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Contents April 2017 Edition
IN THIS ISSUE:
Provinces should work together on new funding models
7 , 201 4–7 e n u J
SPECIAL SHOW GUIDE
▲ Cover story: Top emerging health technologies
APRIL 2017 HOSPITAL NEWS 25
▲ E-Health Supplement
▲ Reducing number of instruments on OR trays = savings
Editor’s Note .................... 4 In brief ............................. 6 From the CEO’s desk .....15 Evidence matters ...........20 Trends in transformation .............. 24 Nursing pulse ................ 37 Safe medication ............38 Doctors without Borders 40 Ethics ............................. 47
▲ Building a culture of philanthropy
Small tumours are now easier to see and remove
▲ Food for thought: Nutrition’s contribution to healing
Welcome to your new
Hospital News! Y
ou may have noticed 2017 has been a pretty big year for Hospital News. It marked our 30th birthday – which is a huge accomplishment for any publication in this new digital age. Over the past 30 years Hospital News has evolved as a print publication as well as embraced the digital world with the development of a user-friendly website and digital subscription offering. Every month our digital subscription list grows and we provide real-time healthcare news to over 40,000 visitors to our website every month. In honour of reaching this milestone, we wanted to celebrate – and who better to celebrate with than our loyal readers who have embraced all of the changes on this journey? With over 350 print issues under our belt we decided it’s time for a change – a big change. Welcome to your new Hospital News! With our new glossy magazine we provide our readers with a more convenient format, improved quality and images and a higher pass-on rate. Although our appearance has changed drastically, we will still provide you with the same high-quality editorial focusing on best practices and advancements in healthcare. Our healthcare system will be facing some major challenges in the coming years. With an aging popu-
lation, the demands on our already strapped system will increase. Hospitals will face increased pressure to do more with less and increase efficiencies in their facilities. That’s where Hospital News comes in – to provide a forum for healthcare facilities to share best practices – like this month’s article about how St. Joseph’s Hospital has found savings after conducting a study to streamline surgical trays (pg. 22). Bluewater Health has also found cost savings (as well as improved food and patient satisfaction) through scratch preparation and preference forms for patients (pg.16). By sharing these stories in Hospital News, it is our hope that other hospitals adopt these cost saving, patient experience enhancing practices as their own – thereby improving healthcare for Canadians. If your facility has recently adopted a new best practice that improves patient care or enhances efficiency, we want to hear from you. Please email me at email@example.com if you have a story you would like to share. Publicly funded healthcare is at the heart of being Canadian. It is not a perfect system and there are most definitely ways it can be better, do better. We all need to take ownership and look for ways to improve and provide the best care possible to every single paH tient, every single time. ■
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MAY 2017 ISSUE
JUNE 2017 ISSUE
EDITORIAL: April 7 ADVERTISING: Display – April 21 | Careers – April 25
EDITORIAL: May 6 ADVERTISING: Display – May 18 | Careers – May 23
Monthly Focus: Surgical Procedures/Pain Management/ Palliative Care/Oncology: Non-invasive surgery, plastic surgery, orthopedic surgery and new surgical techniques including organ donation and transplantation procedures. New approaches to pain management and palliative care delivery. Approaches to cancer diagnosis and treatment.
Monthly Focus: Health Care Transformation/eHealth/Mobile Health /Medical Imaging: Programs and initiatives that are transforming care and contributing to an effective, accountable and sustainable system. Innovations in electronic/digital process in healthcare, including mHealth (health applications on mobile devices). A look at medical imaging techniques for diagnosis, treatment and prevention of diseases.
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Young children of mothers prescribed opioids at increased risk of overdose hildren of women prescribed an opioid painkiller face a nearly 2.5-fold higher risk of being hospitalized for opioid overdose than children whose mothers don’t receive these drugs, according to a new study from the Institute for Clinical Evaluative Sciences (ICES) and The Hospital for Sick Children (SickKids). The dramatic increase in the prescribing of opioids such as codeine and oxycodone over the past two decades in North America has been associated with a marked increase in fatal overdoses. New research shows that young children of women prescribed these painkillers are also at risk of opioid overdose. “With the increase in opioid prescribing and availability of these drugs in North American homes, it’s critical to
NEW RESEARCH SHOWS THAT YOUNG CHILDREN OF WOMEN PRESCRIBED THESE PAINKILLERS ARE ALSO AT RISK OF OPIOID OVERDOSE. understand how this may impact children,” says Dr. Yaron Finkelstein, lead author of the study, staff physician in Paediatric Emergency Medicine, and Clinical Pharmacology and Toxicology, associate scientist at SickKids and adjunct scientist at ICES. “Prescribers, pharmacists and parents should be cognizant of this risk and take measures to prevent overdoses, such as dispensing smaller opioid quantities, considering alternatives to opioids for pain relief, and emphasizing the importance of secure storage and disposal of unused opioids.”
In the study, published in Pediatrics, the researchers looked at children under age 10 whose mothers’ prescriptions were covered under Ontario’s publicly-funded provincial drug plan and who were treated in the emergency department, hospitalized or died of opioid overdose between 2002 and 2015. They found that young children are at a nearly 2.5-fold risk of severe overdose, often resulting in hospital stays, if their mothers were prescribed opioid medications, compared with those whose
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mothers were prescribed non-opioid medications for pain. Information about opioid prescription to fathers was not available and could not be included in the study. The researchers identified 103 children who were 10-years-old or younger with an opioid overdose and 412 children with no opioid overdose, and compared the likelihood that their mothers received an opioid or a non-steroidal anti-inflammatory drug such as ibuprofen before the overdose episode. Half of the children who presented to hospital with an opioid overdose were twoyears-old or younger, and one in 10 of the overdoses involved infants younger than 12 months. Nearly 40 per cent of the children were admitted to hospital, including 13 who were treated in critiH cal care units. ■
any Canadians need medications to treat serious health conditions. A shortage of a drug they need or its discontinuance from sale could be a source of great worry. Prompt public notification of a shortage or discontinuance helps healthcare providers to make decisions and find alternative medication to prevent or reduce potential impacts on patients. In March regulations came into force requiring drug companies experiencing shortages and discontinuances to publicly report them. Drug manufacturers are now required to report on DrugShortagesCanada.ca: • an anticipated drug shortage; • a discontinuation of a drug six months in advance; and • any previously unreported shortage within five days of learning about it. As part of the regulations, a new, independent website, DrugShortagesCanada.ca, replaces the industry-run website, www.drugshortages.ca, where manufacturers have been voluntarily reporting drug shortages and discontinuances since 2012. The new website features enhanced notification features and a mobile application. As well, it provides updated information for healthcare providers and patients, including tools and guidance to help manage shortages. Making public reporting of drug shortages and discontinuances mandatory builds on collaborative steps Health Canada has taken in recent years to help manage and minimize the impact of supply disruptions. When a critical national drug shortage occurs, Health Canada works with stakeholders from across the drug supply chain, including provincial and territorial partners, to confirm the details and status of a shortage, coordinate information sharing, and identify collaborative mitigation strategies. Features of DrugShortagesCanada.ca include drug-specific email alerts, advanced search features, more comprehensive information, and the ability for users to download data subsets using third-party software. The free mobile application is available for download on iOS and Android devices. The reporting requirements and website are being introduced as a result of feedback from stakeholders across the health system supporting mandatory H reporting on a non-industry website. ■
Federal Budget 2017 fails Canada’s seniors
he Canadian Medical Association (CMA) is disappointed that the federal budget has missed an important chance to begin building a much-needed national seniors strategy. “This budget was an ideal opportunity for the federal government to step up and act to strengthen seniors care,” said CMA President Dr. Grang-
er Avery. “Sadly, Canadians have been left wanting and waiting for leadership from their federal government on this important issue.” The CMA continues to urge the federal government to act now to strengthen our healthcare system by ensuring it better meets the needs of Canada’s aging population. To support that effort, last fall the CMA released
Leg movements in sleep may contribute to risk of stroke and heart disease esearchers have uncovered links between sleep-related leg movements and stroke, heart disease and mortality in two new studies published in the journal SLEEP. In one study, involuntary repetitive movements in the hip, ankle and big toes during sleep — known as periodic limb movements (PLMs) — were associated with silent strokes in the brain, which appear as bright white spots on MRI brain scans. In patients who had experienced a first-ever minor stroke or transient ischemic attack (TIA or “mini stroke”), those with more PLMs on an overnight sleep study were shown to have a greater quantity of white matter lesions visualized on neuroimaging. These white matter lesions are known to predict an increased risk of future stroke, dementia and death. “What this tells us is that PLMs may be a risk factor for, or marker of, silent cerebrovascular disease in the brain. Future work needs to explore whether PLMs could be a novel target for us in our efforts to prevent stroke,” says Dr. Mark Boulos, principal investigator of the study and a sleep and stroke neurologist at Sunnybrook. It is thought that the involuntary disruptive limb activity at night gives rise to significant nocturnal fluctuations in
heart rate and blood pressure, and may result in daytime hypertension. PLMs are also associated with increased markers of inflammation and may increase the risk of plaque formation in the arteries and rupture. “We’ve known that stroke can lead to PLMs, however, mounting evidence is starting to suggest that PLMs themselves may also contribute to the development of cerebrovascular disease,” says Dr. Brian Murray, co-lead investigator of the study and director of the sleep lab at Sunnybrook. In a second study, sleep researchers evaluated an association between Restless Legs Syndrome (RLS) and/or PLMs in sleep and all-cause mortality and incident cardiovascular events, this time through a systematic review of studies dating back to 1947. “While evidence was limited, there appeared to be a significant association between PLMs and risk of cardiovascular events,” says Boulos, senior author of the second study. “This work is exciting because it sheds light on the potential importance of PLMs, and adds to our emerging recognition of the importance of sleep for long-term brain health,” says Dr. Richard Swartz, senior author of the first paper and Medical Director of the North & East GTA Regional Stroke Program H at Sunnybrook. ■
a vision for health with clear and concrete recommendations to improve the system such as: • Developing a coordinated home plan so seniors can live and get the support they need to stay in their homes longer; • Creating a national strategy for palliative and end-of-life care; • Boosting key infrastructure investments to improve and provide more residential care options for seniors; • Enhancing ﬁnancial support for family caregivers by making tax credits refundable. “By providing better access to more efficiently delivered high-quality care for seniors, we will help improve access to care for all Canadians,” added Dr. Avery. “We did not see that action to make that happen in today’s budget, but it is not too late. The CMA will continue to push for strategic action, backed by our 50,000 Demand a Plan supporters.” While the CMA lamented the lost opportunity to act in support of Canada’s seniors, it was pleased to note health-related measures that did receive federal support today, including: • $300 million over 5 years for Canada Health Infoway to further expand e-prescribing and virtual care initiatives and supporting the continued adoption and use of EMRs, helping patients to access their own health records electronically, and better linking HER systems to improve access by all providers; • $53 million over ﬁve years for the Canadian Institute for Health Information address health system gaps, supporting improved decision-making and strengthening the reporting on health system performance; • $51 million over three years for the Canadian Foundation for Health Improvements to accelerate innovations in all provinces and territories; • $140.3 million over ﬁve years to improve access to pharmaceuticals, lowering drug prices and supporting appropriate prescribing; • $100 million over ﬁve years to adH dress the opioid crisis. ■ APRIL 2017 HOSPITAL NEWS 7
HOOPP’s investment return
more than doubles in 2016 By Diana Swift he Healthcare of Ontario Pension Plan (HOOPP) was on a healthy track in 2016, posting a 10.3 per cent return on investments after 2015’s gains of 5.1 per cent. And the recent gains were made amidst modest global economic growth and the uncertainties created by Brexit and the election of President Donald Trump. The pension fund’s net assets also climbed in 2016 to a record $70.4 billion – up from the previous year’s 63.9 billion, and it funded status as of December of 2016 was a solid 122 per cent. “Every strategy in every asset class actually contributed to this positive result,” said Jim Keohane, HOOPP’s president and CEO, at a Toronto media briefing on March 9. The plan’s stable funded status has also allowed HOOPP to maintain its pensioners’ CPI-linked cost-of-living allowance at 100 per cent in recent years, with all pensions increasing by 1.5 per cent as of April 1, 2017. “Our strong financial position has enabled us to keep the plan affordable for both members and employer, and we have one of the lowest contribution rates among major plans,” Keohane said. The surplus has allowed contributions to remain at the 2004 level, which HOOPP is committed to maintaining until the end of 2018. HOOPP considers its solid funded status to be the gold standard for measuring its success, and its funding-first strategy is designed to balance the need for growth with the need to manage risk, Keohane said. The fund paid out $2.1 billion in pension benefits in 2016, with about 80 cents of every dollar coming from investment returns, and the plan also maintained a high client satisfaction rating.
THE FUND PAID OUT $2.1 BILLION IN PENSION BENEFITS IN 2016, WITH ABOUT 80 CENTS OF EVERY DOLLAR COMING FROM INVESTMENT RETURNS In addition, HOOPP’s investment income more than doubled to $6.6 billion over 2015’s $3.1 billion, with the fund’s 10.35 per cent return outpacing its portfolio benchmark by $2.7 billion – or 4.23 per cent versus 2015’s 1.17 per cent.
Five, 10, and 20-year annualized return rates stand at 11.67 per cent, 9.08 per cent, and 9.12 per cent, respectively. “We have one of the highest 10-year return rates globally,” Keohane said, while acknowledging that 2016 got off to a slow start in the first quarter
with sluggish stock markets, low interest rates, and market volatility. “Valuations were very high, so we invested very cautiously,” he said. To HOOPP’s credit, 2016’s gains were made at a time when HOOPP was directing considerable resources to retirement research and to a five-year project aimed at upgrading its online client services and pension administration system, with a pilot project involving 13 employers and 10,000 employees. HOOP also maintained a high client satisfaction rating during 2016. In addition, HOOPP moved into new energy-efficient offices on York Street that will allow for the expansion of client services over the next 20 years. The plan now has 516 employees and 321,860 active, deferred, and retired members, 73 of whom are centenarians. HOOP paid out about $2.127 billion in pension benefits and received $2.195 billion in member contributions in 2016. HOOPP continues to invest in major commercial and industrial real estate developments in Canada and the U.S., as well as large-scale warehouse projects in Germany, Sweden, and the U.K., Keohane said. As for the current climate for investment risk, Keohane said, “Valuations continue to be high, and that’s always a concern because it’s hard to find good investments and there’s not much room for error.” And while he sees no recession on the horizon, “if there is a downturn, valuations will not support that.” Asked if the Trump effect exerted any impact on HOOPP’s robust 2016 gains, Keohane told Hospital News, “I think it had a positive effect, particularly on the bond market, and I think the promise of financial deregulation in the U.S. – which is probably more regulated than Canada – it will continue to H have a positive effect.”■
Jim Keohane is President and CEO, HOOP. Diana Swift is a freelance writer in Toronto 8 HOSPITAL NEWS APRIL 2017
The blue light cystoscopy combines a diagnostic agent known as Cysview along with a scope that detects blue light. When used together, cancerous tissue appears bright pink and is much easier for physicians to see and remove.
are now easier to see and remove By John Pereira
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ular basis to check and remove any recurrences,” says Dr. Siemens. “By using this new technique we can now find and remove the smallest tumours, which reduces the number of times a patient must undergo surgery. This represents a significant benefit for the patient.” The technique has been used in Europe since 2006, but it has taken a number of years to be vetted through clinical trials here in Canada. The Cysview diagnostic agent was recently approved for use by Health Canada. KGH performed its first pilot cases in August 2016, becoming the first hospital in Canada to do so outside of a clinical trial. The hospital has now purchased the equipment and will begin to offer the service on a regular basis for patients with bladder cancer. “Most of these low risk bladder tumours do not have mortality rates as high as some other cancers, but they are common with an estimated 8,000 people diagnosed in Canada each year,” says Siemens. “By fully adopting this
John Pereira is a Strategic Communications Advisor at Kingston General Hospital.
The procedure combines a diagnostic agent known as Cysview along with a scope that detects blue light. When used together, cancerous tissue appears bright pink and is much easier for physicians to see and remove. In the past, a white light scope was the standard tool used during cystoscopy procedures. When using white light, small tumours could be difficult to see, making it necessary for a patient to undergo multiple follow-up procedures to remove them once they had grown large enough to detect. “Patients with bladder cancer commonly develop many small tumours rather than one larger one,” says KGH Urologist and Head of Urology at Queen’s University Dr. Robert Siemens. “Now that we can more easily see them, we can remove them more completely during the first procedure.” To complete the blue light cystoscopy, the Cysview diagnostic agent is given to the patient one hour before the surgery begins so that it can be
treat Tuberculosis could also be used to reduce the number and frequency of recurrent tumours, as well as to prevent the disease from progressing. It’s a treatment regimen still in use today, earning Kingston a reputation as a leader in the treatment of bladder H cancer. ■
KGH FIRST HOSPITAL IN CANADA TO USE TECHNIQUE OUTSIDE OF CLINICAL TRIAL TO LOCATE BLADDER CANCER
approach we will be able to improve the quality of life for many patients in Southeastern Ontario.” This is not the first time that KGH and Queen’s have been at the forefront in the treatment of bladder cancer. In the 1970’s Dr. Alvaro Morales discovered that a vaccine commonly used to
Eff ici en t
absorbed by the cancerous tissue. The blue light scope is then inserted into the patient’s urethra and the tumours are removed. The procedure takes about an hour to complete. “Bladder cancer has a high rate of recurrence, which means that they often grow back, so it’s not uncommon for patients to undergo cystoscopies on a reg-
ge system locka ti-b An
ingston General Hospital, (KGH) the first hospital in Canada to complete a blue light cystoscopy outside of a clinical trial, will soon begin offering the procedure on a regular basis to improve the quality of life for patients living with bladder cancer in Southeastern Ontario.
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APRIL 2017 HOSPITAL NEWS 9
Building a culture of philanthropy –
one person at a time By Suzette Strong
n exceptional patient experience is where it all begins. A patient receives great care and they often want to find a way to give back to the hospital. When a patient has an incredible experience and asks their caregiver how to say thanks, that caregiver should know how to properly direct that patient to the foundation and discuss the critical impact that donations have on the hospital. This is just one way that a hospital can exude a strong culture of philanthropy.
That is of course the ideal scenario. But in a hospital where staff work in a 24/7 environment with numerous demands, philanthropy and the role that staff and physicians play in it – isn’t always top of mind. Creating a culture of philanthropy is essential to fulfilling the fundraising requirements necessary to support all the hospital’s vital equipment needs. Employees, volunteers, and members of the public need to understand that the government doesn’t fund all these priority needs. This is a common miscon-
ception that can often deter potential donors from understanding the needs and importance of giving. Building a thriving culture of philanthropy is all about developing a relationship between the hospital and foundation that is rooted in trust and mutual respect. A synergistic relationship between the two organizations must be valued and understood—ultimately fundraising should be viewed as a core shared responsibility. The hospital needs to understand the importance of actively participating in the delivery
of the foundation’s mission of raising funds and awareness for the hospital. This culture shift is essential in raising the funds needed to support a hospital. At Markham Stouffville Hospital we have instilled a strong culture of philanthropy within our walls and are continuously finding ways to grow that culture. From the moment a staff member begins working at MSH they are introduced to the foundation. In November 2015, senior staff members from the foundation began presenting at each new hospital staff orienta-
Suzette Strong is the CEO of the Markham Stouffville Hospital Foundation. 10 HOSPITAL NEWS APRIL 2017
FOCUS Two physician leaders from Markham Stouffville Hospital actively supporting the foundation in their fundraising and awareness activities. from a strong commitment from both hospital and foundation CEOs to work jointly on communications as it supports the overall brand of the hospital. This leads to frequent meetings between hospital public relations and foundation marketing teams as well as the creation of a joint marketing and communications strategy. The collaboration helps to ensure that internal and external initiatives to promote the culture of philanthropy are consistent and top of mind.
tors within their department support the foundation. And that pride translates into action – from being a donor to being an ambassador. Our physicians have stepped up and participated in advertising campaigns and attended fundraising events – all because they felt invested in the success of the foundation. In one instance, our physicians demonstrated their commitment by donating one million dollars towards our Expansion Campaign that ran from 2008-2014.
BUILDING A THRIVING CULTURE OF PHILANTHROPY IS ALL ABOUT DEVELOPING A RELATIONSHIP BETWEEN THE HOSPITAL AND FOUNDATION THAT IS ROOTED IN TRUST AND MUTUAL RESPECT.
tion. This is an opportunity to start off each new hire with an appreciation of philanthropy and the role they play in supporting it at the hospital. Sharing information about the foundation and the benefits of giving with new hires is just the first piece. If we want our staff to not only give back by supporting the foundation, but also become ambassadors and share our information with their patients – we have to develop an ongoing relationship. Through posters and presence on the units, to participating in staff recognition events – the foundation team is highly integrated into the work of the hospital and is able to consistently deliver our messages. By integrating marketing and communications functions within the hospital and foundation, a unified approach to the development of this philanthropic culture emerges. This stems
Working in partnership with the hospital leadership and operations, the MSH Foundation continues to build engagement among physicians to encourage their role as hospital advocates and donors. Awareness throughout the organization must begin with senior staff leading by example, acting as champions, identifying potential donors, and providing their own financial support. Physicians play a key role in a culture of philanthropy and in translating great patient experiences into potential donations. Physicians are leaders within the hospital and within the community. Their support of our hospital speaks volumes to our patients and our staff. A physician who actively supports the foundation is much more likely to share information with patients and community members and be able to speak comfortably about the need for donations and support. Developing and maintaining a relationship with physicians is critical. At MSH, it started with developing one-on-one relationships with each of the Chiefs and then working with the physicians in each department. In some cases, the Chief took on a leadership role within their department to encourage participation. Many physicians take great pride in the ability to say that all doc-
The planning and development of the new building at MSH was another prime example of hospital and foundation collaboration. Both entities
acknowledged the importance of creating a customized space to recognize donors. The foundation was heavily involved in the design process which led to the prominent display of our donor wall featured in the main lobby of the hospital. Having a collective, donor-centred philosophy that honours and recognizes our supporters is essential. This shows our donors how much we care and helps us to maintain a loyal donor base in our community. In the end, all of our caregivers need to be fundraisers – we can’t do it without them. We can’t do it without our staff setting the stage as influencers within the organization. It comes full circle – caregivers work hard to provide great service, patients then choose to give back; donated funds are used to purchase critical equipment and support life-saving programs, ultimately enhancing the patient journey. A unified fundraising approach benefits the patient experience and the ability for caregivers to provide H excellent care. ■
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APRIL 2017 HOSPITAL NEWS 11
Health innovation on the horizon:
Top emerging health technologies 2017 By Andrea Tiwari reakthroughs in health technologies are coming at us fast and furious. Innovative medicines show promise for many diseases, and cutting edge diagnostic tools and procedures are changing how we treat a range of conditions. For guidance on how to prepare for health technologies that may disrupt the status quo, governments, health care organizations, clinicians, and patients turn to CADTH – an independent, not-for-profit agency that delivers unbiased evidence on drugs and medical devices. So, according to CADTH, what innovations should we watch for in the year ahead?
Studies on the procedure indicate that it’s safe and effective. The evidence also shows that the outpatient approach results in high levels of patient function and satisfaction, as well as decreased healthcare costs. However, we need more studies that include a broader range of patients (beyond younger, thinner, and healthier individuals). These types of studies are now underway, along with studies of outpatient knee replacement.
Same-day total hip replacement
Across Canada, a few centres have performed the same-day procedure, including some in Quebec and Ontario. Given the growing demand for total hip replacement, the possibility of giving patients better outcomes, minimizing hospital stays, and reducing costs is appealing.
Total hip replacement is a common surgical procedure where the damaged hip joint is replaced with an artificial joint to help reduce pain and disability for people living with conditions like osteoarthritis. It’s major surgery and typically requires a hospital stay of several days, but could a new approach see patients come into the hospital for their operation and be discharged on the same day? Successful outpatient total hip replacement requires a combination of factors. Patients must be carefully selected and have adequate home support in place. Pain management and anesthesia techniques are very important, including preventative pain relief and the minimal use of narcotics. And, minimally invasive surgical techniques are used to limit muscle damage and blood loss.
12 HOSPITAL NEWS APRIL 2017
telecommunications satellites, which then relay the signal through mobile phone networks to a caregiver’s computer or mobile device, or to a call centre. A transmitter can be installed in items like wristbands, pendants, or even in shoes. The Alberta Locator Device project is a recent Canadian study which concluded that locator devices should be a standard option for home care services and should be provided to people at an
IF YOU’D LIKE TO LEARN MORE ABOUT THE TECHNOLOGIES FEATURED IN THIS STORY, VISIT WWW.CADTH.CA/HORIZONSCANNING.
GPS locator devices for people with dementia
Many families of individuals living with dementia have experienced the frantic search for a loved one who has wandered away, knowing he or she can’t find their way home. But now, the GPS technology found in our cars and smartphone apps is being applied in new ways to help locate loved ones with dementia who wander, while also allowing them more independence. GPS locator devices use a transmitter that sends a signal to a network of
earlier stage of dementia so they can participate in deciding whether they wish to use the technology. Because these assistive devices are a form of surveillance, their use raises important legal and ethical questions, but with more than half a million Canadians living with dementia and that number expected to more than double over the next 20 years, this technology may be an important tool to increase the independence of people with dementia and reduce the anxiety of caregivers.
Robotic exoskeletons for spinal cord injuries
Emerging technologies are one of the most powerful forces that can improve the lives of people living with a spinal cord injury. In particular, the development of robotic exoskeletons is giving some patients with paralysis the chance to stand, sit, walk, turn, and even take the stairs again.
Robotic exoskeletons are supportive, brace-like orthotics that are worn external to the body and support the legs and part of the upper body. Sensors detect shifts in weight and changes in the centre of gravity, and then generate pre-set movements in each leg that result in stepping. Several studies on these powered exoskeletons have been published, assessing the training patients need to use the device, as well as an individual’s ability to perform skills such as starting and stopping movement, walking on uneven surfaces, and navigating things like electric doors and elevators. Powered exoskeletons are expensive and they aren’t yet widely used, but some models can be found in centres across Canada, including facilities in Alberta, Nova Scotia, British Columbia, and Ontario. Before these devices gain widespread use, we need more evidence to help us understand where they fit in the rehabilitation continuum of care, how long the device can be worn comfortably, and which patients are most likely to benefit from the technology.
An implant to treat opioid addiction
Canada is now the world’s second largest per capita consumer of prescription opioids, and growing rates of addiction, overdoses, and deaths are just a few of the consequences stemming from our opioid crisis. But an emerging technology in the form of an implant placed underneath the skin may offer a new treatment option for certain people coping with opioid addiction. The Probuphine implant, the first of its kind, uses four rods placed un-
COVER Robotic exoskeletons are supportive, brace-like orthotics that are worn external to the body and support the legs and part of the upper body.
derneath the skin on the upper-arm to deliver a constant, non-fluctuating dose of the drug buprenorphine, for up to six months at a time. The implant is inserted by a healthcare professional who has been specially trained to perform the procedure. It’s intended for patients who have achieved sustained and prolonged ‘clinical stability’ on low-to-moderate doses of the same medication, but taken in the form of a pill or a film that dissolves in the mouth. The implant is not yet approved for sale in Canada, but when it arrives it will likely attract significant attention, given the collective efforts of governments and health care providers to increase patient access to safe and effective treatment options. While the Probuphine implant may offer a novel opportunity to help patients who have a hard time sticking with a daily medication, it’s not currently recommended for more than two 6-month treatment cycles and its use is limited to only those patients who are considered to be ‘clinically stable’ on other buprenorphine-containing drugs. And important questions still remain about the use of this drug in a wider population, its use beyond one year, and whether it’s cost-effective compared to other treatments that are currently available.
New devices to prevent positional obstructive sleep apnea
People living with obstructive sleep apnea (OSA) know that this chronic condition can wreak havoc on sleep, health, and overall quality of life. OSA is a serious disorder that occurs when a person’s breathing stops
restricted) and alleviate other symptoms. The evidence for positional sleep devices suggests that they are effective at reducing the frequency of these interruptions, but it’s unclear whether they improve outcomes like daytime sleepiness.
CADTH Horizon Scanning
THROUGH A SERVICE CALLED HORIZON SCANNING, CADTH WORKS TO IDENTIFY TECHNOLOGIES THAT COULD SIGNIFICANTLY IMPACT CANADIAN HEALTHCARE. and starts periodically while they sleep. The condition robs people of the restful sleep they need and can lead to serious complications such as fatigue, high blood pressure, diabetes, heart attacks, and strokes. For patients who stop breathing more often while on their backs, the disorder is known as positional OSA. Positional therapy can sometimes help treat OSA by using simple things like a tennis ball or foam wedge to prevent a person from rolling onto their back while sleeping. But these solutions
are uncomfortable, leading many patients to eventually abandon them. Recently, more advanced products have come to market, including devices that are worn on the back of the neck or across the chest. The devices use sensors to detect sleeping positions and they vibrate to discourage back-sleeping. They also come with computer software that analyzes the progress of the treatment. The goal of all OSA treatments is to reduce the number of sleep interruptions (where breathing stops or is
Every year healthcare organizations and governments are inundated with information about new health technologies touted as ‘game-changers’. How do they separate fact from fiction, so they can focus their scarce resources on proven innovations that will bring real benefits to patients? That’s where CADTH comes in. Through a service called Horizon Scanning, CADTH works to identify technologies that could significantly impact Canadian healthcare. In particular, there is a focus on the emerging technologies that may prove to be safe and effective, deliver value for money, and align with the unmet needs of patients. If you’d like to learn more about the technologies featured in this story, visit www.cadth.ca/horizonscanning. We offer detailed reports that assess and summarize information such as scientific evidence, regulatory status, potential costs, and implementation issues. And watch for new reports coming soon – topics include mobile stroke units and patient-controlled tissue expansion. To learn more about CADTH visit www.cadth.ca, subscribe to New at CADTH, or talk to our Liaison Officer in your region: www.cadth.ca/conH tact-us/liaison-officers. ■
Andrea Tiwari is a communications officer at CADTH. www.hospitalnews.com
APRIL 2017 HOSPITAL NEWS 13
Sandy Walker, President NYGH Volunteer Services Board, with Gift Shop volunteers: Lesley Kane, Barbara Liddiard and Liz Davey.
How volunteers are donating more than just time By Melissa Londono
rom knitting newborn hats and making quilts to fundraising for the hospital’s equipment and a state-of-the-art Medical Imaging unit. More than 800 volunteers at North York General Hospital (NYGH) are definitely doing it all to help raise necessary funds to support staff and physicians at the hospital in making a world of difference for the patients they serve. Over the years Volunteers Services have raised more than $7 million for the hospital. In 2003, the Volunteer Services Birthing Centre was named to recognize the $1 million it raised. In 2006, Volunteer Services also generously contributed to the new Gulshan & Pyarali G. Nanji Orthopaedic and Plastics Centre soon followed by a pledge to raise $3 million over 10 years for the
new Volunteer Services Centre for Medical Imaging. “For almost 50 years volunteers have dedicated more than three million hours of volunteer service throughout the hospital,” says Sandy Walker, President of Volunteer Services. “Volunteering on the front lines, we have identified opportunities where we can help make a difference in the lives of the patients and families our hospital serves.” “Thanks to the dedication and commitment of our volunteers, in January 2017 we were able to donate $239,000 towards the Volunteer Services Centre for Medical Imaging pledge that we hope to finalize this year.” One of the big revenue generators for volunteers is the Gift Shop. A team of over 100 volunteers keep the store open and stocked seven days-aweek, closed only on statutory hol-
idays. The funds raised are donated to the foundation and ultimately the hospital. “Our volunteers continue to think outside the box to raise funds for our hospital – a place many of them have seen grow and develop over the years,” says Jennifer Bowman, Vice President of People, Strategy and Clinical Support at North York General. “The fundraising initiatives are just one example of volunteers going above and beyond to support the work done at the hospital.” Funds are also raised through the highly anticipated events throughout the year such as book sales, garage sales and seasonal bake sales, as well as by renting space to external vendors in the onsite Vendors’ Market. Volunteers have formed invaluable partnerships with people across the community who donate items to their
various events and who give through renting the Vendors’ market space at the hospital. “We are very lucky to have such dedicated volunteers, not only in the areas of fundraising but across the hospital helping our staff, physicians and patients and their families,” notes Jennifer. “Through our Patient and Family Advisors who share their unique thoughts and perspectives to ensure the voices of patients and families are heard, and our Service Volunteers who share their time and talent, delivering compassionate and respectful service to our patients, residents and their families across the hospital’s sites to Spiritual and Religious Care volunteers who provide emotional and spiritual support. Our volunteers play an integral role in making a world of difference for our patients, their families and our H community.” ■
Melissa Londono is a communications officer at North York General Hospital. 14 HOSPITAL NEWS APRIL 2017
FROM THE CEO’S DESK
The importance of communication in good times and bad By David Musyj
s stated by George Bernard Shaw “The single biggest problem in communication is the illusion that it has taken place.” We live by the adage you can never communicate enough. This is especially true during times of crisis. Unfortunately, in healthcare, being a 24/7/365 a day operation, taking care of hundreds of thousands of patients a year, with infrastructure and financial constraints, the number of crises has increased and the time between one to the next has been reduced. When not in a crisis we use various methods of communication to both our internal and external communities and stakeholders. This includes paper newsletters, social media, videos, facebook live, town halls and emails to just name some formats. An assumption we follow is that anything we publish for our internal community should be written in the same or similar format for our external community which includes the media. This is done for two reasons. First,
ductions. Second, we faced a medical anything we think important enough to device reprocessing issue that resulted tell our staff team members should be in the complete closure of the operavailable for our patients and commuating rooms at one of our acute camnity to read. The more individuals that puses and finally a bed capacity issue are aware of the day to day issues facduring the recent influening the hospital the better za season. All three lasted chance you have achieving months and with overlap the “illusion that commuconsumed the whole year nication has taken place”. and then some. Second, we want our comDuring each of these munity members speaking crises we used all of the from the same “songsheet” tools described above. In as our internal staff. The addition, during the crisis power of having thousands there was daily email upof individuals sharing idendates provided to all of our tical information with tens internal staff. This updated of thousands of individuals David Musyj our staff on the impact of they come in contact with the changes, the status of is powerful and creates a the implementation plans and projec“viral” communication process without tions into the future. The critical part even the help of social media. of this was that what was shared with When in a crisis communication internal staff in these emails was shared becomes paramount. During this past with the external stakeholders includyear alone three crises faced our oring media without editing. Again, the ganization. We faced an operational more individuals that hear the same funding reduction that resulted in message without editing, the better. operational changes and staffing re-
This promotes open and transparent communication but most importantly factually correct. In today’s day and age of “alternative facts” we cannot afford to create different facts ourselves by modifying our messaging because we incorrectly think the external community will not understand what our internal experts hear or that we have to modify the wording for their consumption. This approach results in people focusing on the changes between both communication documents and questioning “why was it changed” rather than digesting the content and sharing it with others. At the end of the day, being employed in Ontario hospital healthcare we have to appreciate we are not just employed by our hospital corporation but more importantly we are employed by our community and the Province as a whole. These employers are impacted by our problems and as a result should be aware of not only the good news we want to share but also the “not so good news”. H You can never communicate enough. ■
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APRIL 2017 HOSPITAL NEWS 15
Food for thought:
Nutrition’s contribution to healing By Shaylin Kemmerling magine catering a wedding – three times a day… every day… of the year… with 39 different dietary considerations and individual food and beverage preferences. That’s the equivalent of what Bluewater Health’s Nutrition & Food Services group achieves, with a laser focus on innovation to contribute nutritionally to our patients’ health outcomes. What patients eat – or don’t eat – while they’re in hospital can have a real impact. Research shows almost half (45 per cent) of patients are clinically malnourished on admission and those who eat less than 50 per cent of their hospital food are at risk for longer stays and/or readmission. In fact, a Nutrition Care in Canadian Hospitals study found malnutrition increased length of hospital stay by three days. Malntutrition can also result in delayed wound healing, impaired immunity, lower quality of life, loss of independence and impaired function.
Many factors can prevent patients from eating, ranging from lack of appetite related to their condition or environment, to food quality and selection, to physical barriers such as position, tray placement and packaging.
Alex Maghakian, Dietary Aide, and Jane Stephenson, Cook, at Bluewater Health prepare nutritious and delicious menu items for patients. Recently, department staff started a ‘scratch cooking’ movement to maximize the capabilities of their Burlodge carts, which are essentially – but much more than – ovens on wheels. They’ve begun preparing additional menu items – including pasta, baked goods and more – in house. Many improvements are trialed in our Petrolia facility, which we’ve nicknamed our ‘innovation hub.’ “We have found that freshly-prepared foods not only positively impact patient stays, but enhance staff engagement as well,” says Phil Sanders, National Di-
PATIENTS WHO EAT LESS THAN 50 PER CENT OF THEIR HOSPITAL FOOD ARE AT RISK FOR LONGER STAYS AND/OR READMISSION. At Bluewater Health, a variety of approaches ensure nutrition while in our hospitals in Sarnia and Petrolia contributes positively to both patients’ health and their hospital experience. On admission, patients’ nutritional status is assessed, with a treatment plan identified for those who are malnourished or at risk. Patients also complete a preference form on admission and are only given foods they like – since there’s no nutrition in a sandwich you don’t eat.
rector of Operations and Technical Services, Burlodge. “The Nutrition & Food Services team at Bluewater Health has always been forward-thinking and innovative and they were keen to incorporate some new recipes into their menu to benefit local patients.” Department staff consider ideas to improve taste and/or quality without increasing cost, and the suggestions just keep coming! For example, small packages of croutons were replaced
with bulk purchases put in cups, improving freshness and making it easier for patients with limited dexterity to open – all at a lower overall cost. The combination of scratch preparation and preference forms allow for shorter, more accurate forecasting and less food waste. The hospitals’ cost per meal/day has decreased by 25 per cent since 2015, while quarterly patient satisfaction surveys show a 28-30 per cent improvement in taste and temperature of hot food from July 2015 to October 2016. Department staff carries out R&D on the frontlines and monitors trends in the food industry to adapt best practices and innovation. The broader hospital staff look forward to quarterly taste panels, where our team can try new ideas on a big enough scale to gauge success. With a focus on freshness and presentation, the organization purchases as much local/Ontario-sourced, fresh food as possible, and participates in MEALsource –a program under St. Joseph’s Health System’s group purchasing organization which helps 30 Ontario foodservice operations ensure supply consistency at the best price. “We use a two-stage RFP to help determine best value for our members on the products
Photo credit: Bisi Alawode
that best fit their individual need, ” says Wendy Smith, Contract Specialist, MEALsource. “Participating institutions commit volume, or not – and we proceed with decisions on that basis. Bluewater Health has always been revolutionary and not afraid to try new approaches to achieve the best result for their patients, their organization and the health system.”
A helping hand
While the vast majority of patients (90 per cent) can manage mealtime in hospital on their own, mealtime assistance can help with better nutritional intake on the road to recovery. Hospital volunteers not only provide companionship, they help with hand hygiene and check that patients have any assistive devices they need, before making sure the meal tray is within reach. They encourage patients to finish high-protein and nutrient-dense foods such as fruits and vegetables, and supplements first and offer to open packages and lids, cut food, butter bread, etc. Quality food that meets patients’ dietary needs and preferences, combined with a pleasant and social environment during mealtime, helps patients maximize their nutritional experience and H supports their healing. ■
Shaylin Kemmerling is a Registered Dietitian and Manager, Nutrition & Food Services and Diabetes & Clinical Nutrition at Bluewater Health’s two hospitals in Sarnia and Petrolia, ON. 16 HOSPITAL NEWS APRIL 2017
New group provides resources and peer support to
Photo credit: Bruce Zinger
trauma survivors By Kelly O’Brien
fter she was hit by a garbage truck in 2012, doctors told Margaret Harvey’s husband she had only a 30 per cent chance of survival. Harvey pulled through, but the road to a full recovery would prove long and difficult, both physically and emotionally. After being treated for a few weeks at St. Michael’s Hospital, she was transferred to another hospital, and then a private retirement home to complete her rehabilitation. When she returned home, she realized how much her trauma had changed her life. “I thought that when I went home, I would be better, but I wasn’t, and it took me a while to realize that things were just beginning,” she says. She tried to go back to work, at the Terry Fox Foundation, but she said even one day a week was too much for her, so she was forced to take medical leave. It was then that she discovered the Trauma Survivor Network. “I felt so alone, and I thought, who has been through this? I need to talk to somebody so I can know how this is going to end for me,” she says. “I couldn’t sleep and I was up all night, so I went online and found it, and I thought, this is exactly what I need.” However, there was no Trauma Survivor Network branch in Canada. She approached St. Michael’s Hospital with the idea of establishing a group to connect outpatient trauma survivors with support services.
THE GROUP WILL HELP TRAUMA SURVIVORS MANAGE THE PSYCHOLOGICAL AND SOCIAL IMPACT OF THEIR INJURIES. The group, called My BeST (Beyond Surviving to Thriving), is being organized by Harvey and Amanda MacFarlan, a trauma registry manager and quality improvement specialist at St. Michael’s, along with a committee including social workers, trauma surgeons, psychiatrists, physiotherapists, patient experience advisers and spiritual care providers. The group will help trauma survivors manage the psychological and social impact of their injuries. “You can fix bones and you can fix muscles, but you also need to treat minds, and you need to respect that when someone goes through a physical trauma, their whole life could change on a dime,” says Harvey. “How are you going to deal with that?” “How people deal with trauma is determined by a number of different factors,” Harvey says. She was lucky to have the resources necessary to seek out the treatment she needed. My BeST aims to help people who don’t have access to those resources on their own. “I was so lucky that I had a home, money, kids, people around me, I had
lots of support,” she says. “But a lot of people don’t have any of that, and trauma has very real impacts on peoples’ mental health, so it’s something that needs to be addressed.” Harvey says she wants people to understand that post-traumatic growth is possible. “People go through trauma every day, and they can move past it, but first they need to address it,” she says. “If we offer the help and people seek the help, they can improve, they’re not doomed to have post-traumatic stress disorder H forever. You can move on from that.” ■
Margaret Harvey, with orthopedic trauma surgeon Dr. Aaron Nauth, stands in front of St. Michael’s, where she was treated after being hit by a garbage truck in 2012.
Kelly O’Brien works in communications at St. Michael’s Hospital.
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hospital food By Vincent Lamontagne
oasted sweet potatoes. Home-made hummus. Grilled veggie wraps. Soups made from scratch. It’s what you might expect on the menu of a downtown bistro. Yet, thanks to the leadership of the Ottawa Heart Institute (UOHI) and the generosity of its Patient Alumni Association, it’s exactly the kind of healthy, delicious food that staff, visitors and patients are now finding at the Institute’s Tickers cafeteria. Thanks to a $25,000 contribution from the Ottawa Heart Institute’s Patient Alumni Association, the Institute was able to upgrade its equipment in 2015 so that it is easier to prepare healthy food for the 500 or so staff and visitors who eat there every day. Jean Bilodeau is the President of the Patient Alumni Association and was among the main instigators, along with hospital officials, of the transformation. “It really fits into our mandate for patient comfort and support. We kept telling patients to go back home and eat right, so we felt we could also help the Heart Institute in its efforts to promote healthy food.” The motivation to make these changes came out of a larger campaign led by the Champlain Cardiovascular Disease Prevention Network (CCPN), which is housed by and powered at the UOHI. The Healthy Foods in Hospitals Program aims to offer more nutritious food in cafeterias, vending machines, gift shops, and franchises in all 20 hospitals throughout Eastern Ontario. All hospitals are actively participating in the program and making great progress. UOHI was among the first hospitals to sign on. “The deep fryer has been eliminated and we’ve increased the sizes of our ovens,” says Thomas Riding, the Head Chef of Tickers cafeteria, managed by Marek Hospitality. “Instead of doing French fries, we take the same quantity of potatoes, cut them in wedges, brush
Heart Institute President and CEO, Dr. Thierry Mesana, surrounded by partners and colleagues, in celebration of the Institute’s achievements in promoting healthy eating in accordance to the Healthy Foods in Hospitals initiative spearheaded by the Champlain Cardiovascular Disease Prevention Network (CCPN). them with olive oil and herbs, and cook them in the oven.” Other changes include replacing white bread with whole grain bread as the default for sandwiches and toast. Tickers has also introduced a lowfat mayonnaise as well as flavourful, low-sodium home-made salad dressings at their salad bar. Each day there is also at least one vegetarian soup on offer, as well as protein-rich vegetarian options at the salad bar such as chick peas and beans. Regular potato chips have been replaced with snacks such as trail mix and seed and nut bars. Meanwhile, the size of soft drinks and juice has been reduced and the healthier choices such as bottled water are placed front and centre. While Riding is enthusiastic about the transformation, he is well aware of the challenges of making changes too quickly. “It’s a fine line between giv-
ing people healthier options, without having them become resentful,” Riding explains. Thanks to Riding’s culinary skills, there’s little chance of that. All soups and entrees are made from scratch, including a selection of healthy takehome meals for customers. “We also make our own muffin batter,” he adds. “So we have more control over ingredients and can add in things like whole wheat flour, real cranberries, lemon zest, diced oranges and walnuts.” Committed to integrating local food options where possible, Riding is working with local partners to offer some of their healthy products to the Heart Institute clientele. Riding also tells the heartwarming story of another local food supplier who, in this case, approached them. “The owner of Sushi Box in Orleans was so impressed with the care his
mother received while she was a patient at the Heart Institute that he wanted to give back. So he asked us to sell their sushi and donate all the sales to the Institute’s Foundation. Every day he brings in 25 or so fresh items, including wakame (edible seaweed) and octopus salad.” The Healthy Foods in Hospitals Program is based around three progressive levels of change – Bronze, Silver and Gold. Tickers and the UOHI achieved Bronze in December 2015 and are well on their way to fulfilling the Silver-level requirements. According to Bilodeau, “Everyone agrees that what we are doing at Tickers is a good thing. I think it shows real leadership, not only on the part of the Institute and the Patient Alumni Association, but also on the part of Marek Hospitality. We know how important H prevention is.” ■
Vincent Lamontagne is Director, Corporate Communications at the University of Ottawa Heart Institute. 18 HOSPITAL NEWS APRIL 2017
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Pharmacological options for
treating opioid addiction By Dr. Janice Mann
20 HOSPITAL NEWS APRIL 2017
pioids are a class of drugs that are prescribed to treat pain, and include codeine, fentanyl, oxycodone (one of the ingredients in Percocet), and morphine. But opioids aren’t always taken to treat pain. Taking opioids can also result in a feeling of euphoria or a “high.” Opioid use disorder (also known as opioid dependence or drug addiction) is a condition in which people have difficulty controlling their use of opioids. They take opioids because of cravings for the drug and its effects, and to avoid or stop the withdrawal symptoms they experience if they don’t take them. People with opioid use disorder develop a tolerance, meaning higher and higher doses of opioids are needed to feel their effects and to avoid symptoms of withdrawal. People with opioid use disorder will continue to use opioids instead of engaging in other pleasures or interests and despite harm to themselves and others. When thinking about opioid addiction, you might assume that the opioids being taken are illegal drugs (sometimes referred to as illicit or street drugs) such as heroin. But opioids that have been prescribed to patients for pain also play a significant role. Patients who have been prescribed opioids may develop opioid use disorder themselves or the opioids they have been prescribed can be diverted into the hands of others. Opioid addiction is a complicated disorder – with physiological, psychological, genetic, behavioural, and environmental factors all playing a role. This makes effectively treating people with opioid use disorder a real challenge. But oddly enough, one treatment strategy for opioid use disorder involves the use of… opioids! In Canada, there are two such medications approved for the treatment of opioid disorder. One is methadone. Another is a combination of two medications: buprenorphine and naloxone. When taken as prescribed, these medications can alleviate withdrawal symptoms and reduce cravings but without producing a feeling of euphoria or a “high.” They can be used first to manage opioid withdrawal in patients and then can be used long term to prevent relapse. There are differences between methadone and buprenorphine/naloxone. Methadone is a liquid taken combined with another liquid that can’t be injected. It can be prescribed only by a physician with a special exemption under the Controlled Drugs and Substances Act. Buprenorphine/naloxone is a tablet taken under the tongue. Physicians do not require a special exemption to prescribe it. Because of how the two medications work in the body, the potential for abuse is lower for buprenorphine/naloxone and the risk of overdose is higher for methadone. Methadone needs to
EVIDENCE MATTERS be taken every day, but buprenorphine can be taken every other day. Before 2013, buprenorphine/naloxone was significantly more costly than methadone, but it’s now available as a generic drug, making the difference in cost between the two treatments less. Given the availability of two different prescription drugs to treat opioid use disorder, how do treatment programs, healthcare providers, and their patients choose the option that is best for them? To help answer this question, the healthcare community turned to CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – for evidence. CADTH carefully searched the medical literature to find information on how effective the two treatment options are at treating opioid use disorder. Information on whether the treatments offered good value for their cost was also sought. Finally CADTH searched for recommendations from
OPIOID ADDICTION IS A COMPLICATED DISORDER – WITH PHYSIOLOGICAL, PSYCHOLOGICAL, GENETIC, BEHAVIOURAL, AND ENVIRONMENTAL FACTORS ALL PLAYING A ROLE. evidence-based clinical practice guidelines to help guide treatment decisions. After pulling together all the evidence found, the report was reviewed by experts in substance use and the treatment of addictions. And what did CADTH find? One study showed that higher doses of methadone and buprenorphine/naloxone were more effective than lower doses. Patients taking methadone stayed in treatment longer, but patients taking buprenorphine/naloxone were more likely to abstain from using other opioids. There were no differences in harms between the two treatment options. The economic evaluations showed that the
costs of buprenorphine/naloxone treatment were higher but the differences were small, and these economic studies were not Canadian and were conducted before buprenorphine/naloxone was available as a generic drug. This means that in Canada buprenorphine/naloxone may now be more cost effective than methadone – but it’s difficult to know for certain. One evidence-based guideline from 2011 recommended that the choice of treatment be guided by individual clinical circumstances and patient preference. Overall, the evidence shows that buprenorphine/naloxone appears to be a safe, effective, and cost-effective
choice for treating opioid use disorder when compared with methadone. This is an important finding, given some of the advantages offered by buprenorphine/naloxone. So what does the evidence mean for healthcare providers, their patients, and the Canadian health system as a whole? In a nutshell, it offers a choice in treating people with opioid use disorder. This means that each treatment program – and the health providers and patients within that program – can take into consideration the many factors that come into play for a person experiencing opioid use disorder and choose the treatment option that fits best. Effective treatment of opioid use disorder is one of many strategies that will help to address the opioid crisis in Canada. CADTH is committed to providing the needed evidence to effectively address the opioid crisis in Canada. For more evidence on opioids visit www. cadth.ca/opioids or speak to a CADTH H Liaison Officer in your region. ■
Dr. Janice Mann is a Knowledge Mobilization Officer at CADTH.
NURSING WEEK 12th Annual Supplement
The May 2017 issue of Hospital News will be celebrating National Nursing Week in Canada (May 8th – 14th) with a special section showcasing our “Nursing Heroes” contest winners as well as highlighting outstanding leadership and stories from the nursing frontlines!
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905.532.2600 x2235 email@example.com APRIL 2017 HOSPITAL NEWS 21
Reducing the number of instruments on operating room trays saves money By Amanda Jackman
inancial accountability, cost savings and streamlining are very familiar terms for hospitals in Ontario. Publically funded healthcare organizations constantly have to find savings wherever possible. And as hospitals tighten their belts they depend on bright ideas from staff and physicians. Surgeons Dr. Leigh Sowerby and Dr. Brian Rotenberg with St. Joseph’s Health Care London’s Otolaryngology Head and Neck Surgery Program, found savings not only in equipment costs but also in time. “As care advances there are often changes to practice that result in a different way to perform a surgery or procedure,” explains Dr. Sowerby. “We have had several instances where a surgical technique has changed but the accompanying instruments on the surgical trays did not. Tonsillectomy is a great example. Traditionally, tonsils were removed ‘cold’ – using a scalpel and a snare, but for the last 15 years at St. Joseph’s Hospital, we have been using cautery instead. The ‘cold’ instruments remained on the surgical tray, but were never used for the procedure. These instruments would have to be cleaned, reprocessed and the disposable wire replaced every time the tray was used. We wanted to take a closer look at the utilization of these trays to see if there was a cost savings by only including the instruments used regularly.” Dr. Sowerby and Dr. Rotenberg engaged a small group of staff, and together they embarked on a study in hopes of finding a way to streamline surgical trays, which in turn would reduce costs for instruments as well as tray set up and reprocessing times. During the study, five otolaryngology trays were audited and it was found that only 30 to 40 per cent of the instruments were used regularly. With the help of summer student Eric Lortie, Drs. Sowerby and Rotenberg worked with Tracey Yule, RN, Carmela DelVasto, Central Processing, and Pauline
Bessegato, Coordinator Perioperative Services, to reduce the trays and create a new standard surgical tray. To be on the safe side they also included the creation of an ‘extras’ tray. “The extras tray was developed just in case a surgeon needed a tool that wasn’t on the standard tray, but no one has had a need for it, so we will consider the elimination of that as well,” says Dr. Sowerby. After the implementation of the changed trays otolaryngology has seen improvements in three areas:
(removal of the tonsils) • Operating room set up time reduced by 32 per cent (three minutes) for tonsil trays • Redundancies and excess eliminated by removing 20 instruments (59 per cent of the tools) • Tonsil tray assembly time decreased from an average of nine minutes to three and a half minutes
(deviated septum correction) • Operating room set up times reduced by 50 per cent (six minutes) for septum trays • Redundancies eliminated by removing 54 instruments (64 per cent of the tools) • Septoplasty tray assembly time decreased from 22 minutes to eight minutes
• Operating room set up time reduced by 30 per cent (four minutes) for sinus trays • Redundancies eliminated by removing 61 instruments (60 per cent of the tools) • Sinus tray assembly time from 26 minutes to nine and a half minutes “One of the indirect measures we discovered was that by lowering the number of instruments, we decreased the complexity of tray assembly, which
Dr. Brian Rotenberg, left, and Dr. Leigh Sowerby show off a streamlined tray in St. Joseph’s Otolaryngology Head and Neck Surgery Program. led to a shorter learning curve to train new central processing technicians and reduced stress on operating room staff,” says Dr. Sowerby. With these positive results Dr. Sowerby knows other areas of care within St. Joseph’s would benefit from a similar exercise. “When we made the changes in otolaryngology we presented the data to other departments. Determining the instruments to be removed requires engagement and truly is a valuable exercise.” Word is spreading, as the Breast Care Program saw the value of reevaluating their surgical trays and is taking on the exercise. “They will be assembling new
trays soon,” says Dr. Sowerby. “Both the Roth McFarlane Hand and Upper Limb Clinic and oral maxillofacial surgery have expressed interest.” To enable this work Dr. Sowerby was awarded a President’s Grant for Innovation. “Continuous improvement is key to excellent patient care,” says the surgeon. “We want to make sure the improvements are fully meshed within our practices ensuring the best outcomes for patients and our hospital at large.” Dr. Sowerby’s long term plan is to reach out to all St. Joseph’s surgical services and show them how his department benefited from this study and that H theirs may too. ■
Amanda Jackman is a Communication Consultant at St. Joseph’s Health Care London 22 HOSPITAL NEWS APRIL 2017
A selfless wish By Courtney Morgan
wish rooted in philanthropy led to almost 1000 pounds of food and $500 for those in need in London. The wish was that of Korean War veteran George Browning, made possible by the Royal Canadian Legion – Ladies Auxiliary who sponsor the Dreams and Wishes program at St. Joseph’s Health Care London’s Parkwood Institute. The program provides veterans an opportunity to fulfill a special dream or wish. For Browning this meant giving back to the community by ensuring London’s homeless do not go hungry. He organized a food drive, collecting non-perishable food items from staff and fellow residents. “George has such a big heart and always looks out for people,” says Alida van Dijk, staff chaplain at Parkwood Institute. “His wish choice didn’t surprise anyone. He is always giving to others.”
It was a cold and windy day as Browning was bundled and loaded onto the bus on Feb. 15 to deliver the donation to the London Food Bank. This didn’t hinder his joy one bit as he smiled and gave thumbs up all along the way. “I can’t believe how much food is here,” said Browning when looking at all the items donated piled into the bus. “I’ll go down in history.” Once he arrived he was greeted by the London Food Bank’s Honorary Chair, Peter Harding along with staff and volunteers. “It’s because of people like you, George, who make this all possible,” said Harding. “We can’t thank you enough for the wonderful gift you’ve given us.” George was provided a tour of the building and learned how things were sorted, stored and provided to those in need.
From left, Peter Harding London Food Bank Chair, Brenda Bissette (George’s daughter) and George Browning. As a special surprise, George’s daughter presented a $500 donation in honour of his late wife. George’s heart was full of joy and he was brought to tears when receiving the news of a 980 pound donation.
Courtney Morgan is a Communication Assistant at St. Joseph’s Health Care London.
“I’ll tell you right now, I’m happy, so happy and so proud; not only for me, but for the people I’ve done the work for,” said George. “I’m glad I got to help H get what we wanted to get done.” ■
TRENDS IN TRANSFORMATION
Leader Standard Work is a recipe for success On a busy clinical unit the first three hours of the day can set the pace of the next five. Find out how UHN leaders are using Standard work to set themselves up for success. By Michael Ronchka s leaders in clinical units, Patient Care Coordinators (PCC) have a lengthy list of tasks awaiting them every morning: touch base with the night shift staff about their problems or concerns, check emails, coordinate admissions, discharge before and after the 8:40 a.m. patient flow meeting, solve problems and act as the one source of information for their teams. All that while being pulled from one conversation or call to the next, often in mid-sentence. But now, two PCCs are taking back the morning. Members of the Lean team worked with Natalia Evitch, PCC, 6B, Toronto General and Antonia Cole, PCC, 6A, Toronto General, to bring order and focus to the morning chaos using Leader Standard Work. Leader Standard Work is a tool adapted from industry and used at leading healthcare providers such as ThedaCare in Wisconsin to ensure leaders have a structured management system for proactively addressing the most pressing challenges facing their teams. Before creating the standard work, Lean coaches shadowed the PCCs to understand how they spend their time. The data showed the PCCs were spending approximately 15 to 20 per cent of their time in the morning responding to the unexpected, and approximately 20 per cent of their time on activities that improve how work is done, such as problem solving and streamlining processes. Next, Natalia and Antonia worked with their Lean coach to articulate the key goals – safety and flow – they must focus on every morning to ensure their teams have a successful day. The structure provided by Leader Standard Work allowed them to reduce time spent responding to the unexpected and focus on their key goals.
Applying structure to chaos
“That first week using the standard work felt like having someone telling
Natalia Evitch and Antonia Cole. you what to do, literally every minute,” says Natalia. “It was difficult because I’ve been doing this for years and using standard work feels like admitting that you can’t organize your time.” “But by bringing this structure and focus to the morning business we created time for quality. We can spend more time coaching the night shift nurses, or do real problem solving with our team members to prevent problems from reoccurring.” After implementing Leader Standard Work, the time Natalia and Antonia spent on administrative tasks dropped by 73 minutes a day and time spent dealing with unexpected events dropped by half an hour. Time spent improving work during the morning increased more than 10 per cent. With less time lost to interruptions the two PCCs have more time to spend talking with patients. “I can talk to every patient in the morning,” says Antonia. “I really enjoy getting to know them, and I can talk to them about their care plan, their
discharge plan and answer questions about transitioning home.” With questions and concerns addressed first thing every morning there are fewer questions for nurses to field later in the day. That saves time for nurses who would otherwise have had to track down the appropriate person to answer the patient’s question.
Creating a new ‘one source of information’
Interruptions are bad for productivity – research from Carnegie Mellon University’s Human-Computer Interaction Lab found it takes an average of 25 minutes to refocus on the original task after an interruption. The Lean coaches believed Natalia and Antonia could save time by eliminating, or at least reducing, interruptions. The coaches spent several mornings closely observing Natalia and Antonia, tracking minute-by-minute who was interrupting them and why. “When the Lean team shadowed us they verified what we already knew,”
says Antonia. “We were constantly interrupted by nurses on our unit, calls from the flow team, calls from physiotherapists and occupational therapists, and calls from other units. We never finished a task or conversation before moving on to the next one.” Natalia and Antonia worked with all these groups to determine what information they needed the most and where it should live, which turned out to be the electronic whiteboard system. Time was scheduled into the standard work for entering pertinent patient information into the system. Now all members of the care team can easily access whatever information they need. “I was nervous at first about how rigid the standard would be,” says Natalia. “But I can deviate if there is an emergency and we collaborated with our Lean coach to adapt it to work for us.” Leader Standard Work has had such a positive impact on unit operations that the charge nurses on both units are in the process of creating their own H standard work. ■
Michael Ronchka is a Communications Associate, Lean Process Improvement Team, University Health Network. 24 HOSPITAL NEWS APRIL 2017
7 1 0 2 , 7 â€“ 4 June
SPECIAL SHOW GUIDE
e-Health Conference 2017
The future of digital health and the people who benefit
his year’s e-Health Conference is focused on celebrating, growing and being inspired by the past, current and future state of Canada’s digital health community. From coast to coast to coast, we will showcase the many successful products, success stories and leaders in our nation’s digital health journey. Engaging with current and future leaders, you can look forward to maximizing your networking opportunities during the trade show
and social events, and celebrating achievements at the Canadian Health Informatics Awards Gala. Special events such as the Showcase and Hackathon round out the many entertaining and educational opportunities offered this year. More than 250 world-class presenters, this Conference will be your premiere health informatics networking and learning opportunity for 2017. The full conference program is availH able at www.e-healthconference.com ■
hose of us contributing to the healthcare system know that for high-volume healthcare services with chronic wait times, a more coordinated approach, leveraging central intake and information technology, will help address some of our access to care and wait times challenges. It has been demonstrated in various regional programs for example, that centralizing all hip and knee orthopaedic YLMLYYHSZ HUK OH]PUN WH[PLU[Z ÄYZ[ HZZLZZLK I` HU advanced practice physiotherapist before being routed to an orthopaedic surgeon, improves access to care. A similar model is being used for mental health and addiction referrals in the Mississauga Halton region that is transforming access to care. Such innovative coordinated referral and assessment models, enabled with Canadian THKL YLMLYYHS [LJOUVSVN` OHZ KLTVUZ[YH[LK ILULÄ[Z for patients, providers, regional health administrators, ministries of health and for the public treasury.
President, Novari Health
28 HOSPITAL NEWS APRIL 2017
Meet the speakers Monday, June 5th 8:30 – 10:00 a.m. Opening Keynote Address Predicting Excellence: Going for Gold in Health Care
Anne Merklinger, CEO, Own the Podium An elite athlete for most of her life, Anne Merklinger was a member of Canada’s national swim team from
1977–1981. Anne earned a silver medal at the 1979 World University Games in the 200-metre breaststroke. After a distinguished swimming career, Anne focused on curling and since the early 1980’s she competed with distinction at every major event she entered. She was consistently ranked as one of Canada’s foremost curlers, winning the Ontario Women’s Curling Championships in 1993, 1994, 1998 and 2000. She has twice led her team to the final of the Scott Tournament of Hearts (1998 and 2000). A passionate, creative, and inspiring leader, Anne has more than 20 years of management experience with national sport organizations. Prior to becoming CEO Anne held the position of Director, Summer Sports with Own the Podium.
She previously worked with CanoeKayak in the role of Director General, and has also worked with the Commission for Inclusion of Athletes with a Disability and the Canadian Federation of Sport Organization for the Disabled. Anne’s life-long experience in sport as an athlete and professional is complemented by extensive volunteer experience with a number of organizations including the Sandra Schmirler Foundation, Women’s Tour of Curling, CAAWS, and Special Olympics Canada. Paul Robinson, Associate Vice President of Credit Risk Management, Canadian Tire Bank Paul Robinson is Associate Vice President of Credit Risk Management at Canadian Tire Bank. He is responsi-
ble for the oversight of sound risk management strategies and covers the entire credit lifecycle, including account origination, management, collections and fraud. Paul’s mandate also includes showcasing how Canadian Tire Corporation’s deep experience in data analytics extends to sports by helping Own the Podium identify future Olympic and Paralympic medalists. Since joining Canadian Tire Bank in 1999, Paul held a number of progressively senior roles within various departments, including credit risk management, mortgage underwriting, modelling and fraud. Continued on page 30
APRIL 2017 HOSPITAL NEWS 29
Meet the speakers Continued from page 29
TEDx’s and leading international conferences. She is a contributor for ABC World News, Forbes and the Huffington Post, and has appeared on CNN, ABC News, CTV, CBC News, Global National TV, CP24, Discovery and Space Channel.
Prior to his current role, Paul spent three years as an analyst with Dun & Bradstreet Canada where he was responsible for creating custom credit models. Paul holds a Master’s degree in Business Economics from Wilfrid Laurier University and an Honours degree in Business Economics from Brock University. Paul also holds a Certified Credit Professional designation from the Credit Institute of Canada.
Wednesday, June 7, 12:00–2:00 p.m.
Tuesday, June 6th 8:30–9:30 a.m.
Morning Plenary Dr. Julielynn Wong. Founder, Chairman, & CEO., 3D4MD Dr. Julielynn Wong is a brilliant, captivating, and unforgettable speaker who infuses powerful storytelling with a playful personality. She brings an unrivaled passion for ideas that inspires audiences to embrace innovation and engage technology to solve big challenges. Following medical school at Queen’s University, Dr. Wong received a Frank Knox Memorial Fellowship to complete her Masters of Public Health degree studies at Harvard University. She is board-certified in public health and general preventive medicine, has authored over 35 scientific and techni-
30 HOSPITAL NEWS APRIL 2017
cal publications and has filed 6 patents for medical devices. She is a passionate educator who has taught courses and workshops for thousands of grade school, university, and postgraduate students. Additionally, Dr. Wong is an avid pilot and drone racer, has flown as a microgravity researcher with NASA’s parabolic flight program, and served as an analog astronaut for NASA’s Human Exploration Research Analog IX and the Mars Desert Research Station Crew 145 mission simulations. Dr. Wong is a highly sought-out dynamic speaker and has spoken at the UN, Google Canada, Smithsonian, multiple
Closing Keynote Address Dr. Joseph C. Kvedar, Vice President, Connected Health at Partners Healthcare Joseph C. Kvedar, MD, Vice President, Connected Health at Partners HealthCare, is creating a new model of healthcare delivery, developing innovative strategies to move care from the hospital or doctor’s office into the day-to-day lives of patients. He is the author of a new book, The Internet of Healthy Things, in which he describes how everyday objects will capture and use real-time biometric data to learn more about the impact of lifestyle on chronic diseases and wellness, and ultimately change behavior to improve our health. At Partners Connected Health, Dr. Kvedar is leveraging information technology – cell phones, computers, networked devices and remote health monitoring tools – to improve care de-
livery. Partners connected health programs are also helping providers and patients better manage chronic conditions, maintain health and wellness and improve adherence, engagement and clinical outcomes. Based on the technology platform developed at Partners, a personalized health technology company was launched and later acquired by a leading insurance company to support its program encouraging healthy behavior and wellness education among employee populations. In 2013, Dr. Kvedar launched Wellocracy, a leading source of impartial, easy-tounderstand information on new personal “self-health” technologies like activity trackers, wireless devices and mobile apps to empower people to get and stay healthy. He is internationally recognized for his leadership and vision in the field of connected health, and has authored over 100 publications on the subject; his popular cHealth Blog provides his insights and vision for connected health. Dr. Kvedar serves as a strategic advisor at Qualcomm Life, Puretech Ventures and BD Technologies, and is a mentor at Blueprint Health, providing guidance and insight to developing companies. Dr. Kvedar is also a mentor at the Harvard Innovation Lab and serves as a judge for its President’s Challenge for Entrepreneurship. Continued on page 32 www.hospitalnews.com
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Meet the speakers Continued from page 30
e-Poster highlights Poster Presentation Tuesday, June 6, 2017 9:30–10:30 a.m. Workflow Analysis to Inform a Remote Patient Monitoring System Implementation Implementing a large scale RPM system requires the efforts of new workflows, electronic teaching materials, and unique staff. Peter Rossos Chief Medical Information Officer, University of Toronto Peter G. Rossos MD, MBA, FRCP(C), FACP Associate Professor of Medicine, University of Toronto As Chief Medical Information Officer and staff gastroenterologist, Dr. Rossos’ priorities include strategic alignment of clinical systems with workflow and productivity in order to improve outcomes related to patient safety,
quality improvement, education and research. Poster Presentation Tuesday, June 6, 2017 9:30–10:30 a.m. Creating Smart Cities Through IoT Devices Enabled Seamless Healthcare IoT solutions that faciitate seamless healthcare for smart cities, c o n s i d ering the needs of ageing populations, through Living Labs approach of UN Expert group. Chandana Unnithan, Professor, Charles Darwin University Dr Chandana Unnithan is a Health Informatics practitioner and Professor, in Australia. She is currently associated with “Space and Global Health”, an expert group (within the United Nations Committee on Peaceful Uses of Outer Space), engaged in building interdisciplinary projects with glob-
al partnerships in developing public health informatics. Poster Presentation Tuesday, June 6, 2017 9:30–10:30 a.m. Drinking from the Data Fire Hose, Integrating Medical Device Data We will bring our expertise of the task of connecting medical devices and device data for hospitals, researchers, and technologists alike.
Doug Frede President, True Process Doug is the President and co-owner of True Process, a clinical systems consulting firm, based in Glendale, Wisconsin. A business leader, software engineer, and entrepreneur with over 20 years of experience building businesses, exploring strategies, and implementing connected healthcare systems Doug is passionate about using technology to creatively solve problems.
Oral presentation highlights
OS14: Successes in Quality and Efficiency Tuesday, June 6, 2017, 1:00–2:00 p.m. Transcription Services Project Improving Quality, Efficiency and Accessibility The Transcription Project resulted in patients and clinicians receiving reports<2 days across four of BC’s health organizations with $7.9 million annual savings. Naomi Brooks, Regional Director, Transcription Services & Health Information Exchange, Providence Health Care Naomi Brooks is the Regional Director, Transcription Services & Health Information Exchange for Health Information Management, a department of Providence Health Care. Naomi provides strategic leadership and is responsible for overseeing contracted and in-house dictation and transcription services across the four lower mainland health organizations.
32 HOSPITAL NEWS APRIL 2017
Oral presentation highlights OS29: Realizing the Promise of â€œBigâ€? Data Wednesday, June 7, 2017 10:30 a.m.â€“12:00 p.m. Pathology Laboratory Utilization Scorecards (PLUS): A Pathology Data Analytics Platform A big health data analytics platform, using advance analytics methods, to analyze pathology lab data in order to optimize pathology lab utilization. Raza Abidi Director of Health Informatics, Dalhousie University Raza Abidi is Professor of Computer Science and Medicine. He conducts research in clinical decision support, health data analytics, patient empowerment strategies and mobile health. He has published over 200 papers, supervised over 75 graduate students, delivered over 100 invited talks and has secured research grants totalling $20 million.
OS03: Realignment in Health Care Monday, June 5, 2017, 4:00â€“5:30 p.m. You Canâ€™t Do it Alone: Leveraging Partnerships in eHealth Leveraging partnerships is necessary for physician adoption and use of ehealth technologies and for getting them to provide EMR data. Sarah Hutchison, CEO, OntarioMD Sarah Hutchison has been the CEO of OntarioMD since 2014. She has 25+ years of health care delivery experience and is a digital health leader in Ontario. Sarahâ€™s expertise in governance, policy, privacy and physician engagement has been effective in ensuring physicians are active and represented in the evolution of digital health delivery in H Ontario. â–
$SSVIRU+HDOWKLVRQHRI2QWDULRÂˇVSUHPLHU digital health conferences, focusing on LQIRUPDWLRQVKDULQJQHWZRUNLQJDQG UHFUXLWPHQW
Register at: www.appsforhealth.ca
Minister Jane Philpott Minister of Health, PC MP
Nathalie Le Prohon VP, IBM Canada
Apps for Health is Supported by
APRIL 2017 HOSPITAL NEWS 33
Social Events Welcome reception
Sunday, June 4, 5:30 to 7:00 p.m. The e-Health 2017 Steering Committee invites all delegates to the e-Health 2017 Welcome Reception. Start off the Conference with this opportunity to meet colleagues, network and catch up with friends! Admission to the Welcome Reception is included when purchasing a full conference registration.
Monday, June 5, 6:15 to 10:00 p.m. The CHIA Gala will begin with a reception followed by a three course dinner and award presentations. These awards pay tribute to individuals, projects, teams and companies. Awards will be presented to the leading individual or team in the following categories. A $25.00 commitment is requested and it will be donated to the Daily Bread Food Bank.
• Clinician Leadership • Corporate Citizenship • Emerging Leader in Health Informatics • Excellence in Canadian Telehealth • Innovation in the Adoption of Health Informatics • Leadership in the Field of Health Informatics • Project Team – Implementation • Project Team – Innovation & Care Delivery • Project Team – Patient Care Innovation • Steven Huesing Scholarship A complete list of award category descriptions is available at http:// www.e -healthconference.com/so cial-events/
Mix and mingle reception
Tuesday, June 6, 5:00 to 6:30 p.m. All e-Health 2017 exhibitors welcome Conference delegates to a reception. This will be an excellent opportunity to visit the exhibition, network and make connections. Admission to
34 HOSPITAL NEWS APRIL 2017
the Exhibitor Reception is included when purchasing a full conference registration.
Since its inception, the Conference has attracted a steadily increasing attendance, now upwards of 1,500+ delegates. The Trade Show provides an excellent opportunity for participants to connect with vendors and other members of the health informatics community. The year the exhibit floor features The Start Up Zone. Start-ups and innovative subject matter experts to showcase their emerging technologies that are in the following framework: • Newly created company displaying a creative and engaging use of technology and innovative delivery model to improve health service in Canada • Entrepreneurial venture or new business focused on scalability and growth in an emerging health market • Through an application process we will select 20 companies to participate H in the Start Up Zone. ■
mental health in the workplace at e-Health 2017 alling all hackers, designers, developers, and engineers! Hacking Health is back at the National eHealth 2017 conference and collaborating with the Institute of Gender and Health at Canadian Institute of Health Research (CIHR), to tackle one of Canada’s most pressing challenges: workplace mental health and wellbeing. Work stress and mental health are pressing challenges for much of the Canadian workforce. Nearly 40% of long-term disability claims in Canada are related to psychological health. The changing
demographics of the Canadian workforce mean that we require new and innovative ways to foster and support a healthy and productive workforce now and in the future. The goal of this hackathon is to develop innovative, evidence-informed, gender-responsive and culturally-appropriate digital mental health solutions that foster the labour force participation of women, men and gender-diverse people at risk of or struggling with workplace stress or mental health injuries. Over 3 days, CIHR researchers, academics, users, mental health experts,
developers, designers, and engineers will co-design and prototype digital health solutions that impact all of us. The goal is to develop a fully functioning prototype that can be tested in the real world after the hackathon. To that end, Hacking Health has partnered with leading
organizations to support validation and implementation of the prototype. These partners include Desjardins, Interac, Gevity, and Orion Health. Furthermore, CIHR grants to support the commercialization of the solutions post-hackH athon are being negotiated. ■
A FEW DATES TO KEEP IN MIND:
• REGISTRATION – Opening Soon! • OPENING CEREMONY AND PITCH PRESENTATIONS – June 4, 7:00 – 9:00 p.m. • HACKING – June 4 to 6 • FINAL PRESENTATIONS AND AWARD – June 6, 3:30 to 5:00 p.m.
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APRIL 2017 HOSPITAL NEWS 35
Nurses to the rescue: PART 3 OF 3
Calming presence of NP during cardiac emergency Emergencies can strike at any time. Jarring, chaotic and often life-threatening, they startle the senses and send adrenaline soaring. In this three-part series, you will meet three registered nurses and one nurse practitioner whose peaceful off-hours were catapulted into frenzied encounters on planes, in quiet living rooms, and even in a community bar. These nurses jumped into action without hesitation. By Kimberley Kearsey ric Rankin is a nurse practitioner at an aboriginal health centre in Brantford. Outside of business hours, he volunteers as a member of the board of directors for the Registered Nurses’ Association of Ontario and also teaches first aid, CPR, and pediatric advanced life support. He’s just the person one would want on an aircraft when a fellow passenger begins losing consciousness after complaining of dizziness and tightness in his chest. In February 2015, while on a flight home from Cuba, Rankin was one of three volunteers to answer a call for help from the flight crew. “I’m generally comfortable in emergency settings,” the Brantford NP says, noting his experience in trauma nursing and his background in disaster relief with the Canadian Medical Assistance Team (CMAT). “I’m kind of used to situations where emergency response is needed.” In this case, a gentleman in his late 50s was travelling with family and began feeling unwell. Rankin was
the first to arrive by his side, followed by a dialysis nurse and a naturopath. The trio of health professionals began to assess the man and discovered he was seeing a cardiologist for heart irregularities. They were brainstorming possible interventions while also preparing for the possibility that he could go into cardiac arrest at any moment. They laid him across three seats with his feet elevated in the window well.
The flight attendants brought over an oxygen tank and defibrillator. Without an IV available to them, the trio needed to get their patient some fluids orally. The man sipped a water/salt mixture through a straw and chewed two aspirin. Although his blood pressure remained low and his heart raced, he was relatively stable for the remainder of the flight. “I sat on the floor in the aisle,” Rankin recalls, assuring the man that he wasn’t going anywhere until the plane landed. He kept his promise and remained seated on the floor for 90 minutes. He chatted with the man about everyday things, and brainstormed with the family about the logistics of further travel
(they had a connecting flight). He admits in these circumstances, you simply do the best you can with what you have available. A calming presence, he says, is just as important as his critical thinking skills. “As an NP, I can administer medication and use my advanced skills, but it really comes down to basic CPR and first aid.” Once on the ground, Rankin and paramedics carried the man through the aisle to a waiting stretcher. Fellow passengers applauded as he was taken away, as much for the man’s resilience as for the health professionals’ help, Rankin speculates. “I’ll never forget the understanding of the other passenH gers,” he adds. ■
This article was originally published in the November/December 2016 issue of Registered Nurse Journal, the bi-monthly publication of the Registered Nurses’ Association of Ontario (RNAO). Kimberley Kearsey is managing editor/communications project manager for RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario.
APRIL 2017 HOSPITAL NEWS 37
Patients as the last slice of
swiss cheese By Tracy He and Certina Ho
What is the Swiss Cheese Model?
In the realm of patient safety, the Swiss Cheese Model helps visualize how errors may slip through the gaps of human and technological vigilance. Each slice of the Swiss Cheese Model represents an obstacle or a checkpoint that may prevent an error or incident from occurring. However, when the holes in each slice of the Swiss cheese line up, errors are able to slide through and may result in patient harm. Every medication incident has its own set of Swiss cheese slices, but the ultimate endpoint will always be the same – patients. So, how do we make sure that an error will not reach the patient?
The role of patient education
As the healthcare industry gears towards patient-centered care, the notion of equipping patients with knowledge becomes more and more essential and valued. The objectives of patient counselling are evident in improvements in health literacy and trusting
38 HOSPITAL NEWS APRIL 2017
Prime Questions Question 1
“What did the prescriber tell you the medication is for?”
“How did the prescriber tell you to take the medication?”
“What did the prescriber tell you to expect?”
“What side effects are you experiencing from the medication?”
Table 1. IDEA – The 4 Prime Questions to Use in Patient-Pharmacist Dialogue during Patient Counselling patient-provider relationships, but the subliminal outcome is the potential mitigation of medication errors. When educating the patient, the healthcare provider is having a dialogue with the patient and supplying the patient with information and tools to make effective and informed decisions. During this conversation, the patient can also serve as an independent double check and help recognize and catch potential medication errors. The Institute for Safe Medication Practices Canada (ISMP Canada) conducted a multi-incident analysis on how patient counselling can be utilized as an effective way to identify and catch medication errors in a community or ambulatory pharmacy. Over
100 medication incidents were analyzed, and two main themes emerged from this analysis: pharmacist-led identification of errors and patient-led identification of errors.
Pharmacist-led identification of errors
When pharmacists educate patients on their medication use, errors can be caught in three ways – (1) through visual demonstration or showing of the medication; (2) through counselling from or referring to the original prescription provided by the prescriber to the patient; and (3) by verifying or checking with the patient regarding the indication and/or the potential side effects of the prescribed medica-
tions. The 3 Prime Questions have previously been identified as a method to engage patients in a patient-pharmacist dialogue, as they do not only verify therapy appropriateness, but also provide an opportunity for the pharmacist to catch or identify potential medication errors. We also suggested adding a fourth question to check on or monitor patients’ medication therapy management if the medication is a refill prescription.
Patient-led identification of errors
On the other side of the prescription counter, when patients are educated on their medications, they indewww.hospitalnews.com
pendently can identify potential errors and prevent unnecessary harm. Our analysis demonstrated that patients not only verified the logistic appropriateness of their own medications, such as correct patient identifiers and special storage requirements of their medications, but also the clarity of their prescribed medication therapy by recalling counselling points from a previous encounter. Therefore, to prompt for such opportunities, healthcare professionals should apply the IDEA framework (Table 1) and continue to provide key and specific medication information to patients, through visual reminders or descriptive identifiers of the medication(s) when counselling. Despite their subtlety, these methods have demonstrated to be simple but effective com-
WHEN PATIENTS ARE EDUCATED ON THEIR MEDICATIONS, THEY INDEPENDENTLY CAN IDENTIFY POTENTIAL ERRORS AND PREVENT UNNECESSARY HARM. munication tools that can promote patient education and advance safe medication use. Although the healthcare practitioners involved in our multi-incident analysis were primarily pharmacists, the concept of patient education can be translated across various health disciplines; physicians, nurses, and caregivers of patients can all utilize the patient counselling techniques (e.g. the IDEA framework in Table 1) identified through this analysis. Most
educational interventions (e.g. patient counselling) are behavioural in nature and can be implemented at any point of communication. For example, the appropriateness of medication therapy can be monitored by a physician when probing or checking on the patient for side effects; indication of a medication can be explained to the patient by a nurse prior to administration at the bedside; and quantity of a blister pack (or multi-medication compliance pack) can be verified by a caregiver at
the point of prescription pick-up at the pharmacy. When patients, the key stakeholders of medication use, are yielding the right knowledge, they can help independently identify and prevent medication errors. By educating patients at each patient-healthcare practitioner encounter, medication errors can be mitigated, paralleling improved health literacy and the construction of trusting relationships. Healthcare is a collective effort that requires care and vigilance at every level â€“ the physician for the right diagnosis, the pharmacist for the right medication therapy, the nurse for the right administration, and the patient for the right education. Only this way, can we pride ourselves in true H patient-centered care. â–
Tracy He is an Analyst at the Institute for Safe Medication Practices Canada (ISMP Canada) and a PharmD Student at the School of Pharmacy, University of Waterloo; Certina Ho is a Project Lead at ISMP Canada.
DOCTORS WITHOUT BORDERS
Boost hospital is run by MSF in partnership with the Ministry of Public Health. It is one of the biggest MSF runs worldwide: 300 beds, 700 national staff, 25 international staff.
Photo: Kadir van Lohuizen/Noor
A short time in Afghanistan By Kim Pollard y first assignment with Doctors Without Borders/ Médecins Sans Frontières (MSF) was in the city of Lashkar Gah, the capital of Helmand province in the southern part of Afghanistan. My job was to supervise the neonatal and pediatric intensive care unit in MSF’s 309-bed Boost hospital. When I arrived in Helmand, things were relatively quiet and stable. The security changed a few short weeks after my arrival, however. At the beginning of August 2016, shelling and shooting started in the city. We could
hear it all around us. Before long, the Taliban had completely surrounded the city and were about 500 meters away from the hospital and our compound. International forces arrived and we were soon in the middle of a conflict zone. Jet bombers and drones could be heard flying overhead at high speed. All roads out of Lashkar Gah were controlled by armed forces. Many civilians were injured or killed during the conflict. When the fighting intensified in October, people panicked and many patients, caregivers and even staff left the hospital to flee the city.
The impact of the fighting could be most clearly seen in the lack of civilian admissions to the hospital. The malnutrition, neonatal and pediatric intensive care units that are often filled at 200 per cent above capacity during peaceful times suddenly had countless empty beds. While many people had fled Lashkar Gah in fear, others were unable to get to the hospital from surrounding districts because of insecurity and road blocks. Those that did manage to come to the hospital often arrived too late. I was amazed that with all the fighting around us, the children were still
outside playing, and that people still went to work. I got used to the constant sound of bombs, drones and helicopters, and just carried on doing what I was doing. I adjusted to the environment. I remember that when the fighting in the area was escalating to a feverish pitch, we had a patient who had given birth to a premature baby in the hospital. The baby weighed around one kilogram, was in an incubator and was receiving IV antibiotics, tube feeds and oxygen therapy. Continued on page 46
Kim Pollard is a nurse from Calgary. 40 HOSPITAL NEWS APRIL 2017
When actions speak louder than words By Roxanne Hathway-Baxter t had been years since anyone besides his parents had heard Sheldon Lam utter a word when he started his co-op placement at Runnymede Healthcare Centre’s pharmacy department in September 2016. The grade 12 student suffers from a form of anxiety known as selective mutism, which limits his ability to verbally communicate with others. Simple social interactions like saying “good morning” and making eye contact can pose a huge challenge, leaving most of his in-person interactions confined to a pen and paper.
don feel at ease. “We didn’t have a blueprint for how to interact with someone like Sheldon,” she says. The dynamic of the team initially changed; the talkative department became more subdued, not wanting to make Sheldon feel like he wasn’t included. However, Carol and the team realized that Sheldon was at Runnymede to develop. “We weren’t helping him by staying quiet.” Carol started reading more about selective mutism, and even consulted a friend who works in education. “I was told to listen, to take things one day
“BEING AT RUNNYMEDE HELPED ME WORK ON MY GOAL OF IMPROVING MY COMMUNICATION SKILLS WITH THE HELP OF A TEAM.” For many years, Runnymede has been placing students in co-op placements in departments across the hospital, solidifying partnerships with local schools and demonstrating a commitment to the community. These placements have provided numerous students with invaluable opportunities to gain skill sets required for entering the workforce. Sarah King, manager of activation and volunteer services, who placed Sheldon in the pharmacy department at the hospital, knew the team would be a good fit for him, especially pharmacy technician, Carol Sookram. “If anyone at Runnymede could help bring Sheldon out of his shell, it would be Carol,” says Sarah. “He needed to be connected to the right people, so he could live up to his full potential.” His first day with the pharmacy department was the polar opposite of anything Sheldon was comfortable with. “Being in the pharmacy was scary at first, it was very overwhelming,” he shared. Despite his apprehensions, Sheldon quickly indicated that he “felt like part of the team.” At first, Carol and the pharmacy team weren’t sure how to make Shelwww.hospitalnews.com
at a time.” The team started actively including him in conversations, and Carol created a list of goals for Sheldon to accomplish. “The first goal was to smile, and the next week, look up. Eventually it would be saying ‘goodbye’ and ‘good morning.’” As the weeks went on, Sheldon’s transformation became evident, with his social workers and teachers seeing changes in his overall outlook and behaviour. He started to smile and say “goodbye” at the end of the day. At first, it took 45 minutes for him to work up to it, but eventually “goodbye” came out with increasing ease. The transformations were welcome and unexpected for Sheldon too. “Honestly, I never imagined I’d speak a word in my placement. Being at Runnymede helped me work on my goal of improving my communication skills with the help of a team.” “Runnymede has always been committed to providing the tools and resources that help empower its staff,” says Sharleen Ahmed, Runnymede’s VP of Strategy, Quality and Clinical Programs. This commitment is part of the “you first” pillar of the hospital’s
Co-op student Sheldon Lam (right) overcame personal challenges while volunteering at Runnymede Healthcare Centre with support from pharmacy team members like Carol Sookram. Strategic Plan. But Runnymede’s commitment to empowering individuals extends beyond its walls. The reach can be felt in the local community, spurred on by mutually beneficial partnerships, like co-op programs. “At Runnymede, I was greeted, talked to, and appreciated for my work. They never treated me
like just the lonely guy in the corner of the classroom,” Sheldon shared. “Partnerships help to promote the health and well-being of individuals like Sheldon, and wouldn’t be possible without the skills and expertise of the staff members that make up our interH professional team,” says Ahmed. ■
Are you new to Canada? Nouveau au Canada?
Do you want to improve your workplace communication skills? Participate in free Occupation-Specific Language Training courses Workplace Communication Skills Workplace Communication Skills for for Health Care Interprofessional Health Care Teams • dietitian • dental hygienist • medical laboratory technologist • nurse • medical radiation technologist • occupational therapist • nurse • physiotherapist • personal support worker • social worker • sleep technologist Visit http://www.co-oslt.org for more information Pour de plus amples renseignements sur les formations francophones consultez : http://www.lacitedesaffaires.com/service-immigrants/flap.htm To quality, you must have training or experience in the fields listed under each course above. Also, you must be a permanent resident of Canada or protected person and your English/French must be at an intermediate level (Canadian Language Benchmark 6 – 8 for courses delivered in English or Niveaux de compétence linguistique canadiens 6 – 8 for courses delivered in French).
APRIL 2017 HOSPITAL NEWS 41
A new kind of
hospital opens By Alineh Haidery
hey have been around since ancient times, and while healthcare practices and technologies have evolved, the traditional, inpatient hospital continues to have a critical place within our healthcare system. However, needs change and necessity encourages innovation. Intent on finding a sustainable, patient-friendly and cost-effective way to increase its outpatient capacity and promote community health and wellness, William Osler Health System (Osler) has just opened a new kind of healthcare facility – an outpatient hospital – the Peel Memorial Centre for Integrated Health and Wellness.
tions services, a hemodialysis unit, clinics for children, youth, expectant/ new mothers and newborns, and much more. Any patient who comes to Peel Memorial but needs a hospital stay, is promptly stabilized and safely transferred to Brampton Civic, Etobicoke General or the most appropriate acute care facility. Patients also get the information and supports they need to prevent or manage chronic conditions such as diabetes, asthma, or cardiovascular disease, to learn about lifestyle changes including fitness and healthy diets, and to connect with community supports. “This is a new kind of healthcare facility,” Flewwelling says. “One that rep-
“THE FOCUS IS ON FOSTERING A HEALTHIER COMMUNITY AND REDUCING THE NEED FOR CRISIS VISITS TO THE EMERGENCY DEPARTMENT AND HOSPITAL ADMISSIONS.” “Brampton is among the fastest-growing regions of Canada, with one of the highest birth rates and some of the highest incidences of chronic disease in Ontario,” observes Joanne Flewwelling, Osler’s Interim President and CEO. “By adding Peel Memorial to our other two hospitals – Brampton Civic Hospital and Etobicoke General Hospital – we have greatly increased our outpatient capacity, ensuring that we are better able to provide even greater access to the important programs and services our community needs most.”
resents a profound shift to prevention and wellness. The focus is on fostering a healthier community and reducing the need for crisis visits to the emergency department and hospital admissions.” Over time, Peel Memorial will partner with other health organizations and complementary health providers – such as naturopaths and chiropractors – to provide more healthcare options, and collaborate with other community-based services to connect people with more of the supports they need, close to home.
A balance of treatment, prevention and wellness
A seamless experience for patients
The new Peel Memorial offers many specialized, surgical, acute and preventive health services including day surgery facilities, an Urgent Care Centre, seniors’ rehabilitation and wellness programs, mental health and addic-
As a site within the Osler health system, Peel Memorial works seamlessly with Brampton Civic, Etobicoke General and Osler’s community health partners so that patients can move easily between the facilities according to their healthcare needs. Services at Peel
Memorial complement those at the other two hospitals and the care teams at all three hospitals have shared access to patients’ health records. Telephone and internet communications, including videoconferencing, enable healthcare professionals across Osler to readily confer with one another. MyChartTM, a patient portal, also allows patients access to their own clinical information, including laboratory, pathology, diagnostic imaging and cardiology reports, as well as self-entered patient data such as appointments, allergies, medications and immunizations.
Better coordination, less duplication, and a better patient experience
Part of the effectiveness of Peel Memorial is its relationship with community-based healthcare professionals. “We have put significant emphasis on conferring with family physicians and specialists about the services their patients need most,” says Dr. Frank Martino, Osler’s Chief of Staff. “We’re also working to improve the flow of patient information between Osler and the physicians. The more we share, the better we can coordinate care, avoid duplicate tests and enhance the patient’s healthcare experience.”
An accessible and sustainable facility
Peel Memorial’s expansive grounds provide lush, green space for rehabilitation activities, walking or cycling. Courtyards and large windows flood the building with light, with the courtyards providing additional spaces for therapy and relaxation. The building’s wayfind-
ing system, its wide hallways, ‘mirrored image’ washrooms and two-level hand rails and coat racks are just some of the features that make the environment accessible, comfortable, and welcoming for patients and visitors. Sustainability was integrated into the overall project concept and design of the new Peel Memorial from the early stages, leading it to be one of the most energy-efficient buildings of its kind in Canada. The new Peel Memorial features energy-efficient low-flow plumbing fixtures and drought-tolerant landscaping; a geothermal system that allows heat rejected from the building to be stored during the summer for use during the winter; and solar shading controls, LED lighting and numerous other sustainable features.
Plans for the future
Peel Memorial was redeveloped with the future in mind. This first phase focuses on outpatient services (including day surgery and the urgent care centre) most needed by the community. With phase one open, Osler will work with the Ministry of Health and Long-Term Care on the next phase (Phase 2) of the project, which includes inpatient beds for patients needing Complex Continuing Care and Rehabilitation.
The end result
“Peel Memorial embodies a new approach to healthcare, where the focus is on helping patients stay healthy and to be proactive when it comes to healthy living to prevent issues before they become serious health concerns,” Flewwelling notes. “It’s an approach that makes better use of precious resources and, most importantly, ensures H a better patient experience.” ■
Alineh Haidery is the Regional Manager, Public Relations at William Osler Health System. 42 HOSPITAL NEWS APRIL 2017
Personalized medicine is Big Data
Where are the computers? By Gunther Jansen
hen a cancer patient steps into her doctor’s office, she hopes for a treatment that will improve her chances of survival with minimal side effects. Finally, in the age of precision medicine, her treating physician is able to recommend an effective therapy that matches the genetic cause of her specific tumor. If the patient agrees to a genetic test, she can rest assured that she will receive the best possible treatment currently available. At least, in theory. In practice, she may be baffled by the results of genetic tests pointing to mutations in genes she has never heard of. Worse, her physician may struggle to explain the deeper meaning of genetic variants listed in her report, especially if her mutations are not commonly encountered in other cancer patients. Exasperated, she seeks a second opinion. But rather than comfort and reassurance, she finds even greater confusion in expert consultations that yield disparate opinions and conflicting treatment recommendations. Is precision medicine not delivering what it promises? Maybe. Unfortunately, matching genetic mutations with appropriate personalized treatment recommendations remains a considerable Big Data challenge. Take the example of
MATCHING GENETIC MUTATIONS WITH APPROPRIATE PERSONALIZED TREATMENT RECOMMENDATIONS REMAINS A CONSIDERABLE BIG DATA CHALLENGE. non small cell lung carcinoma, one of the most lethal cancers in the US. The genetic analysis of a typical tumor yields as many as 5000 patient-specific mutations. If those relevant to cancer are sifted out, that number shrinks to about 600. This is still too much for a clinician to work with. So which of these are relevant for this patient? One well-known mutation, e.g. an ALKEML4 fusion, begs a lot of attention: a search in the scientific literature mentioning this mutation yields 219 publications in the context of non small cell lung cancer and 4,069 for cancer. About four per cent of NSCLC patients carry this mutation. But it is rather exceptional to have such clear information about mutations; many, if not most, are less well studied, but equally relevant for this patient. Others turn out unimportant. The search continues looking for evidence that links specific mutations and genes to targeted therapies, resistances and side effects – a
challenging endeavor considering the rapid growth in the number of drugs, databases and clinical trials. In the end, the 600 mutations are ranked according to their presumed role in this specific tumor. Weighing evidence is far from trivial and often somewhat personally biased. Finally, after wading through a few thousand scientific papers and looking into dozens of databases, it becomes clear that six drugs commonly used to treat this cancer are toxic to the patient. Five medically viable alternatives will not work because other, at first sight seemingly less relevant, mutations annul the effects of a popular targeted therapy. Missing any of these would have been disastrous for the health of the patient. Eleven other mutations suggest targeted therapy. This narrows therapeutic options to 12 effective treatments, of which only one is approved for lung cancer. The rest are in clinical trial stage, and require extraction of clinical trial information
to assess eligibility of the patient. This Big Data analysis comes to the conclusion that the patient is best treated with crizotinib (Xalkori). A week after visiting the doctor, the patient returns. In the meantime, the physician has seen 40 to 70 other patients, and has fulfilled other obligations such as follow up cases, clinical care, reviews, management duties, research, and teaching. On average, the doctor has spent an hour on this particular patient case, even less studying the complex genetic data on her desk. During her years in medical school, long before the technologies enabling personalized medicine were invented, she memorized all mutations then known to be involved in this particular type of cancer. Today, new genes causing this cancer are discovered almost daily. It is humanly impossible to keep track of all of the newest scientific developments relevant to this patient’s idiosyncratic genetic characteristics. Now, the patient in front of the desk is waiting anxiously for an unambiguous interpretation of her personal Big Data that will identify the best possible treatment for her individual cancer. Continued on page 46
Gunther Jansen, PhD MSc MA Bsc T, is a Scientific Director at Molecular Health, Heidelberg, Germany/Boston, Massachusetts
APRIL 2017 HOSPITAL NEWS 43
44 HOSPITAL NEWS APRIL 2017
C.D. Howe report:
Provinces should work together on new funding models By Neil Fraser
he time is ripe for the provinces to collaborate on integrated healthcare payment reforms, according to a report from the C.D. Howe Institute, which also suggests the federal government could play a strong role in facilitating and supporting this collaboration. Current payment models in Canadian healthcare, such as global budgets for hospitals and fee-for-service reimbursement of physicians, have resulted in a fragmentation of healthcare delivery that contributes to poor patient outcomes and high costs, argue Jason M. Sutherland and Erik Hellsten, authors of the commentary, Integrated Funding: Connecting the Silos for the Healthcare We Need. “Once held in high esteem worldwide,” they state, “Canada has taken a drubbing in recent international comparisons,” faring poorly relative to its peers on healthcare performance measures such as access to services and co-ordination of care, despite being one of the highest-spending countries on health. Provincial healthcare systems that were structured to address the needs of past generations have not kept up with the evolving demands of an aging population that requires care for multiple chronic diseases. The report highlights that much of this failure to change with the times can be traced back to the way provinces pay for healthcare services. Fixed global budgets for hospitals are associated with low productivity and long wait times for elective surgeries, while fee-for-service compensation for doctors results in over-utilization of services and a lack of accountability for patient outcomes throughout the continuum of care.
Other countries have been experimenting with various funding reforms that address these issues by going beyond the traditional healthcare “silos” – such as hospitals, specialists, primary care, and community and home care – to create new payment mechanisms that cross sectors and settings to follow the patient’s entire care pathway. The report urges Canadian policymakers to look at these international solutions, although it warns that funding reforms being tried elsewhere are untested in Canadian healthcare, so the federal and provincial governments would need to work together to decide on the best way forward.
In the United States, experiments with bundled payments have been going on for 30 years and have resulted in closer co-ordination among health services as well as significant cost savings while maintaining or improving care quality. A large-scale program, Bundled Payments for Care Improvement (BPCI), was introduced in 2013 under the Patient Protection and Affordable Care Act, also known as Obamacare. BPCI reimburses providers on a fee-forservice basis, then checks them against an annual target price. The providers share in the costs if they are above the target and share in the savings if they are below it. This sharing of financial
FOR THESE EFFORTS TO BE EFFECTIVE, THE FEDERAL GOVERNMENT, THE PROVINCES AND PHYSICIANS MUST ALL BE ENGAGED AND TAKE LEADERSHIP ROLES IN THEIR OWN AREAS OF EXPERTISE. The report describes two funding models that merit consideration – bundled payments and population-based integrated payments, also referred to as capitated models – and reviews the experience of certain countries in implementing these funding reforms. Bundled payments are single payments made to groups of provider entities involved in delivering a defined “episode” of care for a condition or procedure, providing financial incentives that encourage greater co-ordination of care. Population-based integrated payments, on the other hand, involve single, time-defined payments to groups of providers for a population of enrolled patients. Payments are made whether services are used or not, an approach that rewards improved performance.
risk gives providers more incentive to deliver quality care. Forms of bundled payments have been implemented in two separate pilot projects in Ontario, the authors note: by Cancer Care Ontario for renal care and systemic treatments, and by St. Joseph’s Health System in Hamilton, where providers of acute care have been integrated for a limited number of patients. According to an article in the Toronto Star, early results indicate both the healthcare system and patients are benefitting from bundled payment initiatives at St. Joseph’s Health System. In a presentation at HealthAchieve in 2016, Trillium Health Partners shared similar results for its cardiac surgery bundled payment pilot. The C.D. Howe report also provides
an example of population-based integrated payment – U.S. accountable care organizations offer services across the continuum of care for an entire population in a specific region. As with BPCI, the providers are reimbursed for their services and measured against a target. The result has been lower costs and moderate improvements in patient satisfaction. In Germany, the healthcare management company Gesundes Kinzigtal provides care for 70,000 people and is paid by health insurers based on shared savings and achieving quality targets. This program has reduced costs and improved quality of care. These and other international initiatives offer lessons for Canada’s provinces, which should begin collaborating on integrated payment reforms rather than going their own ways as in the past, the report advises. Federally, Health Canada and agencies such as the Canadian Institute for Health Information can encourage provincial collaboration through transitional funding, analytic tools to generate insights across the continuum, and information brokering. For these efforts to be effective, the federal government, the provinces and physicians must all be engaged and take leadership roles in their own areas of expertise. A clear national vision needs to be articulated, along with an end goal for integrated payment models. Sutherland and Hellsten conclude with a reminder that “payment models for health services are never silver bullets in themselves” – their success depends on how well they enable organizational and clinical reform. The role of policymakers is to create the right environment and support the right systems to allow healthcare organizations H and providers to deliver optimal care. ■
Neil Fraser is Chair of MEDEC and President, Medtronic Canada. He was a member of both the Ontario Health Innovation Council and the federal Advisory Panel for Healthcare Innovation and is a frequent speaker on health system reform and innovation adoption. www.hospitalnews.com
APRIL 2017 HOSPITAL NEWS 45
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Afghanistan Continued from page 40 The mother expressed a desire to leave the hospital with her baby. She explained that there was nobody at home to care for her other children and that the fighting was reported to be very close to her home. Her husband insisted that she should leave. After two days of negotiations with her and her husband, she left with the baby. She said that she understood that the baby would likely die if she left the hospital, but that her family desperately needed her at home. I witnessed this sort of impossible choice repeatedly during my time there.
family, we sat and drank tea and ate an amazing meal. This was truly a highlight of my time there. One day, I spent an hour in our high dependency pediatric unit with three mothers, a grandmother and an orphaned little girl. The lives of all the children were still very much at risk of being lost, but even this did not stop the mothers and grandmother from participating in the universal language of women. Lots of smiles, hugs and laughter filled the room as I sat and visited with them. We talked about the trouble with men and the joy of motherhood.
THE IMPACT OF THE FIGHTING COULD BE MOST CLEARLY SEEN IN THE LACK OF CIVILIAN ADMISSIONS TO THE HOSPITAL. It might seem surprising, but despite the rather scary situation, I had the most wonderful time in Afghanistan. I always felt welcome and included. Local people were happy to share their culture with me and learn about mine. My national staff partner Rohulla invited me to his home, where I spent a wonderful day. He introduced me to his
Afghanistan is an amazing place filled with wonderful people whose lives are overshadowed by war. I will miss the country and the people I have come to call friends. My seven months in Afghanistan have been the most intense, exciting, rewarding experience of my H life. ■
Where are the computers? Continued from page 43
All this hinges on the limited time and imperfect knowledge her physician, with the best intentions, could have invested into understanding the patient’s specific cancer. Not surprising, then, that precision medicine sometimes leaves the patient confused and disappointed. The issue of personalized medicine falling short of its promise is a problem of implementation rather than principle. Scientific innovation is running far ahead of physicians and policy makers. Patients are suffering because they fail to receive the full benefits of the latest breakthroughs. The process of data interpretation in personalized medicine urgently needs to become faster, more reliable, more objective and more comprehensible. To enable personalized medicine in everyday
practice, clinicians need to embrace technological innovation. Personalized genetic information, drug susceptibility and side effects should be at the fingertips of physicians in the same way medical histories and blood tests are. Specialized information technology must ensure physicians receive information that is tailored to individual patients in a form appropriate for their time schedule and level of expertise and interest. Only when physicians can trust a comprehensive, clinically approved technology that translates personalized information and state-of-the-art knowledge into clinically actionable recommendations, patients will leave the doctor’s office knowing they will receive the best, effective treatment H specifically tailored to their tumor. ■ www.hospitalnews.com
Personalized medicines: Better care, but for which persons? By Kevin Reel
ersonalized medicine” might be defined in a few ways. Multiple terms have been identified that speak to the concept: precision, stratified and P4 medicine. Those four P’s are predictive, preventive, personalized and participatory. There are at least four other P’s involved – promise, peril, pragmatics and perspective – which speak to the widely differing opinions about the value of personalized medicine. The theoretical promises of personalized medicine are clear, though the prospects for delivering on those promises is not so clear. There are some huge investments being made in personalized or precision medicine – the US National Institutes of Health Precision Medicine Initiative being among the biggest. Despite the hype and hope, some have begun waving red flags about an overgrown set of expectations for which there is little evidence. Many supporters, though, insist the prize lies just ahead and is worth the price. There is enough debate that the journal Nature devoted the September 8 2016 issues of its Outlooks supplement to the topic. It makes for an engaging read as perspectives range from high enthusiasm to dire warning. Stories of the benefits for some in-
dividuals are undeniable, even if their impact may be minimal. Most widely discussed are the prospects for making earlier matches between a person and the medicines that will work best for them, given their genetic makeup. Also among the advantages of personalized is more precise prescribing and avoiding severe adverse reactions before certain pharmaceuticals are even considered. Among the perils is protecting privacy – which some say is looking more like wishful thinking than anything achievable as we proceed into the era of our own genomes informing our individual healthcare. Perhaps the most concerning part of this peril is insurance cover. If you have your DNA sequence analyzed for the purposes of tailoring treatment, might the same information be used to tailor risk for insurers – with coverage denied for those illnesses you are likely to experience? The proposed Genetic Non-Discrimination Act (Bill S-201) has been hotly debated in Parliament and finally passed, but it currently faces a further delay as the Government plans to refer it to the Supreme Court for review of its constitutionality. The bill also addresses concerns about employment and housing, and goes further still to
address potential discrimination in child custody and adoption. Even in the presence of the best non-discrimination protections, other forms of inequity are more difficult to avoid. Where drugs can be assessed for their more precise effects within a population, will this influence which drugs are developed? If a drug early in its development appears to work well for a small minority of the population, will it be abandoned for one that can be used more widely? Or will it simply be priced many times higher to recoup the development costs? For those individuals whose rare genetic makeup affects the benefits current drugs can offer, will there be investment in developing other effective drugs to help them – or will this be deemed a poor return on investment? Among the pragmatic concerns are the complex data systems needed to work in tandem with the evolution of routine genomic sequencing practice and slow incremental findings about the links with drug effectiveness. These medium term enablers might well lead to long term benefits. Many of those who have great enthusiasm for personalized medicine acknowledge the challenges in realizing the promises, but sustain their hopes when they see
these enablers becoming a reality, albeit slowly. Many of the criticisms, while well-founded at present, may well begin to fade as the elusive pragmatics become realities. Balancing the various ethical perspectives on personalized medicine was one of the goals of the UK-based Nuffield Council on Bioethics in its 2010 report. It highlighted the ethical values of fairly and effectively using public resources and the need for public policy to be informed by what it called ‘social solidarity – sharing risks and working together to protect the vulnerable’. Promoting these values in policy (and law) helps to minimize the kind of discrimination that might otherwise result, even inadvertently. The most robust laws to prevent genetic discrimination are one key component of any fair and equitable system. The other more difficult fix is preventing genetic treatment ‘orphans’ – groups of our fellow humans whose particular genome has meant they are left on the margins as profit focused big pharma seeks the greatest benefits for their shareholders. Let’s hope the legal perspective from the Supreme Court finds a way to promote those values and speak to the many perspectives H within the limits of the constitution. ■
Kevin Reel is a practicing healthcare ethicist and an Assistant Professor in the Department of Occupational Science and Occupational Therapy, an Associate Professor in the Dalla Lana School of Public Health.
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