much value when families are involved,” says Glover. “(The program) helps families as well because they see their loved one sitting in a chair or their feet dangling at the bedside. To them that is a sign of a step forward to improvement,” says Goulart. “I think that the program is great and it has helped the team as well as patients and families understand how important mobilization is,” she adds. Glover explains that ICUs are being outfitted to promote mobility. “We have lower beds now, so that it’s safer for patients to get in and out of bed. There is a lot of equipment coming onto the market to enhance mobility for patients in an acute care setting who may be at a weaker level,” she says. The team is also trialing a passive-toactive arm and leg exerciser to see how our patients can benefit from this type of equipment, Glover adds. ICU patient Bill McDow has used this equipment during his recovery. “This machine is easy to use and I feel great,” he says. The path to developing the program began a few years ago, when the ICU team saw an article in Critical Care Nurse. From there, ICU staff members joined a fivesession webinar series to understand more about progressive mobility for ICU patients. Glover, along with a nursing colleague attended the Critical Care Rehab Conference at the Johns Hopkins Hospital in Baltimore last September. The ICU team took their learnings from the webinar and

conference, as well as gathered input from local hospital colleagues, and pulled together a Working Group. That group focused on developing the program, which launched earlier this year. For patients, it is just as important to support them physically and mentally. “Many patients feel intimidated and feel that they can’t be mobile – so it takes a lot of reassurance and praise, reminding them that it’s just about taking baby steps that will help them over time,” says Ninnis. She adds that the support of the health care team allows patients to initiate movement despite the equipment they need such as tubing, pumps, IV poles and ventilators. This program is important for our patients overall well-being beyond their care in the ICU, explains Ninnis. “It truly is a way we can work to Put Patients First – not just with what we are doing for them today, but to give them the biggest gain in their recovery after their acute illness,” she says. “We are engaging our patients in this process and it shows them that we are all a part of a team working with them. There is a great sense of pride among our staff because they are able to help patients this way.” “Our program is promoting best practice in our ICU and it’s encouraging to see that we are continuing on practices that have started at world-renowned facilities,” adds Glover. “I think this should make our community feel good about what we do here at H St. Joe’s.” ■ Michelle Tadique is a Communications Associate at St. Joseph's Health Centre Toronto. www.hospitalnews.com

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

Focus

‘It’s a roller-coaster ride that I never expected,’ says dad James Steel with tiny baby, Lucas.

Spending Father’s Day in the Neonatal Intensive Care Unit By Polly Thompson

t just over two pounds, baby Lucas was not yet big or well enough to come out of his isolette – but that didn’t stop James Steel from being his dad. Steel never expected to spend his first Father’s Day in the Neonatal Intensive Care Unit (NICU) at The Hospital for Sick Children (SickKids). With his wife Christine, he spends virtually all day at his son’s side. “I talk to him and I tell him, ‘Lucas, you’re going to get better and you’re going to get out of here,” James says. When Lucas was born at just 25 weeks gestation at Sunnybrook Health Sciences Centre this past May, his father had to switch gears overnight. In his profession as a crane operator at CN, James has the sensitive job of safely moving giant shipping containers that weigh up to 80,000 pounds. In the NICU, he focused on every ounce that Lucas gains. Problems with his heart, lungs and bowel made it imperative that Lucas be moved to the NICU at SickKids within days of birth. For James and Christine, spending each day at the NICU is a roller-coaster ride that is made bearable by the skill and support of the medical team, www.hospitalnews.com

and by the encouragement of other parents who say “My baby survived, and Lucas will too.” “James and Christine are doing exactly what they need to do to be a family right now,” says Rita Visconti, parent liaison in the NICU. “Every way that they are providing personal care and attention to Lucas is part of his medical plan too. That’s why family-centred care is now fully integrated into how the NICU operates.” (Visconti knows what they’re going through: she was a mom of triplets in the NICU six years ago.) As James approached his first Father’s Day he wanted other dads and future dads to know that spending Father’s Day in the NICU is special. “It’s special because it will be another day that Lucas gets better, little by little.” Lucas is still being cared for in the NICU at SickKids and is now four pounds two ounces. He is expected to stay at SickKids until the end of August, which was his exH pected due date. ■ Polly Thompson is a Senior Communications Specialist at The Hospital for Sick Children (SickKids). AUGUST 2013 HOSPITAL NEWS

10 Focus

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

New horizons for Ontario’s

air ambulance service

By Dr. Andrew McCallum

ne summer in the late 1980s, when I was still in the early stages of my career in medicine, some emergency residents were given the opportunity to fly as paramedics in Ontario’s air ambulances. As a licensed fixed wing airplane pilot with a background in aviation medicine with the Canadian Forces, I naturally jumped at the chance. During that brief period, I gained an appreciation for the work of flight paramedics, and learned what it was like to take care of a critically ill patient in the back of a helicopter. It was – and is – demanding, stressful work that requires a strong commitment on the part of everyone involved, including the pilots, paramedics, dispatchers and support staff. Since that time, the program has become a vital component of Ontario’s health care system, one that now involves helicopters, fixed wing airplanes and land ambulances, all operating under Ornge, a non-profit charitable organization. Ornge,

it’s also fair to say, has been through a lot recently – a financial scandal, official inquiries, and the political and media spotlight. Now, more than 25 years after I took that air ambulance helicopter flight, I have been given the privilege of moving the organization forward and mapping out a future direction for air ambulance in this province. It is a significant undertaking, but one that energizes me and everyone on the Ornge team. That said, it has been a challenging time for the people at Ornge. On May 31st, we lost four valued colleagues– Captain Don Filliter, First Officer Jacques Dupuy, and Flight Paramedics Chris Snowball and Dustin Dagenais – in the crash of an air ambulance helicopter in Moosonee. While this loss has been devastating for our people, I have been struck by the resilience of our staff through the most difficult of circumstances. They continue to show remarkable dedication to the patients we serve.

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HOSPITAL NEWS AUGUST 2013

To ensure each and every patient receives the best possible care, we continue to support our frontline staff with the proper systems and tools to do the job. To that end, we have come a long way already. We have improved patient care with an interim interior for our AW139 helicopters and are committed to a permanent solution to further improve the paramedics’ work environment. We have introduced certification examinations for our flight dispatchers, flight followers and medical call takers, and have purchased new dispatch software which will be implemented over the next year. This will significantly improve our ability to effectively manage our resources and to communicate with hospitals and ambulance services. With respect to transparency and accountability, we have introduced a wide variety of new measures including a conflict of interest policy, whistleblower protection and public reporting of executive expenses. We are now submitting quality improvement plans and key performance indicator reports annually to the Ministry of Health and Long-Term Care as part of the reworked Performance Agreement with the Government of Ontario. We have appointed a Patient Advocate to ensure questions and concerns over our service are addressed in a timely, professional fashion. These are but a few of the many improvements already implemented. These improvements, however, are just the beginning. There are many other longer-term, system-wide changes that require thoughtful consideration. For example, to arrange a patient transport, a sending hospital often has to make multiple phone calls. While there are a number of excellent resources in the system, particularly Criticall, which is the provincial coordinator of critical care and high acuity bed resources, reviewers such as the Chief Coroner have indicated that we need to integrate the system of transfer and transport to a much greater degree than we do now. As a former emergency room physician in a small town, I recognize that hospital staff are challenged managing a very sick or injured patient, and often have little time to navigate a complex system of transfer and transport. We are working with our partners to simplify and streamline the process in an effort to improve

customer service for our hospital stakeholders. We also need to establish our mission profile to make sure we deploy all our assets and people optimally across Ontario to provide the best service to the most people. Simply put, this means a system that ensures that each patient will receive the vehicle best suited to their needs. For example, you might think that a helicopter will always be faster than a land ambulance. Not so. Our analysis shows that land vehicles win the race within a 35 mile radius most of the time.

We continue to make progress on our goal of transforming Ornge into nothing less than an elite air ambulance operator By contrast, the helicopter is the choice from 35 miles out to about 130 miles. Beyond this, our fleet of fixed wing aircraft is the choice given that these airplanes fly twice as fast as a helicopter. Understanding the mission profile is vitally important given the high demand for Ornge service and the vast reach of the air ambulance system from southern Ontario to the James Bay coast. For issues like these, our approach is to be as collaborative as possible, and we are actively reaching out to our stakeholders in hospitals, EMS services, Central Ambulance Communications Centres and other agencies to ensure there is broad understanding of these ideas. In the early fall, we are convening a two day symposium with key partners and stakeholders aimed at developing our strategic plan for the next five years. That plan will dovetail with the foregoing initiatives, and will set the course for Ornge. It is indeed an exciting prospect. Though I look back fondly on those days 25 years ago, our focus is not on the past but on the future, as we continue to make progress on our goal of transforming Ornge into nothing less than an elite air H ambulance operator. ■ Dr. Andrew McCallum is President and CEO of Ornge. Prior to joining Ornge, he was the Chief Coroner for Ontario. www.hospitalnews.com

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

Focus 11

Family draws on experience with son’s traumatic brain injury to help others cope By Kate Taylor

n the late morning of April 5, 2008, Andrew McCallum was doing what he did most days: walking his shortcut along the train tracks near his house. What made this morning different was that he has no recollection of being there that day. In fact, the only way he even knows he was there is because that’s what the police records show. He’s lucky a neighbour saw him as he strolled the tracks, face bloody and clearly out of sorts. The police and ambulance were called and although McCallum was coherent enough to give them his parents’ phone number, he still has no idea what happened to him. He was rushed to St. Michael’s after a team at St. Joseph’s Hospital determined he had suffered a traumatic brain injury and needed a craniotomy, to be performed by Drs. James Mahoney and Richard Perrin. He awoke seven weeks later in the ICU with no memory of the day he was brought there – or of the previous 10 years of his life.

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During those seven weeks, as McCallum underwent various other surgeries, his family and loved ones interacted with dozens of health care professionals from diverse areas of the hospital – dietitians, social workers, the chaplain, physicians and nurses. “My recovery wasn’t entirely pleasant,” said McCallum, now 37. “I should have died, but I didn’t. I may have lost mobility, hearing, sight, physical sensation, emotional control, and yet somehow I’ve retained it all. I had surgeries, I had infections and I also deeply felt everyone else’s emotional trauma of what had happened.” For McCallum’s father, Ian, watching his son deal with a traumatic brain injury was emotional and overwhelming. While there were a lot of technical manuals to explain what had happened, there was nothing to guide families through coping with the experience and its emotional impact. Ian McCallum decided to take the matter into his own hands and has recently published “From Grave to Cradle,” a narrative of his family’s journey, designed to help others who have under-

Approaching the five-year mark since his accident, Andrew McCallum still regularly visits St. Michael’s for appointments and check-ups but has regained almost of all of his memory. gone or are undergoing similar journeys. “I knew there was an interest and a need for a manual from the patient and family perspective,” said Ian McCallum. “When you fall into that situation you can’t think straight. There is chaos, trauma and fear. I felt I had to pass lessons learned from my multiyear, daily experience with a traumatically injured patient, with health care professionals and with the hospital system that could bring some order to people’s lives who are also going through a similar situation.” The book includes useful information such as to-do lists at various stages in the

recovery process for the family, a first-hand account from Andrew McCallum’s perspective detailing the emotional effects and a list of support networks. The book has been placed on the mandatory reading list for Queen’s University’s introductory nursing course and is being considered by universities world-wide for inclusion in 2014 curriculums. It is also available in the St. H Michael’s gift shop. ■ Kate Taylor is a Communications Adviser for St. Michael’s Hospital in Toronto.

AUGUST 2013 HOSPITAL NEWS

12 Focus

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

SickKids T3 team members Dhanesh Balkaran, Systems Analyst, Norbert Chin, Programmer/Analyst, and Abdellah Djebli, Manager, Storage Services and Unix Systems.

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HOSPITAL NEWS AUGUST 2013

Innovative program

manages flow of information from bedside to enhance clinical decision making predicts a patient’s real-time trajectory By John Pires

n innovative, web-based software tool that captures realtime data from bedside monitors, calculates trends in the data, predicts a patient’s real-time trajectory and visualizes it all on one screen is enhancing clinical decision making in the Critical Care Unit and Cardiac Critical Care Unit at The Hospital for Sick Children (SickKids). Known as T3 (Tracking, Trajectory and Triggering), the software tool went live in early May on the two units. The data generated by the software’s sophisticated algorithms is designed to help staff better assess their patient’s condition and also enables them to be more proactive. By examining the historical data and the trending, staff can take action to change the predicted outcome or quickly see what preceded or possibly triggered a negative event and can take action to prevent further events. T3 is accessible from every bedside workstation and monitor throughout the two units. It is also being pushed to desktops in Critical Care, Cardiology and Cardiac Surgery. Data coming through the monitors is captured continuously for all patients admitted to the CCU and CCCU are stored permanently on a separate server. Data is aggregated, calculations made and then displayed on an interactive, webbased platform. Whether or not the T3 application is open on a particular workstation, the data is being collected and stored. “T3 provides a meaningful view of patient information. I’m hopeful the improved visualization and relationships between data will enrich our discussions at the bedside, improve learning and enhance communication,” says Dr. Peter Laussen, Chief of Critical Care Medicine

at SickKids. Laussen led the development of T3 at Boston Children’s Hospital, where he was Chief of the Division of Cardiac Intensive Care. “My longer-term goal is to form a consortium of hospitals using T3 to collaborate, co-ordinate and collect additional data across an entire network of paediatric units to help predict outcomes based on that data.” At this early stage only data coming through the Philips bedside monitor – such as blood pressure, heart rate and oxygen saturation – is being collected and viewed on T3 at SickKids, but over time additional data feeds from ventilators, infusion pumps and other monitors at the bedside will be incorporated into T3. The CCU attending staff and cardiac surgeons have been assigned “modifier roles” which enables them to set targets and annotate notes. While everyone else has a “user or read only” function, they will be able to interact with the displayed data using a drag-and-drop feature and expanding and contracting time periods. Because it is important to understand how a new tool such as T3 can influence practice and workflow, a graduate student from the Institute of Biomaterials and Biomedical Engineering at the University of Toronto will be studying human factor engineering and the implementation of T3. The Information Management and Technology team at SickKids conducted vulnerability testing prior to going live with the T3 tool, which is standard implementation methodology for all technology solutions at SickKids, and also added enhancements to the software to meet the H needs of SickKids. ■ John Pires is Manager of Internal Communication and Publications at The Hospital for Sick Children (SickKids). www.hospitalnews.com

Focus 13

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

New Physician Assistant

enhancing patient care in Emergency Department By Donna Faye

en Piper realized he wanted to work in the Emergency Department (ED) while doing rotations as a student in the Physician Assistant (PA) program at the University of Toronto. â&#x20AC;&#x153;It is so rewarding to help or refer a patient with something acute immediately,â&#x20AC;? says Piper. â&#x20AC;&#x153;To be able to see the result of your work in one visit is very rewarding.â&#x20AC;? Piper, a Thunder Bay native, graduated from the Physician Assistant Professional Degree Program (BSCPA) at the University of Toronto last year and began orientation at Thunder Bay Regional Health Sciences Centre (TBRHSC) on January 14, 2013. As a Physician Assistant (PA), Piper is a physician extender providing care and performing procedures in collaboration with the healthcare team. Examples include patient interviews and physical examinations to assist in developing treatment plans under the direction of supervising physicians. His role currently centres around the Rapid Assessment Zone (RAZ), getting patientsâ&#x20AC;&#x2122; tests started and performing initial assessments which are then re-

viewed with the physicians. Since he is also trained in minor procedures which include suturing, splinting, and casting, Piper can, under the direction of a physician, perform these non-urgent procedures. "The Physician Assistant is a relatively new role in Ontario and it will take some time to develop it,â&#x20AC;? says Dr. FrĂŠdĂŠric Sarrazin. â&#x20AC;&#x153;We're confident that by attracting quality candidates such as Ben, this position will enhance our efficiency in delivery of quality Emergency Medical care. The physician group is encouraged by Benâ&#x20AC;&#x2122;s enthusiasm and look forward to process changes that will allow us to use Ben to his full potential." How are patients reacting to being seen by a Physician Assistant rather than a Physician? â&#x20AC;&#x153;I think people are just happy that someoneâ&#x20AC;&#x2122;s able to see them quickly and get things started,â&#x20AC;? says Piper. â&#x20AC;&#x153;If they have questions about my role, I just explain that Iâ&#x20AC;&#x2122;m being supervised by the physician on duty.â&#x20AC;? In addition to helping the ED reduce wait times for initial assessments, Piperâ&#x20AC;&#x2122;s

â&#x20AC;&#x153;To be able to see the result of your work in one visit is very rewarding,â&#x20AC;? says Ben Piper, Physician Assistant in the Emergency Department at Thunder Bay Regional Health Sciences Centre. skills and experience are contributing to overall patient safety and enhancing patient and family centred care for emergency patients. Piper follows up by telephone with Left Without Being Seen (LWBS) patients â&#x20AC;&#x201C; those who have registered at the triage desk but have left the ED before being seen by a physician. He may ask them to return to the ED or provide other recommendations and document that information on the patientâ&#x20AC;&#x2122;s file. Piper also follows up with patients in the event of abnormal test results to ensure that appropriate treatments are put in place. â&#x20AC;&#x153;In the past charge nurses would do follow-up calls, but with increasing ED visits, finding time to do this is a chal-

lenge,â&#x20AC;? says Lisa Beck, Director of Trauma Program, Emergency and Critical Care Services. â&#x20AC;&#x153;So this is a big help to the nurses and frees them up to do other things.â&#x20AC;? Piper provides discharge instructions and education to patients and families in hopes of reducing return visits due to complications. â&#x20AC;&#x153;Benâ&#x20AC;&#x2122;s role complements the physiciansâ&#x20AC;&#x2122; and the nursesâ&#x20AC;&#x2122; roles,â&#x20AC;? says Beck. â&#x20AC;&#x153;His role is still developing based on patientsâ&#x20AC;&#x2122; and the departmentâ&#x20AC;&#x2122;s needs, in order to best H benefit the patient.â&#x20AC;? â&#x2013; Donna Faye is Communications Officer at Thunder Bay Regional Health Sciences Centre.

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AUGUST 2013 HOSPITAL NEWS

14 Focus

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

TTP Diagnosis saves lives

Shedding light on a rare autoimmune blood disorder that is considered a true medical emergency By Taryn Byrne

here was nothing that could be done; the diagnosis came too late and Gergana Sandeva was fighting for her life in the emergency department. If just one of the three doctors she had seen before finally being diagnosed with TTP (Thrombotic Thrombocytopenic Purpura) had access to direct information about diagnosing TTP – such as patient order sets which are evidence-based checklists used by medical professionals to ensure that patients are diagnosed and get the appropriate treatment more quickly – her experience may have been different. She could have been diagnosed on her first visit to the walk-in clinic. She could have been started on treatment before her veins collapsed. She could have avoided becoming a near-fatal medical emergency. The Answering TTP Foundation, together with Patient OrderSets.com and hematologists with TTP expertise from Canada, USA, England, and Australia, has developed a set of order sets as well as a discussion document to help speed the diagnosis of TTP. Please join the movement to help

save lives, by adding these TTP order sets to your hospital's working library. Gergana is just one of the countless TTP patients who were not diagnosed until it was almost too late. Unfortunately many other TTP patients continue to suffer irreversible complications, such as kidney disease, stroke, heart attack – or even death – because they aren’t diagnosed soon enough. TTP is a rare autoimmune blood disorder, with three out of one million people diagnosed each year and is considered a true medical emergency. TTP is caused by small blood clots made up of platelets forming throughout the body, restricting vital blood flow, placing organs such as the brain, heart and kidneys at risk for damage. Since platelets are being used up to form these numerous unnecessary blood clots, their availability to perform their normal function is also compromised, and life-threatening bleeding can occur. If TTP is suspected it is crucial that a hematologist is contacted immediately and plasmapheresis treatment is begun without delay. This treatment can mean the difference between life and death for patients suffering a TTP

crisis and offers them the best chance for survival. The Answering TTP Foundation was formed in 2009 by a patient, for patients and families of those affected by TTP. Since that time, Answering TTP Foundation has incorporated and gained charitable status in Canada. Answering TTP Foundation is a Canadian charity run by volunteers both in Canada and internationally. The Foundation is committed to engaging and connecting the TTP community

to further common goals while creating life-saving awareness and raising funds for research to find a cure. The Foundation needs your help to improve the prognosis for TTP patients; and you can do this simply by adding the TTP order sets to your hospital’s working H library. ■ Taryn Byrne is Charitable Programs Director at the Answering TTP Foundation. www.AnsweringTTP.org

Thrombotic Thrombocytopenic Purpura

A patient’s perspective By Gergana Sandeva

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HOSPITAL NEWS AUGUST 2013

or a month I had been experiencing unusual symptoms; headaches, bruising, uising, bleeding gums and constant fatigue. But I knew something was really wrong when I noticed petichea all over my body. I de-cided to go to a walk-in clinic where I had to convince a doctor that I needed blood work because he was sure it was just eczema. After days off not hearing back from the clinic nic about the blood test results I called the lab directly to ask that they forward orward my results to my dermatologist, who I had an appointment with later that at week. They were surprised too see me when I arrived for my appointment. pointment They showed me my lab results, which showed a platelet count of seven and advised that I head straight to the nearest emergency department. Armed with my test results, I arrived at the ED but they too were unable to diagnose me and sent me home suggesting I schedule an appointment with a hematologist the following week. I knew that things were getting worse and time was not on my side. The next morning I went to the ER of another local hospital. They repeated my blood work, asked some questions and then I waited for ten hours. That evening a team of doctors gave me my diagnosis – TTP. I spent the next five hours battling for my life. I needed to receive

life-saving plasmapheresis treatment, however due to my collapsed veins the doctors could not insert my central line. They had given up on me but I remember hearing the apheresis nurse begging a doctor to try again, telling him I had no other chance and that I was dying. Thankfully he decided to give it another try and was successful. I don’t remember much more from that night. I quickly forgot the excruciating pain – all I remember is how lucky I felt to be alive. Not a day goes by now that I don’t feel thankful for my life and feel lucky that my diagnosis wasn’t H too late. ■ Gergana Sandeva is a patient advisory board member at Answering TTP Foundation. www.hospitalnews.com

Legal Update 15

Hospital Employee Vaccinations By Kate Dearden

ospitals are a unique workplace for many reasons, particularly with respect to employee health and patient safety. The question “should flu shots be mandatory for Hospital employees?” is often asked during each flu season. In an October 2012 editorial, the Canadian Medical Association Journal estimated that approximately 50-60 per cent of Canada’s health care workers get an annual flu vaccine.Voluntary measures in place to date have resulted in a reported 22-52 per cent increase. The editorial further stated that the participation rate should be above 90 per cent to adequately protect patients from contracting the flu.

Kate Dearden Many Hospitals have policies, and/or provisions in collective agreements, to exclude workers who have not been vaccinated for the flu. In some cases, the workers are placed on unpaid leave until they are vaccinated or the risk of infection to patients has decreased. In addition to efforts by individual hospitals, various provincial governments have attempted to implement policies to make the flu shot mandatory for health care workers. In November 2012, the Canadian Nurses Association (CNA) published a position statement on its website (www. cna-aiic.ca) on influenza immunization of www.hospitalnews.com

registered nurses. CNA’s position is that influenza is a serious illness, and that immunization is the most effective method of prevention.CNA therefore states that all registered nurses should receive an annual flu vaccine, and that this should be a condition of service in the workplace. Notwithstanding the support from CNA and influenza experts, workers and unions have challenged the policy of excluding non-vaccinated workers from the workplace. The reasons for opposing such policies have included: 1. Complaints about the unpaid leavefor non-vaccinated employees during an outbreak. 2. Failure to consider alternative approaches for non-vaccinated employees such as re-assignment. 3. Breach of section 7 of the Canadian Charter of Rights and Freedoms, which is the right to life, liberty and security of the person. 4. Unreasonable exercise of management rights under a collective agreement With respect to the Charter objections, unions have argued it violates Section 7 of the Charter to suspend an employee without pay for not introducing a foreign substance into his or her body. Hospital employers have typically taken the position that there is no Charter violation because a worker has the choice of whether to be vaccinated. Many labour arbitrators across Canada have accepted the position that a policy of excluding non-vaccinated workers is reasonable.For example, in a 2006 arbitration award from British Columbia involving a nurses’ union, the arbitrator found that the evidence established the policy was reasonable.The policy provided for voluntary vaccination, and the option of taking anti-viral medication if an outbreak is declared.He considered this combination to be “necessary in order to contain the spread of an influenza outbreak in a fragile population.”More significantly, he found that the employees had a “choice in the matter”, even though there could be financial consequences for those who chose not to be immunized. However, in a 2002 Ontario arbitration award involving the Canadian Union of Public Employees, an arbitration panel

framed the issue differently.The panel characterized the policy of excluding nonimmunized workers without pay as follows: In this case the employees have done nothing wrong and they are not ill with the flu, yet they are being prevented from working unless they undergo medical treatment. Clearly if someone were contagious and they were sent home then the sick policy would apply and there would be no issue. The case here is unique in that perfectly well employees are not being permitted to work. The arbitration panel in the CUPE decision concluded that the non-disciplinary unpaid suspension of non-immunized workers violated Section 7 of the Charter. The panel considered the circumstances to amount to enforced medical treatment for which there was no consent. In this case, we note that the employer had not bargained for a provision on un-

paid suspensions for non-immunized workers during an outbreak with this particular union, but had done so with its nurses’ union. As the two cases outlined above illustrate, arbitrators may reach opposite conclusions about non-immunized employees based on similar facts and policies. Whether a particular Hospital policy on employee vaccinations is enforceable will depend on the reasonableness of the policy, and the language in the applicable collective agreement or individual emH ployment contract as the case may be. ■ Kate Dearden is an associate in the Toronto office of Borden Ladner Gervais LLP. She practises labour and employment law, as well as human rights and education law and can be reached at kdearden@blg.com or at 416.367.6228.

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AUGUST 2013 HOSPITAL NEWS

16 Focus

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

Edmonton EMS expedites evacuations

“We help our community. It’s just what we do” By Shelly Willsey

Photo, Evan Yaceyko

Mike Dingle of Calgary EMS poses with Kim Sarsfield, Sal Humberstone and Jay Dell from Edmonton EMS in front of the Multiple Patient Unit, an Edmonton-based emergency vehicle that helped Alberta Health Services quickly relocate patients out of High River and Drumheller during the floods in June.

hen the floodwaters started to rise in southern Alberta, an Emergency Medical Services (EMS) team from the Edmonton Zone of Alberta Health Services was ready to answer the call. EMS sent its Multiple Patient Unit (MPU) and a team of three paramedics to southern Alberta where they worked to relocate patients out of High River and Drumheller. The MPU transports up to five stretcher patients and six seated patients, speeding evacuations. “These members were on duty at the time they were asked, and left for prolonged assignment without hesitation,” says Kevin O’Keefe, Edmonton EMS Metro Supervisor. “The bus was a great tool in helping evacuate hospitals and move patients out of potentially dangerous areas.” On Sunday, June 23, the first team was relieved by a second from Edmonton. In the lull between response and recovery phases, this team trained Calgary Zone EMS staff in operation of the MPU, while also attending Emergency Operation Committee meetings and remaining on standby for further evacuation responses and repatriation assignments. “The important part now is helping to get evacuated patients back to their original hospital,” says Kim Sarsfield, a member of the second team and acting supervisor for Inter-Facility Transfer (IFT) in Edmonton. “In just a day and a half, we were able to train members of Calgary’s IFT, metro and suburban /rural teams on how to use the MPU, and leave them with the right resources so they can do the job as easily and efficiently as possible.” Edmonton’s paramedics returned home Tuesday, June 25, but left the MPU to continue to assist the recovery phase in the Calgary and Central zones. For paramedic Jay Dell, there wasn’t even a question if he should give up time off to assist. “I sat down with my seven-year-old son and showed him pictures of the flooding, and asked him if I should go,” says Dell. His son said yes. “We help our community,” says Dell. H “It’s just what we do.” ■ Shelly Willsey is a Communications Advisor with Alberta Health Services in Edmonton. This story was provided by Alberta Health Services and was originally posted on their website.

HOSPITAL NEWS AUGUST 2013

www.hospitalnews.com

Focus 17

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

AHS Staff

give High River a helping hand By Greg Kennedy

Photo, Paul Rotzinger

Dr. Mark Smillie, a High River-based family physician whose home was flooded, reviews charts with medical student Chelsea Pocock at the Okotoks Health & Wellness Centre.

p to their shins in stinking cellar muck, a trio of speech language pathologists from Calgary couldn’t help but talk “filthy dirty” as they rolled up their sleeves and slid on boots to help seniors at an adult-living townhouse complex clean up after catastrophic flooding. “Some people got tears in their eyes; they were so happy to see us,” says Shara Line who, with her South Calgary Health Centre speech colleagues Tanya Hibbs and Barb Hardcastle, numbered among the hundreds of Alberta Health Services (AHS) staff who volunteered their time and energy to go to High River and help its residents move forward with their lives.

“We were happy we were assigned there,” adds Line. “The seniors there really had nobody to help them clean up. We did the basements of five units. We got all covered in muck. Working in window light, with no electricity, it was quite dark. When you’re going down the stairs, you hit the fourth or fifth step — and then you take a little slip, because that’s where the mud started. No one had been down in these places yet. We were the first.” Hundreds of gritty assignments were taken on in the Town of High River where AHS also contributed by getting the word out to AHS personnel from the region who arrived to staff the High River Re-entry Centre on the town’s Rodeo Grounds. Continued on page 18

Just what the doctor ordered Service ensures meds follow High River residents to Okotoks By Greg Harris

magine having only moments to grab what you need from your home before fleeing ahead of advancing floodwaters. Do you take clothes, some heirlooms or some photos? Prescription medication can be easily overlooked in a hurried decision like that. A temporary service at the Okotoks Health and Wellness Centre has stepped in to help people whose medications were left behind or are running out. “Depending on the circumstances, discontinuing a prescription medication for a day or two could have huge implications,” says Dr. Chris Powell, a family physician who normally practises out of High River and is now seeing patients in Okotoks. “Particularly for elderly people with multiple medical problems, it’s really important that they come in and see us if they’ve been without their normal prescriptions.” Up and running since Monday, June 24, the service was seeing up to 30 patients daily. People who arrived at the centre were triaged through the urgent care unit to make sure they had no outstanding health issues, and then their prescription records were pulled and reviewed with an attending physician. Lori Ellice, a secretary in the Rural Rehabilitation Department, escaped from the High River Health Unit on Thursday with several other people in the back of the High River mayor’s pickup truck. A friend subsequently gave her a ride back to her home. “We only had a few moments to relax and then were told we had to evacuate,” she says. “I was thinking I was only going to be evacuated for a day or two, and so I didn’t grab any medications.” www.hospitalnews.com

Anyone in the High River area whose prescription medications are missing or running out was able to come to the Okotoks Health and Wellness Centre at H 11 Cimarron Common. ■ Greg Harris is a Senior Writer and Communications Advisor with Alberta Health Services in Calgary.

AHS East Lake Centre employees Kristen Brown, Lauren Sutherland and Reynaldo Cruz volunteer to help with the High River clean up. They helped prevent fungal and microbial growth, pulled nails from walls, did general clean up and spoke to residents about their experience.

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AUGUST 2013 HOSPITAL NEWS

18 Focus

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

AHS gives a helping hand Continued from page 17 Emotions, tempers and heartbreak came with the job as volunteers broke the news on the status of flooded homes to returning residents. “For seven days, we ran three shifts to keep the centre open from 8 a.m. to 8 p.m., with anywhere between 20 and 35 volunteers per shift, depending on the day and which neighbourhoods were allowed to return home,” says Carmelle Steel, an AHS co-ordinator of Volunteer Resources, who was there to support her High River counterparts Grace LeDoux and program assistant Robin Carnegie. By phone, email, Facebook social media and every avenue available, Steel and LeDoux put a call out to all AHS staff in High River, Black Diamond, Okotoks, Claresholm, Vulcan and Nanton. “We also tapped into Rockyview Hospital and South Health Campus in Calgary,” says Steel. “We had amazing response from our volunteers, their families and community supporters. Our volunteers certainly played a key role in getting residents home. They put together packages of information on how to clean up after a flood; when to turn your power back on; tips for keeping safe as they cleaned up, and more. “We had people at the door assisting with crowd control because, at times, we had two-hour lineups. We had a long desk with 21 volunteers stationed to give residents the status of their home. Due to the safety issues in the town, we gave out passes for residents to go into their homes, to get in and out of town, because the hardest-hit parts of their community were still not open to the public.”

AHS staff also gave residents information cards that could be hung in their windows: Power Needed; Water Needed; Sewer Needed; Need Fridge Removed; We Need Volunteers. “They literally built on the fly a volunteer force that was responsive to what the town needed,” says Michele Rondot, Manager of Volunteer Resources for AHS Calgary Zone, which encompasses High River. “I have never been so proud of my entire team — how they stepped forward and how they gave so much of themselves to the community of High River,” adds Rondot. “They were awesome, incredible and compassionate. It’s times like these, when our volunteers step up, that reminds me how much I love my job and what I do.” Line, who first witnessed severe flooding as a student in Grand Forks, N.D., says: “It was sad to see the families going through their things to see what could be saved, but they were just so happy and so appreciative that we were there. “But we did manage to rescue an unusual, sentimental treasure that brought a big smile back for one elderly gentleman — his trophy antelope head, with record-size antlers — from a hunting trip he made to Saskatchewan back in 1977. “As we left, he asked: ‘Can I give you H a hug?’ ” ■ Greg Kennedy is a Senior Writer and Communications Advisor with Alberta Health Services in Edmonton. This article was provided by Alberta Health Services and was originally posted on their website.

One resident asks: ‘Can I give you a hug?’ 2

1. View from the High River General Hospital on June 20th. 2. Community paramedic Brenda Stanger mans a first aid table at a Disaster Relief Funding Centre at Connaught School in Calgary. 3. Alberta Health Services medical photographer Mathew Martin, also a member of the 41 Combat Engineer Regiment, starts his day in the cool early-morning hours, examining a flood-ravaged area near Deerfoot Trail in Calgary. 4. Hayley Shepherd, a registered nurse at Foothills Medical Centre, and fellow volunteer Devin Wanamaker distribute bottled water at a Disaster Relief Funding Centre at Queen Elizabeth High School in Calgary.

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Focus 19

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

Building towards system integration for Critical Care:

The Ontario experience Dr. Bernard Lawless and Linda Kostrzewa

ospitals, in particular their critical care units, across Ontario have become familiar with initiatives under the provincial Critical Care Strategy. The Critical Care Strategy was introduced to facilitate improvement across the health care systemâ&#x20AC;&#x2122;s capabilities in managing critical care resources across hospitals. This Strategy encompasses key areas that strive to ensure that current and future capacity needs are met while supporting hospitalsâ&#x20AC;&#x2122; agendas for quality patient care. Across the board, the Strategyâ&#x20AC;&#x2122;s initiatives are underpinned by the core principles of improving access, quality care and system integration in order to build an enhanced critical care system for Ontarians. In collaboration with the Ministry of Health and Long-Term Care (MOHTLC), Critical Care Services Ontario (CCSO) is tasked with implementing the Strategy and relies heavily on rigorous and transparent partnerships with frontline clinicians and health system administrators. â&#x20AC;&#x153;We were initially set up to implement the core initiatives of the Strategy â&#x20AC;&#x201C; a two or three year project,â&#x20AC;? says Dr. Bernard Lawless, Provincial Lead for Critical Care and Trauma. â&#x20AC;&#x153;Seven years later, with ongoing evaluation, the work is not just specifically in critical care, but also in program areas that rely heavily on availability of critical care services.â&#x20AC;? Many of the programs implemented speak to the underlying principle of improving system-level integration and this is only made possible through partnerships at all levels for care provision in the system. One such example is the development of an eLearning tool aimed at supporting members of Critical Care Response Teams (CCRTs). The CCRT Training Program focuses on CCRT-specific skills for clinicians, such as communication and conflict resolution. Through the input of clinical experts and current CCRT members, a five-module orientation and training program was developed. With a pending launch of the CCSO website, the training tool will be available online allowing CCRT members to learn at their own pace. â&#x20AC;&#x153;As it became apparent that success towards system integration was achievable in critical care, CCSO also became involved in supporting the work of Provincial Neurosurgery Ontario, the Ontario Trauma Advisory Committee and effort towards a more integrated system for organ transplantation,â&#x20AC;? says Linda Kostrzewa, Director of Critical Care Services Ontario. CCSOâ&#x20AC;&#x2122;s experience in facilitating policy development and provincially focused change management has been beneficial to this work. This experience in system-level planning has been transferrable to new project areas. Crucial to the implementation of the Critical Care Strategy and of these new project areas is an extensive consultation and engagement process with clinical care providers and system-wide leaders.

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â&#x20AC;&#x153;Bridging these partnerships has been effective in contributing to the success seen in Critical Care Strategy initiatives,â&#x20AC;? says Kostrzewa. â&#x20AC;&#x153;The implementation of programs and initiatives would not be possible without the participation of influential and relevant key groups, including hospital leaders, CritiCall Ontario, the LHINs and our Critical Care LHIN Leaders, as well as the MOHLTC. Everyone brings an important perspective to the table. This provides the input and support

necessary to make system-wide improvements to the provision of critical care. In taking on new projects, frameworks and processes that have been used to achieve some measure of success with previous programs are being applied to ensure consistency and transparency towards consensus-based deliverables.â&#x20AC;? While the scope of CCSOâ&#x20AC;&#x2122;s project portfolio has grown, the goals and objectives for system improvements remain the same. â&#x20AC;&#x153;The common thread throughout all of

the work has been to ultimately support system change in working towards improved access to care, quality of care, and the integration of processes and resources to deliver care,â&#x20AC;? says Kostrzewa. â&#x20AC;&#x153;Hopefully successes can be leveraged across H multiple program areas.â&#x20AC;? â&#x2013; Dr. Bernard Lawless is the Provincial Lead of Critical Care and Trauma, and Linda Kostrzewa is the Director of Critical Care Services Ontario.

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20 Focus

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

Emergency preparedness at

Runnymede Healthcare Centre By Debbie Kwan

coordinated, timely and effective response is critical in an emergency situation to ensure patient safety—the number one priority at Runnymede Healthcare Centre,” says Corinne Wong, Chief Operations Officer. Loss of infrastructure, natural disasters or fires in the surrounding community were considered as examples of incidents that would need to be addressed during the development of Runnymede’s comprehensive Disaster and Emergency Management Plan. This plan ensures that incidents are handled in the most effective manner possible, causing minimal disruption to critical operations and patient care at the hospital. It includes guidelines and resources such as an Incident Management System (IMS) Framework, Departmental Recovery Plans, emergency code policies and a Crisis Communications Plan. A primary component of the plan is the Incident Management System (IMS) Framework, a model that outlines staff, equipment, procedures and other resources that should be utilized in response to an emergency. The framework also provides guidance on how to create and maintain a safe environment. “Education is the key to ensuring an appropriate response in an emergency situation at Runnymede, says Stewart Dankner, Director, Support Services. “This begins at orientation for new staff and volunteers when we teach the importance of emergency preparedness at the hospital, and the role that they play in the response. Patients and visitors are also engaged so that they understand what they should do in

“

an emergency such as a Code Red, and we provide a variety of resources to reinforce this going forward to ensure patient safety is ingrained within our organizational culture.” The Departmental Recovery Plans – which were developed in collaboration with all departments across the hospital – highlight the primary business processes for each department and outlines the alternative ways they can continue to provide services in the event of a disruption to normal operations. This ensures the hospital’s medically complex patients will continue to get the care they require. Runnymede’s state-of-the-art facility has numerous built-in redundancies, another mechanism that keeps the hospital appropriately prepared to maintain critical functions in an emergency. Failsafe telephones are located on the patient floors and in other essential areas of the hospital such as at reception and in the pharmacy, guaranteeing open lines of communication at all times. Similarly, backup generators re-route power to vital healthcare equipment such as IV pumps and feeding tubes in the case of a power failure. Leading-edge synchronized transfer switches –sometimes referred to as “make-beforebreak” switches – further act as safeguards for the hospital’s energy systems. Through the synchronization of independent power sources, energy flow should remain uninterrupted, and the momentary disruptions that might typically occur from the transfer of energy sources in other facilities should not be noticed at Runnymede. Another innovative design feature of the hospital is Runnymede’s building auto-

Chief Operations Officer, Corinne Wong (centre) with Director, Support Services, Stewart Dankner (left), and Risk Management and Safety Specialist, Kevin Maloney (right) in the Central Alarm and Control Facility (CACF) room at Runnymede Healthcare Centre. mation system (BAS). A distributed control system that monitors device failures and optimizes the performance of heating, ventilation, air conditioning and alarm systems, the BAS reduces energy use and notifies staff if a malfunction occurs. Housed virtually on the hospital network, the BAS is accessible from anywhere, allowing seamless monitoring and the identification of changes as they happen. This information facilitates effective decision making in an emergency and guides the best use of staff and resources. Runnymede also has a dedicated resource to champion emergency preparedness at the hospital. The Risk Management and Safety Specialist leads education and training initiatives for staff, volunteers, patients and visitors, and ensures they understand what they should do in a crisis in order to protect themselves and each other from harm. A significant part

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of this education consists of emergency code procedures and is provided on an ongoing basis. An emergency code is an alert for a critical event that requires immediate action and is denoted by a standardized colour set by the Ontario Hospital Association for hospitals in Ontario. Standardization across hospitals and healthcare organizations facilitates effective communication and coordination between organizations and their stakeholders and is especially useful when organizations are affected by the same emergency. Annual Safety Week is another event for staff and volunteers at Runnymede to advance their knowledge of emergency code procedures through a diverse range of resources such as presentations, videos, quick reference guides and hospital-wide competitions. The hospital also implemented a Code of the Month initiative, which highlights a different code each month and the salient steps that need to be taken in response. Advertised in high traffic areas throughout the hospital, this initiative has received positive feedback and support. The crisis communication plan, another facet of the Disaster and Emergency Management Plan, provides procedures for the co-ordination of communications within Runnymede, and between the hospital and any applicable external stakeholders (e.g. emergency responders) and the public, in the event of an emergency. This plan not only addresses media relations issues and the communication methods for responding to situations quickly and effectively, but it helps to restore confidence and reassure staff, patients and visitors. Emergencies can happen at any time and when least expected. Providing ongoing education and having a comprehensive Disaster and Emergency Management Plan in place not only fosters a culture of emergency preparedness at Runnymede, but ensures the hospital maintains a strong commitment to the highest standards of H quality and safety. ■ Debbie Kwan is a Communications Associate at Runnymede Healthcare Centre. www.hospitalnews.com

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

Focus 21

St. Michael’s tight squeeze: Maximizing an outgrown ED

By Emily Holton

he Emergency Department at St. Michael’s Hospital in downtown Toronto sees 72,000 patients per year – in a space built for 45,000. “We have some pretty severe space restrictions, and we are always working to get wait times down,” said Dr. David MacKinnon, deputy chief of operations for the ED. “At the same time, our ED patient volumes are growing alarmingly fast, at about five to eight per cent per year. We needed a new model that would go a long way to maximize our space and help us see patients as quickly as possible.” “Rapid Assessment Zones” or “RAZ” are in use in several hospitals on a small scale, but St. Michael’s recognized the model’s space-saving potential and implemented it for 60 per cent of its patients. Six months later, the result is a shorter wait for patients, thanks to a much more efficient use of what is a hot commodity in St. Michael’s tight quarters: exam rooms. St. Michael’s is a Level 1 trauma centre equipped to receive the most severely injured patients. However these patients make up a relatively small portion of the total ED patient population. Almost two-thirds of the hospital’s ED patients – about 120 a day – are considered “minor.” That means that they may need tests or medication but are still reason-

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ably comfortable sitting up and walking around. Traditionally, “minor” patients would wait in an ED exam room for their initial assessment with a physician or nurse practitioner and remain there until all tests were complete and results analyzed. With RAZ, these patients are hived off to a small, dedicated waiting area right outside a bank of exam rooms. Patients enter exam rooms only to interact with a physician or nurse practitioner, after which they leave the room and move on to another, nearby area to wait for test results. The quick turnover frees up the exam rooms for the next patients. Each stage in the RAZ patient’s journey – from triage to the first waiting area, exam room, results area and then the exit – is located next to the previous one, with just a short walk between. If the wait time to see a physician reaches more than two hours, the RAZ model also enables nurse practitioners to step in to assess the next patient waiting in line. In the past, nurse practitioners would see only patients triaged to them, based on the patients’ specific complaints. “Having nurse practitioners and physicians working side by side has been a great change,” said Dr. MacKinnon. “Our patients are happier because they’re moving faster. And it’s a more collaborative

Pa ents with less urgent condi ons wait in a dedicated “Rapid Assessment Zone” instead of exam rooms, freeing up the rooms for the next consulta ons. environment for our staff.” Patients deliver their own charts from triage to the RAZ coordinator, reducing the steps in the staff’s process. The St. Michael’s model is unique in that the RAZ coordinators do not have a clinical background. They focus on flagging excessive wait times, addressing administrative or logistical roadblocks and coordinating the frequent exam room changes. The resulting reductions in wait times extend beyond RAZ patients; when the RAZ stream moves faster, “intermediate” patients on the cusp of “minor” can be retriaged to RAZ, reducing bottlenecks for the sicker patients. The St. Michael’s ED opened in 1892, consisting of a one-room emergency, a simple outpatient clinic and 26 beds. After several different incarnations, the ED moved to its current location in the hospital in 1983 and has changed little since. Plans are underway to renovate St. Michael’s ED by 2018

and almost double its size. “We thought the RAZ model would be a good shortterm solution to keep us functioning until the new ED is built,” said Dr. MacKinnon. “But it’s worked so well that it’s now our new normal. It may sound like a lot of transitions for patients, but that’s part of the benefit – it’s healthier for ‘ambulatory’ patients to be up and walking around. We’ll continue with RAZ even when we have more space.” Along with several more exam rooms, the new ED will feature quiet and comfortable waiting areas for family and friends, dedicated care space for mental health patients and additional, confidential workspace for ED staff. All design decisions are being made with the patient experience in mind, based on the best H available evidence. ■ Emily Holton is senior communications adviser at St. Michael’s Hospital in Toronto.

AUGUST 2013 HOSPITAL NEWS

22 Nursing Pulse

Celebrating a decade of evidence-based care By Melissa Di Costanzo

n the 10th anniversary of the Registered Nurses’ Association of Ontario’s (RNAO) Best Practice Spotlight Organization (BPSO) initiative, nurses share their successes implementing evidencebased guidelines into daily practice. Gordon’s* foot ulcer was just not healing. The toonie-sized wound, located below the 50-year-old’s ankle, had been growing steadily for months. Gordon, who was uncomfortable and at risk for developing an infection, was diabetic, which meant the limited flow of blood to his foot was hampering his recuperation. His physician was fairly certain the wound was not going to get any better, and prepared Gordon for the worst: a possible below-theknee amputation. The wound care team at Saint Elizabeth, a national home health-care organization based in Markham, was asked to step in. Using best practice standards, they performed an assessment of the wound and its underlying causes. They instructed their new client to take pressure off his foot whenever possible, selected dressing materials that would enable the wound to heal, and offered advice on foods rich in protein that would help him to better manage his condition, and help heal his stubborn sore. All of these evidence-based nursing practices can be found in the Registered Nurses’ Association of Ontario’s (RNAO) Best Practice Guideline (BPG) Assessment and Management of Foot Ulcers for People with Diabetes. The nurses talked to Gordon about his options, and because they could articulate best practice recommendations that were backed by research,

RNs:

he was receptive to the lifestyle changes they recommended. Gordon defied the prognosis offered by his doctor and, in five months, his foot ulcer was healed. He had a much better understanding of his diabetes and how to prevent future wounds from forming. His case is not unique, says clinical resource nurse Kay McGarvey, who works with the wound care team and nursing staff to ensure patients receive care that reflects best practice recommendations. In fact, she can think of several instances when RNAO’s BPGs have contributed to more effective wound healing, and have potentially saved limbs.

"We have seen outcomes that are nothing short, of formidable, and we are not done yet." “I’ve seen too many cases where (a clinical situation) has gone poorly,” she says, adding that because nurses have adhered to and advocated for use of recommendations in RNAO’s BPGs, patients’ care has improved, in some cases, dramatically. Outcomes collected by Saint Elizabeth back McGarvey’s claim. The organization has successfully reduced the average time it takes nurses to complete lower leg assessments on clients with diabetic foot ulcers. The organization has also seen an increase in the percentage of clients who meet its 30-day wound healing target. Before implementing 19 of RNAO’s

guidelines, nurses mostly relied on anecdotal evidence with outcomes that were not tracked. The BPGs now help nurses structure client care and “articulate what we’re trying to do and why,” explains McGarvey. They also boost nurses’ confidence when talking to patients and other practitioners, she adds. These are some of the reasons Saint Elizabeth is proud to have implemented so many of them. This year, the home-care organization celebrates its 10th anniversary as an RNAO Best Practice Spotlight Organization (BPSO®). Designation as a BPSO involves a competitive application process, and is reserved for health-care organizations and academic sites that successfully implement a minimum of five clinical BPGs in the first three years of the formal agreement, and commit afterwards to ongoing uptake of new guidelines and evaluation of their impact on outcomes. “To see the evolution of our organization as one that uses evidence from the bedside to the boardroom to give the best care possible to get the best care outcomes for our clients, and to engage our staff in that process…that’s why we continue to be a BPSO,” says Nancy Lefebre, the home care organization’s chief clinical executive and senior vice-president of knowledge and practice. Saint Elizabeth is not alone in witnessing a transformation. Sixty eight BPSOs, representing 298 sites across Ontario, Quebec, and outside Canada, have formally joined the BPSO program and are systematically implementing numerous BPGs, and engaging in outcomes evaluation. RNAO began developing guidelines in 1999. Today, there are 48 clinical and

Membership in RNAO satiﬁes the professional liability protection (PLP) requirement of the CNO

RNAO membership is available to lapsed and new members through to October 31, 2013. 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, CNA’s journal the Canadian Nurse, essential email updates, educational resources, group rate savings on home & auto insurance, effective advocacy that speaks out for nursing …and more. Yes, even at this low rate, you will receive memberships in 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 2013.

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healthy work environment BPGs. Thanks to continued support from the provincial government, more are on the way. The association also maintains a rigorous guideline review and revision cycle, and robust implementation strategies such as institutes and the Best Practice Champions Network. The latter was developed in 2002 to support nurses and other health-care professionals who are passionate about implementing BPGs. Through this program, well over 10,000 volunteer champions access tools and strategies such as workshops and teleconferences to help support use of BPGs in their workplaces. By 2003, RNAO’s Chief Executive Officer Doris Grinspun wanted to take BPG implementation a step further, and worked with the association’s staff to create a structured approach for organizations to use BPGs and evaluate their impact. Thus the BPSO program was born. Looking back, Grinspun couldn’t be more pleased: “My vision was that we would contribute to demonstrating how nursing care, based on evidence contained in our BPGs, can improve patients’ health, and organizational and system outcomes,” she says, adding “we have seen outcomes that are nothing short of formidable, and we are not done yet.” Though the program is based in Ontario, its influence and reach is international. BPSOs have been established in Chile, Colombia, and the United States. RNAO has also partnered with two large BPSO Host organizations in Spain (government) and Australia (nursing union). Both act as RNAO satellite sites, ensuring BPG implementation in several health-care organizations in their countries, using RNAO educational materials and methodology. Apart from the sheer growth of the program, Grinspun is also extremely proud that it has ignited passion for the profession at the clinical level. “This has brought the focus back to where it matters most: the patient and the front-line care provider who is trying to deliver the best possible care.” Currently, 14 organizations from Sarnia to Tavistock to Burlington to North Bay are hoping to become BPSO designates, having been accepted into the initiative last year. If they meet the requirements, they will become designates in 2015. This is an excerpt from a longer feature published in the March/April 2013 issue of Registered Nurse Journal, the Registered Nurses’ Association of Ontario’s (RNAO) bi-monthly magazine. To read some of the other success stories featured in the magazine, including stories from hospitals in Windsor, Toronto and Sudbury, visit www. RNAO.ca/resources/rnj/back-issues. To access information about evidence-based practice, the BPG and BPSO initiatives, or for a complete list of RNAO’s clinical and healthy work environment BPGs, visit H www.RNAO.ca/bpg ■ Melissa Di Costanzo is staff writer for RNAO. www.hospitalnews.com

Focus 23

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

Unique Response to victims of assault By Catalina Guran

Mackenzie Healthâ&#x20AC;&#x2122;s DASA Care Centre serves individuals and families who have experienced: â&#x20AC;˘Domestic Abuse /Assault â&#x20AC;&#x201C; An act of power and control by a person over his/her current or past partner, spouse, boyfriend or girlfriend. It can include physical, sexual, financial or emotional abuse. â&#x20AC;˘Sexual Assault/Abuse â&#x20AC;&#x201C; Any form of sexual activity with another person without his/her consent. â&#x20AC;˘Sexual Harassment â&#x20AC;&#x201C; Unwelcome, uninvited remarks, gestures or actions of a sexual nature that make a person feel unsafe or uncomfortable. â&#x20AC;˘Criminal Harassment â&#x20AC;&#x201C; A pattern of threatening conduct that causes a person to reasonably fear for their safety or the safety of anyone known to them.

exual assault, domestic violence, human trafficking and criminal harassment are traumatic events and unfortunate realities in todayâ&#x20AC;&#x2122;s society. Those involved often need medical treatment and emotional support, and subsequently become part of criminal investigations. That is where a unique new partnership is helping to create a more compassionate response to those who have experienced a sexual assault or domestic violence. Thanks to a new partnership between Mackenzie Health and York Regional Police, patients who have been assaulted can now speak to police while still in hospital, eliminating the need to visit a police station separately. Following treatment for injuries resulting from assault and counselling by specially trained Domestic Abuse and Sexual Assault (DASA) staff, patients who arrive at Mackenzie Richmond Hill Hospitalâ&#x20AC;&#x2122;s Emergency Department now have the option to have a formal interview with York Regional Police within the hospital. Investigators can speak with patients who have experienced an assault and any persons who may have witnessed the assault in private, comforting surroundings, while a second investigator records the process on video and takes notes from an adjoining room. Removing the need to attend a police station after being treated in hospital also reduces the potential for ongoing trauma or deterring patients from continuing with criminal proceedings or medical treatment. The interview and monitor rooms provide the best evidence-gathering capa-

bilities, streamline the process and reduce trauma and stress that results from changing locations. â&#x20AC;&#x153;Our staff address the medical, emotional and forensic needs of our patients in a confidential, safe and non-judgmental manner,â&#x20AC;? says Frances Reinholdt, Operations Director for the Medicine and Emergency Program at Mackenzie Health. â&#x20AC;&#x153;Mackenzie Health is proud to be able to offer an expanded collaborative service with York Regional Police in a new â&#x20AC;&#x2DC;softâ&#x20AC;&#x2122; interview room where patients will be able to give a statement to police without having to leave the hospital.â&#x20AC;? This is all possible through the donated use of space by Mackenzie Health and funding from the Ontario Ministry of the Attorney General. The money was provided through the Civil Remedies Grant Program, a fund that assists law enforcement agencies across Ontario in purchasing state-of-the-art equipment and establishing programs that reduce unlawful activity and support victims of crime. At Mackenzie Richmond Hill Hospital, the grant was used for the soundproofing, monitoring equipment and furnishing of the rooms. Ontarians who experience sexual assault, domestic violence, human trafficking or criminal harassment and go to a hospital emergency department have the right to receive the best possible care available. The interview and monitor rooms within the DASA Care Centre are a great example of government, healthcare and law enforcement working together to help people in York Region in times of distress. The partnership is also testament to

Mackenzie Healthâ&#x20AC;&#x2122;s efforts to relentlessly improve care to create healthier communities, and create a world-class health experience.

More on the Mackenzie Healthâ&#x20AC;&#x2122;s DASA Care Centre Mackenzie Health is a regional healthcare provider for Southwest York Region offering much needed healthcare services through the Mackenzie Richmond Hill Hospital and the future Mackenzie Vaughan Hospital, as well as a network of community services located in Vaughan, Richmond Hill and the surrounding communities. Mackenzie Healthâ&#x20AC;&#x2122;s DASA Care Centre is a regional centre for the care of patients who suffered sexual assault and/or domestic abuse and offers services free of charge. At the DASA Care Centre, confidentiality is respected and language interpretation services are available. DASA Care Centre staff are registered nurses who are trained in forensics and trauma related to abuse and assault. They care for individuals and families who have experienced criminal harassment, sexual harassment, sexual assault and domestic assault by treating and documenting injuries, conducting risk assessments and preparing safety plans. The DASA Care Centre also provides client counseling and support to H family members and caregivers. â&#x2013; Catalina Guran is a Communications and Public Affairs Consultant at Mackenzie Health.

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AUGUST 2013 HOSPITAL NEWS

24 Focus

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

Pam Durocher, ED Clinical Nurse Educator assists Mike Bedard, Environmental Services staﬀ with his PPE (Personal Protec ve Equipment) while Kari Loach, Environmental Services Supervisor looks on during a recent Code Orange training exercise.

Code Orange at North Bay General Hospital Re-evaluating emergency preparedness at the new hospital site By Lindsay Smylie Smith

hen the staff from the former Northeast Mental Health Centre and North Bay General Hospital moved into their brand new, state-of-the-art facility in January of 2011 there was a lot of changes— and emergency preparedness was one of them. “The move to the new hospital forced us to re-evaluate and change our plans for everything,” explains Eric Bouchard, Emergency Department Manager. “The emergency department alone is three times the size it was at our old site. It became clear very quickly that our plan did not suit our new physical space.”

The new North Bay Regional Health Centre is located on a 32 hectare site adjacent to Highway 17. The District Hospital has 275 acute care beds and the Regional Mental Health Centre has 113. Combined, the hospital has a gross area of 70, 171 m2. The first year after moving into the new building was full of changes, including the amalgamation of the former hospitals into the North Bay Regional Health Centre. Ellie Naismith, Coordinator Parking Security and Emergency Response says there were so many changes and adjustments for staff, that the emergency response plan wasn’t front and centre. “It took time to get in and get used to our

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new surroundings. Then we were ready to tackle the new plan.” Naismith says there were also a few events in and around the North Bay area that really pushed the need for an updated plan. “There was an overturned tanker truck that leaked formaldehyde into Trout Lake, a lightning strike directly across the highway from the hospital caused a gas pump fire, and some other emergencies in the region that threatened to have an impact on our hospital.” “We knew more players had to get involved because of the physical layout and sheer size of our new hospital. We had to figure out how we were going to set up for an emergency, how things would flow,” Bouchard says. A multidisciplinary group comprising of representatives from the Emergency Department, Health and Safety, Environmental Services, and the Laboratory began to meet bi-weekly to create a new plan that would meet the needs of the new facility. “One of the successes is having this great cross section of staff from the hospital, each bringing different perspectives,” Naismith says. “At this point we have mainly been working on Code Orange & CBRNE.” Naismith says the size of the new building has enabled the committee to plan for scenarios that they never could before. “In a small or large surge respiratory scenario, we have the capability of changing one of our 32 bed inpatient units into a

negative pressure unit. Also other areas such as our ambulatory care unit and our gymnasium can be utilized if needed,” Naismith says. “We also have the ability to instantly lockdown the building with the security software.” Training staff and getting their buy-in was the next step. “All of our emergency department and environmental services staff have to be trained,” Naismith says. “The environmental services staff are key to setting up everything and helping to make sure patients are transported properly to prevent contamination of the rest of the building.” Bouchard says to date about 60 per cent of the emergency and environmental services staff have been trained. “We have had two training sessions, with a third planned in the fall. They are full day sessions from eight am to four pm with a debrief at the end of the day. The feedback from our frontline staff about what went well and what could be improved upon has been helpful in framing our next sessions.” Bouchard says after some initial hesitation, the staff have embraced the training and are asking to sign up for upcoming sessions. “Our staff have bought into the idea that is all about safety—we want to keep you safe, and to be safe you need to have H this training.” ■ Lindsay Smylie Smith is a Public Relations Consultant at North Bay Regional Health Centre.

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Focus 25

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

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O C TO B E R 2013

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AUGUST 2013 HOSPITAL NEWS

26 From the CEO's Desk

Achieving excellence through cultural transformation By Dr. Dave Williams

for this young mother with complex medical conditions. As healthcare professionals, it is both part of our culture, but it is also something we don’t take for granted. These transformative moments are the opportunities that we all strive for.

his is both an exciting and a challenging time in healthcare. There are a myriad of challenges facing hospital administrators – an aging population; a growing number of people with complex chronic diseases; operational financial pressures; and accountable care initiatives that focus on the delivery of patient-centred safe, high quality healthcare. There has never been a greater need for innovation in developing solutions that bring value through clinically effective, cost effective care. At Southlake Regional Health Centre, our approach to creating sustainable change is focussed on shifting the culture across the entire organization. The word culture can be interpreted in many different ways. At Southlake, it is The Southlake Way – the way we interact with each other; the way we think; the approach we take to problem solving; and our commitment to living our core values, every day. The Southlake Way is our commitment to the importance of organizational culture and falls under the leadership of our Director of Culture and Communication. Our evolving culture has enabled us to work towards creating value in healthcare without compromising quality outcomes. We are relentless in our commitment to build an environment that expects and embraces high performance, celebrates tradition while welcoming innovation, and focuses on safety and quality. Our physical transformation over the past decade has been dramatic. Now, our focus has shifted from building our infrastructure to using it to build upon our culture as a high-reliability organization where safe, high-quality healthcare is pivotal to exceeding the expectations of our patients. Our evolving culture is represented in our Vision – Shockingly Excellent Experiences, a proclamation that Southlake is creating a culture that thrives on delivering safety & quality, innovation, patient-centred care, and providing excellence to everyone we interact with – patients, team members and partners.

Safety & Quality As healthcare professionals, we come to work each day with a set of beliefs and priorities that are formed by our individual life experiences. When I joined Southlake two years ago, I brought with me a heightened sense of the importance of safety and quality acquired from working in the aerospace sector, coupled with an understanding of the importance of core values, in building trust and developing culture. Delivering excellence in healthcare in an environment that respects safety is something patients and staff expect yet it takes a dedicated daily commitment to achieve. As an emergency physician and later as an astronaut, I have spent my career working in zero fault-tolerant environments, where errors can have significant consequences. However, it was not until I became an astronaut that I learned of the importance of human factors, risk mitigaHOSPITAL NEWS AUGUST 2013

Patient-Centred Care

Dr. Dave Williams is CEO and President of Southlake Regional Health Centre. tion and culture in achieving peak performance in these environments. A zero fault-tolerant culture differs from a zero fault-tolerant environment in that there is an understanding that as humans, we are fallible. Yet in healthcare there is the expectation that we will perform without fault. In order to deliver safety and excellence in healthcare, we must reconcile human fallibility with the need to eliminate errors by embracing a system of checks and balances; to use error-trapping to create a zero fault-tolerant culture. Error-trapping every day in every department and at every step is instrumental in developing a zero fault-tolerant culture. The space program accomplishes seemingly impossible objectives by embracing the credo Fail Ops Fail Safe meaning that the first error or anomaly will result in a situation where normal operations are not compromised. A subsequent second error will not impact safety. In fact it would take three sequential errors or anomalies before safety could be compromised. This error-trapping is achieved by building redundancies into the system – not unnecessary procedures, but rather additional processes to ensure errors do not impact operations. In healthcare there are many potential single point failures where an error or technology failure can immediately impact patient safety. If we have the ability to provide care with redundancy built

in, we build a higher expectation for safe outcomes. Southlake recently implemented Quality Huddle Boards for department-specific error-trapping. Whether it is the medicine unit, emergency department or administrative offices, they provide every member of the team with the ability to identify, discuss and address quality and safety concerns while immediately generating solutions. The Rapid Response Team, part of the Safer Healthcare Now initiative, is another example of a process that empowers staff to ensure that safe, quality healthcare is at the forefront. If a patient’s physiological state is called into question by any team member at any time, this team rapidly assembles to proactively intervene and determine next steps.

Innovation Another key way in which our Southlake culture supports our Vision is through innovation to push the envelope and find better solutions for our patients. Justine, a 35-year-old wife and mother, spent Christmas day with her family last year feeling ‘safe’ about her health for the first time in a long time. She became the first person in North America to receive an MRI-friendly implantable cardioverter defibrillator. Southlake’s Heart Rhythm team searched around the world to seek out a solution

To focus our efforts to evolve and develop our culture, Southlake recently created a new five-year strategic plan. While we are working to take a number of bold steps in healthcare safety and innovation, one of my favourite commitments within this plan is that we will treat patients like family. Isn’t that a nice thought – to treat patients with the same care and respect we would treat those closest to us? Whether this is a cultural shift, or simply formalizing what most of us already subscribe to, this philosophy of patient-centred care is truly impactful. I am very passionate about our institutional commitment to hand-hygiene as it crosses all of our cultural initiatives, safety & quality, innovation, and patientcentred care. This is an aspect of patient-centred care that literally places success in the hands of every single person who interacts with patients. Just a couple of years ago, Southlake had an overall score of 60 per cent hand-hygiene compliance. Now, we are continuously over 90 per cent. How did we achieve these remarkable results? We made it part of our culture. We communicated why it was important and, even took it one step further by going ‘Bare Below the Elbows’, asking members of the Southlake team to roll up their sleeves and take off their jewelry while on patient care units. We have included patients in our handhygiene efforts by placing sanitizer dispensers at the foot of beds in our Medicine Unit. That way, patients see that we are actively seeking to protect their wellbeing by cleaning our hands and they can encourage family members to comply as well. We have made it a part of our culture to seek and share solutions. Our culture is woven into every interaction, whether with patients, between members of our team or with our partners. It means walking the talk and making commitments. At Southlake, we are very proud of The Southlake Way. We have defined this as a culture that characterizes the qualities of compassion, innovation, excellence, and the ability to create opportunities out of seemingly impossible challenges. When I came to Southlake I had learned about the transformative power of culture from my varied work and life experiences. What I have learned in this dynamic healthcare environment is that culture is something that evolves every day in very meaningful ways to ensure sustainable high quality care. I am thrilled to H be part of the journey. ■ Dr. Dave Williams is CEO and President of Southlake Regional Health Centre. www.hospitalnews.com

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Researchers question practice of automatically transfusing large amounts of blood to trauma patients By Leslie Sheperd

esearchers at St. Michael’s Hospital are asking questions about the practice of automatically transfusing large amounts of blood and blood products to trauma patients with major bleeding. Trauma patients were resuscitated primarily with blood until the second part of the 20th century when the practice was modified so that blood transfusions were given only after lab tests suggested they were needed. The idea of resuscitating primarily with blood was revived after U.S. military physicians in Iraq and Afghanistan reported in 2007 that this practice was associated with dramatic drops in mortality.

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Hemorrhaging, coupled with poor blood clotting, remains one of the leading causes of preventable death after trauma, and blood-based resuscitation was quickly adopted in both military and civilian trauma centres. Many researchers, however, questioned this practice and raised concerns about the risks of transfusing patients who may not need blood. Researchers led by Dr. Sandro Rizoli, the new trauma director of St. Michael’s, published recently in the Canadian Medical Association Journal the results of the first prospective study comparing bloodbased resuscitation vs. conventional resuscitation and found higher rates of complications in the former group with no statistical difference in mortality rates. Trauma patients, by the very nature of their injuries, bleed a lot and often receive large amounts of blood. Physicians have known since 2003 that one-quarter of trauma patients do not clot well, which worsens their blood loss and increases their already high risk of dying at least three times. Until then, the conventional practice to resuscitate trauma patients was to give them saline or water intravenously and give blood transfusions only when a blood test diagnosed a coagulation defect. U.S. military physicians postulated in 2007 that it made more sense to give blood preemptively to everyone rather than wait to see whether the patient was the one in four with poor clotting and was at risk of dying while waiting for the test results. Since blood banks no longer store whole blood, patients are given equal parts of red blood

cells, plasma and platelets, a formula known as 1:1:1. All research studies so far looking at the effectiveness of 1:1:1 have been retrospective, where researchers go back and look at patient records to see what happened. They also have other limitations known as statistical bias where it is not clear whether the intervention (giving plasma) was making patients live longer, or whether they were getting the intervention because they were already living long enough for the plasma to be thawed (plasma takes 20 minutes to be ready for use). Once thawed, plasma must be used within 24 hours or discarded at a cost of about $500 a unit, so hospitals are reluctant to keep large amounts of thawed plasma on hand. Dr. Rizoli led a randomized control trial at Sunnybrook Health Sciences Centre in Toronto comparing 1:1:1 and previous standards of care (using saline and-or water while waiting for lab tests). He said that while the study was small and showed no statistical difference between the two practices, it showed more wastage of blood and more respiratory complications on the 1:1:1 patients, proving that researchers could – and should – do more clinical trials in this area. He is already part of a larger study taking place in 12 centres. Dr. Nascimento, Callum, Tien and other investigators from Sunnybrook noted that even a small study did not duplicate the significant drop in mortality rates found in other retrospective studies. This is important because of the high cost of blood products and the potential waste if they’re not used. For example, Type AB is

the universal donor for blood plasma, but it’s also the rarest blood type, found in only four per cent of people. Hospitals generally thaw four units of plasma at a time, and if they’re not used, they have to be discarded. There is also strong scientific evidence that patients who avoid transfusions – or have fewer of them – have fewer complications, faster recoveries and shorter hospital stays. St. Michael’s has long been a leader in blood research and blood conservation. In 1998, St. Michael’s became one of the first hospitals in Canada to implement a blood conservation program. The Ontario Transfusion Coordinators (ONTraC) program administered through St. Michael’s sets the standard in the province for patient blood management. St. Michael’s has also created a Centre of Excellence for Patient Blood Management, the first of its kind in Canada and a global leader in patient care and in training and educating health care professionals. Dr. Rizoli was recently appointed for a five-year term as the St. Michael’s Hospital-University of Toronto Endowed Chair in Trauma Research. This research was funded by the Canadian Forces Health Services, Defense Research and Development Canada, the National Blood Foundation and the American Association of H Blood Banks. ■ Leslie Shepherd is Manager, Media Strategy at St. Michael’s Hospital in Toronto. www.hospitalnews.com

Focus 29

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

Knowing your location can save a life in an emergency

Dr. Sandro Rizoli

appointed the first St. Michael’s Hospital-University of Toronto Endowed Chair in Trauma Research By Leslie Shepherd

Summer adventure essentials By Lisa Pilling

ritish Columbia is well known for its wide variety of outdoor activities and summer in B.C. is all about outdoor adventures and exploration. It is also a time when BC Ambulance Service (BCAS) emergency medical dispatchers (EMDs) receive more calls from people who can’t describe where they are when calling 911. 911 callers who can advise dispatchers of their specific location help ensure that paramedics can provide assistance as soon as possible. Without a confirmed location, critical minutes are lost trying to locate callers and help can be delayed. “We’ve all seen TV crime dramas that make it seem relatively quick and easy to use modern technology to find someone in distress. The unfortunate reality is that the best information about a patient’s location comes from the 9-1-1 caller,” said BCAS Dispatch Operations Director Gordon Kirk. “Knowing where you are helps us get an ambulance on the way in a matter of seconds, instead of minutes. Valuable time is lost when dispatchers have to locate where a call is coming from.”

The Best Laid Plans Tapping into the broad base of experience, BCAS EMDs share their five key safety tips for exploring remote areas: Plan – know where you are going and how to get there and follow that route. Tell – a loved one where you are going, estimated arrival time and check in with them at the end of your trip. Know – where you are; keep track of landmarks, road and trail names, communities, and direction. Prepare – pack a map, compass, food, extra cell phone battery and first aid kit in case of emergency. Practise – how you would describe your location to emergency services. Vernon resident Jason Dudar recently called 911 for a friend who had a medical emergency outside of town. “I was impressed with the way the BC Ambulance Service dispatcher worked with us to obtain our location and inform us they were www.hospitalnews.com

enroute,” says Dudar. “The two paramedics arrived quickly and were very efficient and effective in dealing with the situation, especially given the terrain. They saved my friend.”

Technology Help or Hinder? If a caller can’t provide a specific location, BCAS EMDs use several strategies to determine the caller’s location, from a series of questions about road names, direction and landmarks, to engaging Search and Rescue partners and using technology that triangulates cell phone location based on proximity to closest cell phone towers. While technology can be very useful, triangulation of location can vary from several feet to many kilometers away and is limited to latitude and longitude, not heights within structures. The different varieties of technology also limit BCAS EMDs’ ability to use cell phones to pinpoint a caller’s location, as does whether or not a cell phone with GPS installed has been turned on. Backcountry users should also never assume that there will be cell coverage in remote areas. Although it will take longer to get assistance without a specific location, people should call 911 in the event of an emergency. BCAS EMDs can provide first aid instructions to bystanders over the phone while paramedics are enroute.

Help Us, Help You “Usually when people call 911 and don’t know their location, they are helpful in trying to assist us in locating them; it is not so much a matter of people being lost but more that they don’t know exactly where they are,” says Kirk. “We just want our paramedics to help our patients as quickly as possible and if people can benefit from our experience, so much the better.” This summer, remember to know your location and be prepared for your adventures in order to make the most of the H great outdoors. ■

r. Sandro Rizoli has been appointed as the first St. Michael’s Hospital-University of Toronto Endowed Chair in Trauma Research, beginning July 1. The five-year chair will support Dr. Rizoli’s research and innovation in trauma care. A national leader in trauma resuscitation research, Dr. Rizoli plans to use the chair’s support to continue his work in developing new, more effective approaches to stopping life-threatening bleeding and ensuring that blood products are used appropriately in acute trauma patients. As the director of trauma at St. Michael’s Hospital, Dr. Rizoli is uniquely positioned to apply his research discoveries to improve outcomes for trauma patients. St. Michael's is one of 11 Ontario hospitals designated by the Ontario Ministry of Health and LongTerm Care as a Level 1 trauma centre, equipped to receive the most severely injured patients. Dr. Rizoli is also a full professor in the Department of Surgery and Critical Care Medicine at the University of Toronto and a research scientist at the Keenan Research Centre of the Li Ka Shing Knowledge Institute, chief of Region XII (Eastern Canada) of the Committee on Trauma of the American College of Surgeons and president of the Trauma Association of Canada. Dr. Rizoli completed his MD and surgical training at the State University of Campinas in Brazil and at the Univer-

YOU

sity of Toronto, where he also completed a PhD. In 2006 he was awarded the Royal College Gold Medal in Surgery, and in 2008 received the Endowed De Sousa Chair in Clinical Trauma Research and the Canadian Institutes of Health Research/NovoNordisk New Investigator Award. The St. Michael’s Hospital-University of Toronto Endowed Chair in Trauma Research is funded by generous donations to the St. H Michael’s Hospital Foundation. ■ Leslie Shepherd is Manager, Media Strategy at St. Michael’s Hospital in Toronto.

Dr. Sandro Rizoli is a national leader in trauma resuscitation research.

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Lisa Pilling is the A/Communications Specialist with BC Ambulance Service. AUGUST 2013 HOSPITAL NEWS

30 Care Giving

Educational & Industry Events To list your event, send information to “events@hospitalnews.com”.

We try to list all events and information but due to space constraints and demand, we cannot guarantee it. To promote your event in a larger, customized format please send enquiries to “advertising@hospitalnews.com” Q Sept 8-10, 2013 CSAO Conference – Canadian MDRD Processes Double Tree Hilton, Toronto Website: www.csao.net Q Sept 13-14, 2013 Canadian Association of Ambulatory Care Conference Delta Toronto East, Toronto Website: www.canadianambulatorycare.com Q Sept 22nd-24th, 2013 Dynamics 2013 Conference – Shattering the Silence – Voices for Advocacy in Critical Care Nursing World Trade & Convention Centre, Nova Scotia Website: www.caccn.ca Q Sept 24-25, 2013 National Forum on Patient Experience The Westin Bristol Place, Toronto Airport Website:www.patientexperiencesummit.com Q Sept 25-27, 2013 Brain Injury Association of Canada Conference Ambassador Conference Resort, Kingston Website: www.biac-aclc.ca Q Oct 1-2nd, 2013 Wellness: It’s for Life 2013 International Wellness Symposium Lake Louise, Alberta Website: www.wellness4alberta.com Q Oct 3-4, 2013 I.T. Healthcare Canada Conference and Exhibition International Centre, Toronto Website: www.ithealthcare.ca Q Oct 17-19th, 2013 &$* $JLQJ IURP &HOOV WR 6RFLHW\ QG $QQXDO 6FLHQWLÀF DQG Educational Meeting Canadian Association on Gerontology Halifax, Nova Scotia Website: www.cagacg.ca Q Oct 27-29, 2013 20th Canadian Conference on Global Health The Westin Hotel, Toronto Website: www.csih.org Q Oct 28-29, 2013 National Reducing Hospital Readmissions & Discharge Planning Conference Hyatt Regency, Vancouver Website: www.healthcareconferences.ca Q Nov 4-6th, 2013 Health Achieve 2013 Metro Toronto Convention Centre, Toronto Website: www.healthachieve.com Q Nov 28-29th, 2013 National Correctional Services Healthcare Conference Ottawa Convention Centre Website: www.healthcareconferences.ca Q Dec 2-3rd, 2013 National Operating Room Management Conference Hyatt Regency, Vancouver Website: www.healthcareconferences.ca Q Jan 30 – Feb 1, 2014 2014 Better Breathing Conference Toronto Marriott Downtown Eaton Centre Website: www.on.lung.ca

To see even more Healthcare Industry Events, please visit our website www.hospitalnews.com/events HOSPITAL NEWS AUGUST 2013

Music can help with an aging loved one

By Bart Mindszenthy

few years ago as my mother was sliding slowly but surely into her own mind’s dark spaces; engaging her become more and more difficult. She’d more or less stopped talking in sentences and for periods of time barely spoke more than two or three connected words. She’d begun to eat less at most meals, and had stopped using utensils. When she fed herself at all, it was using her fingers. Sleep was more often than not the activity of the day. A few of my friends in the field of geriatrics suggested I play music for my mother. Figuring I had nothing to lose by trying, I bought a small CD player with a good quality headset. I remembered that she really used to like the Viennese waltzes and that she also liked the 1920s and 1930s musicals, which we used to play on an old ’78 record player when I was young.

Music made her day The first time I showed her what I bought she shook her head, almost violently. So with great caution and very slowly and methodically, I organized to play one of the CDs. I first put the headset on my ears to show her how it worked and that it was okay. Then I applied the headset to her ears and hit the play button for the waltz CD. For about two minutes there was absolutely no reaction whatsoever. And then there was the hint of a little smile. A moment or two later, my mother’s eyes, which had been almost wildly open, slowly receded almost entirely from view as her eyelids became small slits. She liked the music. She liked listening to the music. What I discovered from a number of other like-minded children of aging parents at her nursing home was that indeed, soothing, known and liked music was calming and welcomed. And the more I asked around, the more I found that the right kinds of music seemed to be just about as good as some of the prescription mood management drugs were and with a lot less potential negative interactions with yet other drugs.

Even musicals and music shows on the communal television set seemed to make my mother more engaged.

Miss the music One of the part time helpers I’d retained to spend time with my mother on weekends decided my mother actually didn’t really want to listen to music. It never registered on me until weeks later that when I’d go visit her on weekends she seemed more withdrawn and even more agitated. I was baffled until one Saturday it dawned on me that there was no music. I asked the helper where the music was. She said my mother didn’t need it, that it made no difference. So I found the CD player, flipped in a CD, put the headset on my mother’s ears and upped the volume a bit. She liked the music. That’s when I suggested to the helper that if she failed to ensure my mother had her music at least a couple of hours a day, she’d be looking for another job.

Diversions, distractions, pacifiers The past years, I’ve spoken with many personal support workers, health care professionals and families. I’ve read reports and medical journal articles. All suggest that music, pets, children, plants – whatever the diversion, distraction, pacifier might be – seem to help refocus the elderly, especially those with some form of dementia, to some kind of better, gentler, nicer personal place. I suppose there are no guarantees, but there’s nothing to lose by trying the right kind of music or other mental pacifiers with your aging loved ones. Just remember, the first time may not work; it may take a few efforts before there H is a benefit. ■ Bart Mindszenthy, APR, FCPRS is the Host of www.mycarejourney.com and best-selling author on the issues and challenges of caregiving for elderly family members. His column on caregiving appears quarterly in Hospital News. www.hospitalnews.com

Focus 31

EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS:

Mississauga Halton Community Care Access Centre Rapid Response Nurses For our frail, elderly citizens, leaving hospital often means a return visit. This is not healthy for them or for our health system. We recognize some of our citizens with very complex care needs require more constant care coordination to ensure they thrive out of hospital and are not readmitted. They need an intensive level of care coordination to ensure medications are taken as instructed; follow-up doctor’s visits are made and kept, and ongoing medical assessments continue through constant monitoring by a consistent care coordinator during the crucial first 30 days after leaving hospital.

Rapid Response nurse Lynda Amodeo-Thomson helps Roy Brown, her patient learn to manage his care. Among other things, she makes it easy for him to remember to drink water every day to avoid dehydration.

Rapid Response Nurses Provide Intensive Care to Keep Frail Elderly Safe By Roberta Greenberg

oy Brown is an active and independent 89-year-old who still drives, does his own shopping and cooking. Roy lives alone in his Oakville house, the same house that he has lived in for the past 65 years and shared with his wife who passed away two years ago. Roy’s past reads like a Hollywood movie. He joined the Royal Canadian Air Force in 1942 and served overseas where he was a gunner. He was shot down in Belgium, hidden by a local family and later was turned over to the Germans. He spent his 21st birthday in a German prison where he was repeatedly ‘questioned’ by the Gestapo. Rescued by the Resistance, Roy returned to Canada where he served until 1946. In 1993, he went to Willems, France with his wife, where he was honoured by local dignitaries at a civic reception. Fast forward 46 years. Today, Roy has multiple health conditions, including congestive heart failure, diabetes, COPD and hypertension. Studies have shown that there is a high probability that high-risk seniors, such as Roy, will be re-admitted to hospital within 30 days. The Mississauga Halton Community Care Access Centre (CCAC) partnered with Halton Healthcare Services – Oakville Trafalgar Memorial Hospital and Trillium Health Partners – Mississauga Hospital to identify and provide intense care to vulnerable seniors with complex clinical needs. The Mississauga Halton CCAC introduced Rapid Response nurses, part of an innovative new initiative, launched in January 2013. High-risk patients like Roy now receive an intensive level of care from highly-experienced registered nurses to remain safely at home. Lynda Amodeo-Thomson, a Mississauga Halton CCAC Rapid Response nurse, met with Roy before his discharge www.hospitalnews.com

from hospital and arranged to visit him at home the following day. During that first home visit, Lynda re-assessed Roy’s needs and ensured he was taking his medications as instructed. Lynda also helped Roy connect with his family doctor to arrange follow-up appointments. Over the next 30 days, Lynda continually assessed Roy to make sure his care plan was meeting his needs and that he was taking his medication and visiting his doctor. She helped Roy identify his signs and symptoms to help him better anticipate when he might be in medical trouble. Lynda also taught him ways to manage his health to prevent re-hospitalization. This example illustrates the teach-back method that Lynda used with Roy to help him make the necessary changes to maintain his health. She came up with an ingenious way of helping Roy with his fluid intake to prevent dehydration as he wasn’t drinking enough fluids. She asked Roy for his favourite mug and explained that he needed to drink eight times a day from that cup. As she explains, “My philosophy is to help patients self-manage their care, to teach them how and why they are doing particular tasks such as weighing themselves, watching sodium intake, etc. I want them to be able to recognize what’s normal versus what’s not, and to visit their doctor as soon as they recognize any warning signs.” Since working with Lynda, Roy takes a much more proactive approach to his health and made the following changes: He weighs himself every day. He needs to be extra careful of any rapid increase in body weight because he has congestive heart failure He checks all the labels on the cans he buys in the supermarket to better monitor his sodium intake

He records his weight, his fluid intake, and what he eats daily on his computer and sends this information to his family doctor. Roy wants to stay out of hospital and avoid repeated visits to the emergency department. “It is great to work with Lynda. She is a good teacher. And, physically I H am feeling better.” ■ Roberta Greenberg is Manager of Media and Public Relations at the Mississauga Halton Community Care Access Centre.

Introducing the Mississauga Halton CCAC Rapid Response Nurses – partnered with Oakville Trafalgar Hospital and Trillium Health Partners – Mississauga Hospital – to identify patients who need this level of care most. Our Rapid Response Nurses will visit those patients within 24 hours of leaving hospital. They will visit their clients at home, as needed, over a 30-day period to reduce the risk of clients being re-admitted to hospital. Their clients will then be discharged from services provided by the Mississauga Halton CCAC or will have their less-intensive, ongoing care needs provided by their community-based case manager, a highly qualified, experienced registered health professional.

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