Inside: From the CEO’s Desk | Evidence Matters | Trends in Transformation | Product Spotlight | Safe Medication
June 2017 Edition
unnecessary medical tests per year What can we do about it?
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FOCUS Programs at BC Children’s now using tele-health include: • Audiology and Early Hearing • Biochemical Diseases • Cardiology • Complex Care • Cystic Fibrosis • Endocrinology • Diabetes • Gastroenterology • General Surgery • Hemophilia • Immunology and Allergy • Infectious Diseases • Mental Health • Neurology (epilepsy and ketogenic diet) • Oncology (long term follow up) • Organ Transplant Clinic • Orthopedics • Rehabilitation Medicine • Renal (kidney) care • Respiratory • Speech Language Pathology • Urology
Canada’s first tele-paediatric intensive care program launched in BC By Cara Christopherson anada’s first tele-paediatric intensive care service (tele-PICU) provides children with increased access to specialized care closer to their home community. The service is currently available at Kootenay Boundary Regional Hospital, Nanaimo Regional Hospital and Victoria General Hospital as well as BC Children’s Hospital. Tele-PICU was established by Child Health BC in partnership with the Island and Interior health authorities. Tele-PICU allows teams at BC Children’s or Victoria General Hospital to assess children closer to their community through real-time, two-way videoconferencing. Tele-PICU teams
TELE-PICU IS PART OF CHILD HEALTH BC’S CHILDREN’S VIRTUAL CARE INITIATIVE THAT INTEGRATES TELE-HEALTH AND OTHER TECHNOLOGIES TO ENHANCE SERVICES TO CHILDREN THROUGHOUT BC use high resolution cameras and digital stethoscopes that enable physicians and nurses to see patients as well as to listen to and amplify sounds of the heart and lungs of seriously ill or injured children. As a result of this initiative, intensive care teams can now collaborate with healthcare providers in communities across the province to
help children receive diagnosis and treatment sooner and often without leaving their community. When a child does not need to be transferred to BC Children’s or Victoria General, families face fewer burdens including reduced travel costs, time away from work and are able to stay better connected to their community support networks. The service also supports
healthcare providers by sharing new knowledge and best practices to further building the capacity of health care providers. Tele-PICU is part of Child Health BC’s Children’s Virtual Care initiative that integrates tele-health and other technologies to enhance services to children throughout BC. These sites include technology and tele-health equipment as well as equipment to support pediatric visits with trained nurses and support staff. Children’s Virtual Care is available in 17 communities, four of which include Tele-PICU. Availability will expand in areas where families experience the greatest challenges of isolation and H geographical barriers. ■
Cara Christopherson is a Communications Officer at BC Children’s Hospital. 2 HOSPITAL NEWS JUNE 2017
Contents June 2017 Edition
IN THIS ISSUE:
Connecting the docs: TSecure smartphone app
▲ eHealth solution to streamline patient care
▲ Cover: Unnecessary medical tests and procedures
▲ Using creative problem solving
Guest editorial ................. 4 In brief .............................. 6 Trends in transformation .............. 24 From the CEO’s desk .....25 Ethics ..............................26 Nursing pulse ................ 27 Safe medication ...........28 Product spotlight ...........30 Careers .......................... 31 www.hospitalnews.com
▲ Retinal unit improves safety
Evidence matters: Dialysis at home
▲ Process improvements in medicine
What Canada can learn from Australia on healthcare By Stephen Duckett
ustralia and Canada share many characteristics, but Canadians may not know one of them is that Australia’s universal health insurance scheme, Medicare, was modelled on Canada’s – albeit adapted to account for constitutional differences between the two countries. A recent conference in Toronto addressed whether Australia has anything to teach Canada about how Canadian medicare might evolve. There are a number of areas where Australia’s experience might prove helpful. The first is the public funding of pharmaceuticals. Australia has had a national Pharmaceutical Benefits Scheme since the late 1940s. It now provides comprehensive coverage against the cost of pharmaceuticals for the whole population. The scheme, though, requires patients to make a modest co-payment for each prescription. For people on income support (retirees, unemployed) the co-payment is $6.30; for the rest of the population, it is $38.80. There is a safety net, which drops the price to zero or $6.30 after about 50-60 prescriptions a year. The upside of the scheme is obvious: medicines – even the most expensive of the new formulations – become affordable to most people. Drugs are listed on the scheme only if they have been shown to be cost-effective. This helps to ensure the costs of the scheme are commensurate with the benefits. The scheme pays more than some other countries for listed drugs – for example, New Zealand and the United Kingdom pay less. But the prices paid in Australia are about one third of those paid by Canadian provinces. One downside of the Australian design is the man-
datory co-payments. About one in twelve Australians who used medication say they have deferred filling or did not fill a prescription because of cost. Among the 20 per cent of Australians with the lowest incomes, that figure rises to one in 10. Another area where Canada can learn from Australia is in-home care. Australia has a national home care program that aims to keep people in their own home as long as possible, and out of more expensive residential aged-care facilities. The program has grown over the past 50 years, with a major enhancement in the 1980s. It provides funding support for a wide range of services, from low-intensity programs such as “meals on wheels,” through to intensive in-home nursing care. The program is being transformed, so funding will no longer be provided to organizations but rather to individuals who need what is described as “consumer directed care.” A third area where lessons may be learned is in efficiency. The Australian hospital sector is more efficient than Canada’s and further efficiency is being driven by national adoption of activity-based or case-mix funding. Under this arrangement, hospitals are paid for the work they do – up to a cap. The price per patient reflects average national costs, with marginal adjustments for such factors as whether a patient comes from a remote area. Case-mix has replaced a variety of other schemes such as “area funding,” which was problematic in metropolitan areas where a significant number of patients came from outside the local area, and “global budgets,” which were associated with substantial variations in efficiency between hospitals, with no evidence that higher-cost hospitals were providing higher quality services. Continued on page 7
JULY 2017 ISSUE
AUGUST 2017 ISSUE
EDITORIAL: June 12 ADVERTISING: Display – June 23 | Careers – June 27
EDITORIAL: July 12 ADVERTISING: Display – July 21 | Careers – July 25
Monthly Focus: Cardiovascular Care/Respirology/Diabetes/ Complementary Health: Developments in the prevention and treatment of vascular disease, including cardiac surgery, diagnostic and interventional procedures. Advances in treatment for various respiratory disorders, including asthma and allergies. Prevention, treatment and long-term management of diabetes and other endocrine disorders. Examination of complementary treatment approaches to various illnesses.
Monthly Focus: Paediatrics/Ambulatory Care/Neurology/ Hospital-based Social Work: Pediatric programs and developments in the treatment of paediatric disorders including autism. Specialized programs offered on an outpatient basis. Developments in the treatment of neurodegenerative disorders (Alzheimer’s, Parkinson’s etc.), traumatic brain injury and tumours. Social work programs helping patients and families address the impact of illness. + ANNUAL CAPHC PEDIATRIC SUPPLEMENT
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New pregnancy clinic at Sunnybrook supports women with disabilities By Marie Sanderson
he first North American clinic caring for pregnant women with a wide range of physical mobility disabilities has opened at Sunnybrook. The Accessible Care Pregnancy Clinic cares for women who have both invisible and visible physical disabilities. Invisible disabilities are disabilities that are not immediately apparent. Women seeking care at the clinic may have spinal cord injuries, severe arthritis, spina bifida, a history of trauma such as a car accident, cerebral palsy, multiple sclerosis, a history of amputation, scoliosis or be a little person. Women may also have other conditions impacting their mobility, making them a good fit for the clinic. “Our goal is to offer care options individualized to each women and her family,” explains Dr. Anne Berndl, a maternal fetal medicine specialist and director of the Accessible Care Pregnancy Clinic at Sunnybrook. “Disabled women often face a host of specialists when they’re accessing the healthcare system. We’re committed to providing holistic care throughout a woman’s childbearing year, with centralized care where all members of your healthcare team are speaking to each other.” The clinic offers preconception counseling, prenatal education, obstetrical care during pregnancy and
postpartum care including breastfeeding support. Dalia Abd Almajed experienced the care firsthand. Dr. Anne Berndl delivered her first child in 2015 and her second just before Mother’s Day this year.
THE ACCESSIBLE CARE PREGNANCY CLINIC CARES FOR WOMEN WHO HAVE BOTH INVISIBLE AND VISIBLE PHYSICAL DISABILITIES. “I was so afraid when I first knew that I was pregnant with the first baby, because I use a wheelchair with all these complications and problems,” says Dalia, as she holds her healthy newborn son, Abbas, close to her while breastfeeding. Sunnybrook’s Bayview campus offers a wheelchair accessible Birthing Suite, although the clinic’s patients may or may not use mobility devices or aids. The ultrasound department is in the same location as the clinic, performed by an experienced sonographer. The healthcare team assesses patients’ needs ahead of time, including whether TTC Wheel-Trans will be used, to ensure a comfortable environment where women don’t feel rushed.
“Having a disability should not be a barrier to being a great parent,” says Anita Kaiser, a mother and advocate for disabled women. “To have a service where care is holistic across the continuum of care, with physical and emotional support for women and families, is helping to address a much-needed gap in our health care system.” The clinic has many relationships with community supports, to ensure there is a plan for women following their delivery, once they have delivered their baby.
“Mobility conditions can wax and wane throughout a woman’s life; and can affect any limb or part of the body,” says Dr. Berndl. “You may look at a woman with an invisible disability and have no idea she requires specialized pregnancy care. Being pregnant with a disability can be both an exciting and anxiety-filled time; we want to ensure women are supported to receive the individualized medical care they need and feel the excitement they deserve H to feel.” ■
Marie Sanderson works in Communications at Sunnybrook Health Sciences Centre.
JUNE 2017 HOSPITAL NEWS 5
New national innovation hub launched to support healthy aging T
he AGE-WELL Network of Centres of Excellence (NCE) and the New Brunswick Health Research Foundation (NBHRF) are pleased to announce the launch of a national innovation hub to advance policies, practices and services in the fast-evolving field of technology and aging. With Canada’s aging population, the new AGE-WELL National Innovation Hub will help ensure Canadians benefit from new and emerging technologies that can support independent living and improve quality of life of older adults and caregivers. This hub is the first of its kind. The Advancing Policies and Practices in Technology and Aging (APPTA) hub will design innovative solutions to specific policy, program and service challenges, and will develop best practices for rapid adoption of new technologies.
THE NEW HUB IS AN IMPORTANT INITIATIVE THAT WILL SUPPORT THE DEVELOPMENT OF POLICIES, PRACTICES AND SERVICES ACROSS CANADA THAT HARNESS THE POWER OF TECHNOLOGY TO PROMOTE HEALTHY AGING
The hub was officially opened recently in Fredericton by the Honourable Lisa Harris, New Brunswick Minister of Seniors and Long-Term Care. Seniors now make up 19.92 per cent of New Brunswick’s population, making it the province with the oldest population in Canada. Nova Scotia is a close second at 19.90 per cent. It’s projected that within a generation, the number of New Brunswickers aged 65 and over may climb to 29 or even 31 per cent. “The new hub is an important initiative that will support the development of policies, practices and services across
Canada that harness the power of technology to promote healthy aging,” said Minister Harris. “Through the New Brunswick Aging Strategy and other important initiatives such as the long-term care assessment tool, age-friendly communities and Home First, New Brunswick has taken significant steps to address the challenges of an aging population. “We are delighted to be the host province for a hub that will be a national resource for policymakers, researchers, clinicians and others working to implement novel technologies that will improve the health and wellbeing of
older Canadians and their caregivers.” The hub will help innovators and entrepreneurs transform their ideas into market successes by connecting them with end users, policymakers and service providers, and nurturing the transfer and early adoption of new technologies. It will give stakeholders ready access to the latest research findings and information on emerging tools and health technologies. “As smart homes, assistive and digital technologies become more available, we want to maximize their impact on people’s lives, and produce economic benefits for Canadians. This hub – a first for AGE-WELL – will be a platform for knowledge mobilization and policy innovation that will ensure new technologies get to the people who need them as quickly as possible,” said Dr. Alex Mihailidis, Scientific Director of AGE-WELL, Canada’s Technology H and Aging Network. ■
STRENGTH in numbers
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Nine million opioid prescriptions filled P
eople in Ontario filled more than nine million prescriptions for opioids in 2015/16, up by nearly 450,000 prescriptions from three years earlier, and the opioids being prescribed have shifted toward stronger types like hydromorphone and away from weaker opioids like codeine, a new report has found. According to 9 Million Opioid Prescriptions, a report by Health Quality Ontario, nearly two million people in Ontario fill prescriptions for opioids every year – translating into one in every
seven Ontarians, or 14 per cent of the province’s population. And despite the increasing awareness publicly and in the physician community regarding the numbers of opioid-related deaths and the prevalence of opioid addiction, the number of people who filled opioid prescriptions in the province has not decreased from three years ago. Looking at the types of opioids being prescribed in Ontario, the report found the number of people who filled a prescription for hydromorphone – which
is approximately five times stronger than morphine – increased by nearly 30 per cent over three years, to almost 259,000 people, from just over 200,000. Over that same time, the number of people who filled a prescription for codeine and codeine compounds – a weaker opioid than morphine – decreased by seven per cent to more than 912,000 people, from almost 986,000. The number of prescriptions filled for oxycodone and oxycodone compounds, meanwhile, remained almost unchanged over three years, despite the
Healthcare system sustainability key concern as Canadians get older ecently released Census data showed that, for the first time ever, seniors now outnumber children in Canada. These changing demographics present a unique challenge to the sustainability of the Canadian healthcare system that will have pressing implications for public spending, the labour market, and housing and institutional infrastructure. In 2016, Canada’s total health expenditures reached an estimated $228 billion – representing more than 11 per cent of GDP. This figure is estimated to consume between 44 and 55 per cent of provincial and territorial reve-
nues moving forward. Added to unmet needs that currently exist in Canada’s health system, pressures to deliver the care Canadians want and expect will continue to increase. “As the country’s aging population rapidly increases, the gap between government budgets and Canada’s healthcare needs continues to widen,” said Louis Thériault, Vice-President, Industry Strategy and Public Policy, The Conference Board of Canada. “But, healthcare sustainability is more than a funding matter. The road to sustainability must also include disease prevention efforts, health and wellness promotion, and a redesign of elements
What Canada can learn Continued from page 4
Canadians should not get the impression, however, that all is rosy in Australia. Australians have to pay relatively high out-of-pocket costs, not only for pharmaceuticals as discussed above, but for medical services. This hits the poor hardest. Australia also has a mixed public and private system, with physicians permitted to work in both sectors. Private health insurance for private hospital care is subsidized – at about 25 per cent of the cost of premiums – and there
are tax penalties on middle-to-high income earners who do not have private insurance. Contrary to the original political justification for the subsidies, there is no evidence that subsidizing private care has had any benefit on the public hospital system. In fact, waiting times for public hospital care and proportion of care in the private system are directly rather than inversely related. In other words, more private care is associated H with more public waiting. ■
Stephen Duckett is an expert advisor with EvidenceNetwork.ca and director of the health program at Grattan Institute, an independent public policy think-tank based in Melbourne, Australia. He is a former head of the Australian Government Department of Health and was the inaugural president and chief executive officer of Alberta Health Services. www.hospitalnews.com
of the current health system.” Launched in 2011, The Conference Board of Canada’s Canadian Alliance for Sustainable Health Care (CASHC) has been examining some of the key challenges facing the Canadian health care system, including aging Canadian seniors, unmet care needs, labour requirements, sedentary behaviour, workplace health and wellness, and health system design to develop forward-looking qualitative and quantitative analysis and solutions to make the health system sustainable. CASHC’s research compendium, A Road Map to Health System Sustainability, synthesizes key findings from CASHC’s extensive research program and provides recommendations for achieving health system sustainability. Future Care for Canadian Seniors series estimates that 2.4 million Canadians age 65+ will require paid and unpaid continuing care supports by 2026. By 2046, this number will reach nearly 3.3 million. Spending on continuing care for seniors is forecast to increase from $28.3 billion in 2011 to $177.3 billion in 2046. Canada’s aging population will affect more than just public and private expenditures and go beyond clinical care. As more and more Canadians retire, labour shortages in specific areas of the health system will become more pronounced. A necessary shift from acute to home, community, and long-term care will also put pressure on existing institutional infrastructure and on caregivers who must reduce their work hours or leave H the workforce. ■
increasingly common knowledge about the harm from opioids. To help tackle the growing opioid problem, and at the request of the Minister of Health and Long-Term Care, Health Quality Ontario is developing three sets of quality standards – one will provide guidance to patients and clinicians about what high quality care looks like for adults and adolescents with opioid use disorder and the other two will provide guidance on how to prescribe opioids for management of chronic and acute pain. These standards are being developed in collaboration with patients, caregivers, physicians, nurses, clinicians and orgaH nizations across the province. ■
Organ transplants increase in Ontario
ore lives are being saved than ever before as a result of leading organ and tissue donation practices implemented in Ontario by Trillium Gift of Life Network (TGLN), Ontario hospitals and other partners. In the 2016/17 fiscal year (April 1, 2016 – March 31, 2017): • 1,256 people received a second chance at life through transplantation, thanks to the generosity of donors and their families (compared to 1,029 in 2012/13); • 354 deceased organ donors (an increase of 90 per cent over the last decade), and 242 living organ donors gave the gift of life; • 2,247 tissue donors enhanced the lives of thousands through the gift of eyes, bone, skin, and heart valves; and • Nearly 250,000 people joined the growing list of 3.8 million Ontarians who have registered consent for organ and tissue donation. Currently, 31 per cent of Ontarians have registered their decision to donate, giving hope to over 1,500 patients waiting for a lifesaving organ transplant. Trillium Gift of Life Network is working to build a culture of donation in the province, one in which the majority of eligible Ontarians are registered. To date, only 18 of 170 Ontario communities have met or exceeded the 50 per cent registration rate benchmark. Find out how your community is doing H at www.BeADonor.ca/scoreboard. ■
JUNE 2017 HOSPITAL NEWS 7
Niagara Health physicians are able to communicate key patient information By Melissa Raftis hen most of us want to get a hold of someone quickly, we pull out our smartphones and send a text message. In healthcare, however, communication becomes more complicated. That’s why Niagara Health has become one of the first hospitals in Canada to adopt a new app for physicians, which makes it faster and more secure for them to communicate with one another on their personal devices.
Working with IBM and Vocera Communications, Inc., Niagara Health designed and deployed an innovative smartphone app called qConnect that allows our physicians to instant message each other through their own phones. Jeff Wilson, Niagara Health’s Director of Information and Communications Technology (ICT), says doctors can now share test results and other key patient-related information with the click of the send button, ultimately re-
Take on the Medical World with Scrubs from Mark’s
Mark’s scrubs are made for the woman who is on her feet all day caring for others — in clinics, hospitals, schools, and dental ofﬁces. This is the nursing and healthcare professional you want in your corner, and Mark’s wants to help her to deliver the very best patient care. Our HEALTH PRO® collection features quality scrubs designed with comfortable and quality fabrics for a great ﬁt. These scrubs incorporate purposeful designs and practical features so you can focus on the work that really matters. Scrub Kulture™ introduces a new playful attitude to healthwear. With bright colours, vibrant prints, and the softest of fabrics, these scrubs offer a perfect blend of function and fashion to make you feel conﬁdent and stand out from the crowd. Mark’s wants to ensure you’re comfortable on the job; The HEALTH PRO® and Scrub Kulture™ collections feature a range of fabrics and technologies to make them lightweight, soft, breathable and offer a great amount of stretch. To make the ﬁt just right for you, there are ﬂattering, practical styles like wrap tops, side-slits, and pants with adjustable hems to achieve a tailored length. From notepads and pens, to bandages and gloves, our scrubs offer lots of pocket space so you have the room to carry around all your essentials. At the end of a hard day, they are also durable enough to put through the washing machine and dryer. HEALTH PRO® and Scrub Kulture™ scrubs are exclusive to Mark’s. We also carry a large assortment of footwear and accessories to equip the healthcare professional to take on the medical world.
Niagara Health Orthopedic Surgeon Dr. David Martin uses the qConnect app. sulting in more timely care for patients. “Streamlining the communications between physicians and nurses and ward clerks ultimately does impact patient care because the turnaround times are reduced,” says Mr. Wilson. “It’s about helping our physicians be more efficient and more effective because every step we can take to reduce seconds or minutes communicating can make a huge difference for our patients.” “The use of pagers has been the mainstay of communication for doctors in hospitals since the 1980s,” says Dr. Rafi Setrak, Niagara Health Chief of Emergency Medicine and clinical lead for the qConnect project. Unlike a paging system, qConnect lets the user know when a message has been sent, received and read by the correct person in one easy step. It also includes built-in contact lists, which allow users to reach the on-call physician without having to know who is on call. “It’s more efficient than regular texting because if you’re going to text or email you need to know the person’s contact information,” says Dr. Setrak. “With qConnect you don’t because those contacts are already built into the system.”
“Most importantly, the information shared is secure as it is stored on servers housed on Niagara Health property,” says Tammy Chaput, Niagara Health Information and Communications Technology Project Manager. “Because we house all of our own servers, everything that is shared in this app stays behind Niagara Health’s firewall,” says Ms. Chaput. “Doctors can now send patient information like diagnoses and X-rays to each other through their own smartphones without risking a breach in patient privacy.” Niagara Health’s ICT department worked with the hospital’s doctors to customize the app to specifically meet their communication needs. “Because this is a two-way texting solution with multimedia capabilities, it opens so many new doors for communication,” says Dr. Setrak. “A heart monitor from the Critical Care Unit could forward the patient’s rhythm right to the cardiologist’s cellphone, for example. The possibilities are endless. We’re just starting to scratch the surface.” Other hospitals in Ontario are now looking to Niagara Health to see how they can implement similar leadH ing-edge communication technology. ■
Melissa Raftis is a Communications Specialist at Niagara Health. 8 HOSPITAL NEWS JUNE 2017
Blend function & fashion with ďŹ‚attering ďŹ ts, engineered designs & vibrant colours.
FOCUS Kelsey Missons, Carolyn Tran and Leyla Seyitler, setting up clinical dictionaries on Meditech 6.16
Hospitals kick off partnership on ehealth solution to streamline patient care By Kathy Foisey
stablishing a shared patient record over a catchment area that includes more than 1.5 million residents is a huge undertaking. It would also have significant benefit for patients in that region. Markham Stouffville Hospital, Southlake Regional Health Centre, and Stevenson Memorial Hospital have come together to make this a reality. The three hospitals will be working in partnership to launch a shared electronic patient record to support seamless patient care and improve the patient experience across these three organizations. “This partnership puts patients first in that it improves quality and seamless access to health records between the
10 HOSPITAL NEWS JUNE 2017
three hospitals,” says Dr. Dave Williams, president and CEO of Southlake Regional Health Centre. “As a regional centre, Southlake provides care to patients from across York Region and Simcoe County and there are tremendous benefits and efficiencies that integrated technology will provide.” Staff from all three sites collaboratively came up with ideas on what the new endeavour will be called. SHINE – short for Shared Health Information Network Exchange, was the winner. The partners are working towards having the implementation of Meditech 6.16, the first priority in the SHINE partnership, up and running in early 2018. Meanwhile, work is being done to prepare for the implementation, such as
creating a master patient index and the merging and purging of patient records. Many patients in the region visit two or more of the partner hospitals, and creating a robust, integrated system, will allow clinicians to access more information about their patients when they need it from almost anywhere. This will be particularly beneficial to patients who are cared for at multiple sites, such as cardiac and cancer patients, who receive care at both their local hospital and at one of Southlake’s regional programs. It’s the first group of hospitals to take a cue from the Ontario government’s new eHealth 2.0 strategy, which encourages hospitals to create geographical clusters that can share computerized systems as a way of reducing costs
and improving efficiency. “We are excited to work with Southlake and Stevenson on this collaborative partnership,” says Jo-anne Marr, president and CEO of Markham Stouffville Hospital. “We believe that by working together we can maximize our resources and invest in systems and technologies that will benefit our patients. This new partnership builds on Markham Stouffville Hospital’s expertise with Meditech and we are excited to leverage this knowledge to the mutual benefit of all three organizations.” Southlake and Stevenson will be able to leverage the expertise of Markham Stouffville Hospital, which has already achieved Stage 6 in the HIMSS EMRAM framework. Southlake and www.hospitalnews.com
FOCUS Stevenson will implement the Meditech system and Markham Stouffville Hospital will be upgrading to the latest version of Meditech’s system, Meditech systems are in use at over 50 per cent of Ontario hospitals. “I am inspired to see this partnership unfold, and am pleased to work with two excellent organizations like Southlake and Markham Stouffville Hospital on a critical project to deliver safe, quality care, says Jody Levac, president and CEO at Stevenson Memorial Hospital. “This ground-breaking partnership allows smaller hospitals opportunities to bring optimal technology to daily operations, and ultimately improve patient experience.” “There are substantial savings,” says Tim Pemberton, chief technology officer at Southlake. He noted that Markham Stouffville Hospital, which has been a long-time Meditech customer, was footing 100 per cent of the bill for its own electronic health records system. Now that it has partners, it will bear only part of the cost of the shared solution, with the other two hospitals
MANY PATIENTS IN THE REGION VISIT TWO OR MORE OF THE PARTNER HOSPITALS, AND CREATING A ROBUST, INTEGRATED SYSTEM, WILL ALLOW CLINICIANS TO ACCESS MORE INFORMATION ABOUT THEIR PATIENTS WHEN THEY NEED IT FROM ALMOST ANYWHERE sharing cost proportional to the size of their organization. Updating health information systems through this partnership will create an electronic foundation that will enable Southlake and Stevenson to more rapidly move to a fully electronic health record, joining MSH, the top ranked community hospital in Canada as ranked by Healthcare Information and Management Systems Society (HIMSS), completing paperless records and a highly integrated health information technology systems throughout all the departments that are connected seamlessly and work efficiently, and they are connected to an electronic health record the region.
Paul Heck, CFIO of Stevenson Memorial, says “This collaboration with hospital partners in Ontario represents a remarkable opportunity to gain access to significant new technology and medical talent that a small hospital such as ours would normally not be able to achieve on its own. I believe the improving the technology and implementing this shared client record will bring great value to the partners and the community that we serve.” Lewis Hooper, CIO of Markham Stouffville, said that Markham Stouffville will also learn from the Stevenson Memorial, a smaller hospital where clinicians and staff have learned to accomplish a lot with fewer resourc-
Kathy Foisey is a Digital Communications Associate at Markham Stouffville Hospital.
es. One person will often do a lot of things, and they’ve learned to do them very efficiently, Hooper asserted. On the technological side, Hooper asserted that a shared EMR will make things easier and faster for clinicians and patients. Not only will more information be available at the touch of a few buttons, but the processes for reaching the data will be the same across all facilities – meaning that clinicians going from one site to another will know how to obtain the information without re-training. The partners plan to deploy the patient portal component that is part of Meditech Web EHR. “It’s part of our strategy to engage our patients,” says Pemberton. He noted the system offers features like appointment scheduling, prescription renewals and an interface for contacting physicians and other clinicians. The hospitals are still in the planning stages, however, about which of the features to provide. “We’ll see what the patients want,” H says Pemberton. ■
New resource for
health information management By Paula Weisflock and Kelly Abrams
he Canadian Health Information Management Association (CHIMA) is pleased to introduce the first ever comprehensive Canadian Health Information Management Lifecycle. This 290 page resource will assist individuals and organizations tasked with the responsibility of managing health information in an evolving healthcare system. The Canadian Health Information Management Lifecycle was created with contributions from a pan-Canadian multi-disciplinary group including physicians, nurses, lawyers, administrators, academics, and a vast selection of certified health information management (HIM) professionals – subject matter experts in the various stages of the Lifecycle. Canada has a complex healthcare system – in reality, a system of systems – that is constantly evolving and in need
of standardized policies and processes to support quality healthcare. The goal of eHealth in Canada is, basically, one patient, one record. The development of a semantically interoperable electronic health record is necessary in order to exchange data and maintain intent and meaning across care providers and those using the data. Without common standards throughout the health information management lifecycle, Canada’s eHealth goal may not be achieved. We may get to a connected system, but semantic interoperability will not be possible if disparate information is gathered in different formats through different media. Given the fact that some of the data capture will remain reliant on humans for the foreseeable future (e.g., dictated clinical reports) and in a hybrid form, standardization with HIM practices in Canada becomes an imperative.
THIS 290 PAGE RESOURCE WILL ASSIST INDIVIDUALS AND ORGANIZATIONS TASKED WITH THE RESPONSIBILITY OF MANAGING HEALTH INFORMATION IN AN EVOLVING HEALTHCARE SYSTEM During the creation of the Lifecycle document, it became clear that Canadian HIM standards mostly do not exist. We are not talking here of the information technology or health informatics standards that support the technology and connectivity itself. We are speaking to HIM content standards, for example, what minimum content must be included within a discharge report to support both patient care and secondary data use? What constitutes the legal electronic health record? How long must secondary documents be re-
tained and how is this tracked? Without pan-Canadian standards to guide us, individuals must gather disparate policy, rules, regulations, legislation and create processes to support their own organizations or individual practices. When you throw in the range of media (e.g., paper, hybrid, electronic/ digital), these challenges create chaos for those tasked with the responsibility of managing health information. So how will the Canadian Health Information Management Lifecycle help? The editors and contributors surveyed
Building a virtual QI community in Ontario By Lee Fairclough and Dr. Darren Larsen
ospitals and long-term care facilities serve communities and are themselves communities of providers and patients united by common outlooks and goals. However with the advent of electronic and digital communications and social media, community members are no longer bound by physical proximity and online disease-specific patient communities and professional social networks are now common in healthcare. What is harder to initiate and maintain are communities of practice that transcend geographic, organizational or professional boundaries where individuals are bound by common interests or goals. Health Quality Ontario’s latest initiative – Quorum – falls squarely into this category as it is a community of practice dedicated solely to those working in or interested in quality improvement (QI) in healthcare.
While there are numerous individuals and teams working on QI initiatives across the province, the opportunities to share experiences and learnings are often limited to occasional regional or provincial conferences. Existing networks or social media channels are often restricted to one profession or are not focused enough on information about quality to be useful. Quorum is an open community dedicated to improving quality by encouraging people to learn from each other, share experiences and support innovation from idea inception to meaningful improvement. It is intended to complement a number of tools and resources the organization already has in place to support quality initiatives in Ontario. Officially launched in April, Quorum allows you to: • Find credible QI information curated by Health Quality Ontario and generated by partners and community members.
Lee Fairclough is VP, Quality Improvement for Health Quality Ontario and Dr. Darren Larsen is CMIO, OntarioMD 12 HOSPITAL NEWS JUNE 2017
leading HIM practice across Canada and created a document that synthesized practice in each of the seven stages of the Lifecycle. Where legislation or regulation differed across the country or across practitioners or levels of care, guidance on where to look and what to look for when creating processes, was provided. Where no substantive legislation, regulation, or policy existed, leading HIM practice from within the HIM community was provided - individuals will find guiding principles and items to consider for each of the seven lifecycle stages. Below is an excerpt from the Canadian Health Information Management Lifecycle: Several strategies are available to effectively manage data assets and improve the quality of data for system-wide use. These strategies include developing and implementing a data governance program to oversee and provide direc-
tion for the management of data, developing standardized minimum data sets, creating a comprehensive list or an inventory of relevant data sets, developing policy and procedures, implementing a data quality program, and embracing data principles. The employment of these strategies within a jurisdiction will promote data quality and raise awareness that data is an organizational asset
and increasingly a health system-wide asset. (p. 65-66). This is not only an invaluable resource to support you in the effective and efficient management of health information; it is a toolkit with real world examples to support you in strengthening or implementing your own HIM plans for the various stages of the lifecycle. You will find tools, such as an
example of an Information Governance and Accountability framework, a sample policy framework, sample contract clauses, and many other templates, and tools you can use to support your journey. You can order a copy of this new resource at this link www.echima.ca/ him-lifecycle-book. $54.95 soft cover, H $24.95 for eBook. ■
Paula Weisflock is Director-Professional Development at the Canadian Health Information Management Association and Kelly Abrams, is VP, Canadian College of Health Information Management.
• Give and receive QI support from the community by asking a question on the Q&A page. • Find out what works and what doesn’t when implementing change ideas by sharing experience on the Lessons Learned page. • Browse and submit for discussion high quality QI projects including those already developed from IDEAS teams. • Find like-minded people and communities of practice in a provincial QI directory. Here, anyone can create a group or join a group to tackle common QI challenges together. For instance, some individuals in the long term care community have already formed a group on the site. • Engage in dialogue with others on QI issues by commenting, up-voting, and sharing content.
Quorum was built with and for the QI community
By definition, a quorum refers to the minimum number of members
of an assembly or society that must be present at any of its meetings to make the proceedings of that meeting valid. As a community of practice, Quorum was named to reflect that the principle of participation. The aim of Quorum is to strengthen collaboration and the overall capacity for QI across Ontario. This will only occur with widespread participation and engagement from those in the QI community. Quorum was built for you but needs your participation to be successful. In the spirit of living up to this, the authors have already published material on Quorum. One (DL) published an article on the challenges of managing transitions in care, while the other (LF) published the first post on the site welcoming people to take advantage of all its functionality. As Health Quality Ontario CEO Dr. Joshua Tepper wrote in response to the welcoming post: “An exciting day H for QI in Ontario.” ■
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Retinal unit eyes better safety with new technology By James Wysotski here’s no limit to better, even for the largest retina unit in the country. The Eye Clinic at St. Michael’s Hospital already uses a diagnostic machine that is unique among Canadian hospitals and soon it will get another kind that’s even better, notes Ophthalmologist-in-Chief Dr. David Wong. Since July 2016, the clinic has been taking pictures of blood vessels at the back of the eye using wide-angle angiography, which involves injecting fluorescein dye into a patient’s arm that flows to blood vessels in the eyes and allows them to be seen more easily by doctors’ cameras. “Typically, angiog-
raphy machines offer a narrow field of view, but the hospital’s wide-angle unit allows St. Michael’s physicians to see more than anyone else in Canada,” says Dr. Wong. By injecting a second dye, indocyanine green, the field of view expands to the retina’s periphery. “We’re finding diseases in the eye that we couldn’t see in the past,” says Dr. Wong. “Now, we can actually view what we had always assumed to be true.” Dr. Wong says the clinic sees a lot of people with diabetes, but also vascular diseases such as hypertension and eye strokes. There’s also talk of detecting Alzheimer’s disease earlier through thinning of the retina. The clinic also
Photo by Yuri Markarov, Medical Media Centre
Ophthalmic technician Vladimir Evlampiev takes pictures of Eustace Nembhard’s right eye using wide-angle angiography after registered nurse Aresna Silverman injected fluorescein dye into the patient’s arm.
“AS AN ACADEMIC UNIT, IF WE CHANGE OUR THINKING, WE CHANGE EVERYBODY ELSE’S BECAUSE WE ARE THE LEADERS.” – DR. DAVID WONG, OPHTHALMOLOGIST-IN-CHIEF deals with uveitis – inflammation of the eye – and Dr. Wong explains that once inflammation is found in the eye, it’s usually somewhere else in the body, often in the form of arthritis, colitis or Crohn’s disease. “We’re defining what’s normal and, ultimately, what’s abnormal,” adds Dr. Wong. “And it’s changed the way we do patient care.” Diagnostics used to be somewhat qualitative, but the new machines offer enough scope and refinement to make accurate measurements down to five one-thousandths of a millimeter. As a result, therapies are safer since the effectiveness of drug treatments can be better evaluated. As good as wide-angle, fluorescein angiography is, the future is digital. Instead of injecting dye to see the eye’s blood vessels, new optical coherence tomography, or OCT, machines use lasers to obtain cross-sectional im-
ages non-invasively. The technology scans so quickly that “we can actually see the retina in living detail,” says Dr. Wong. Like many clinics, St. Michael’s already owns OCT machines. However, by fall, the hospital will be the first in Canada to get the next generation of the technology, swept source OCT, which provides a wide-angle view and even greater resolution. The new machine has other benefits. While the technology with the dye requires 20 minutes with a nurse and a photographer, OCT needs one technician for just two minutes, meaning that more patients can be seen at less of a cost to the healthcare system. And since two per cent of patients have an allergy to the fluorescein dye, OCT’s non-invasiveness improves safety. “We’re going from a safe technology H to an ultra-safe one,” Dr. Wong says. ■
James Wysotski works in communications at St. Michael’s Hospital. 14 HOSPITAL NEWS JUNE 2017
JUNE 2017 HOSPITAL NEWS 15
How hospital staff can improve patient outcomes and
stop wasting healthcare resources By Karen Born and Wendy Levinson ach year, there are at least one million unnecessary tests, treatments and procedures done in Canadian healthcare settings, including hospitals.
What is ‘unnecessary care’?
THE REPORT FOUND THAT UP TO 30 PER CENT OF THE TESTS, TREATMENTS AND PROCEDURES ASSOCIATED WITH THE EIGHT SELECTED CWC RECOMMENDATIONS ARE POTENTIALLY UNNECESSARY. THIS EQUALS MORE THAN A MILLION POTENTIALLY UNNECESSARY MEDICAL TESTS AND TREATMENTS EVERY YEAR
Unnecessary care is medical care that offers no value to patients and can in fact be harmful. This could be a prescription drug, diagnostic test or medical procedure that is not needed, does not improve a patient’s health outcomes and is not backed by the best available evidence. It may also involve risks and harmful side-effects. A recently released report from the Canadian Institute for Health Information (CIHI) in partnership with Choosing Wisely Canada demonstrates how pervasive unnecessary care is across the country and highlights several key examples where changes could be made to benefit patients and the health system. So, what are we better off without? And how can hospital staff help to curb unnecessary care?
increase in dispensed prescriptions for the powerful antipsychotic quetiapine for insomnia in children and youth in Manitoba, Saskatchewan and British Columbia. Other options for treating insomnia should be considered first, such as behavioral changes and ensuring good sleep hygiene. Quetiapine is not recommended for children or youth and has a long list of harmful side-effects, including obesity, high blood sugar and cholesterol, even if given in low doses.
Unnecessary care wastes valuable resources
Unnecessary imaging has consequences
The report says about 30 per cent of patients visiting Ontario and Alberta emergency departments for minor head injuries have CT scans. CT scans deliver strong x-ray radiation. Exposure to this radiation can increase lifetime cancer risk. Yet evidence shows there are good alternatives to CT scans for investigating head injuries. Emergency department staff are trained to use clinical decision rules to assess the severity of a head injury, and decide if further diagnostic testing is warranted. Not only does this reduce harm associated with unnecessary imaging to patients, but it also reduces wait times for those who truly need imaging. 16 HOSPITAL NEWS JUNE 2017
Unnecessary medications have side-effects
The report estimates that one in 10 Canadian seniors regularly uses sleeping pills, known as benzodiazepines, and other sedative hypnotics, on a regular basis. Benzodiazepines are often prescribed for hospitalized seniors who are having difficulty sleeping, and are intended for short-term use. The
long-term use of these medications outweighs benefits and increases the risk of falls causing injuries and car accidents in seniors. It is worth asking yourself – are there non-pharmaceutical based therapies that can be used instead of these powerful medications? Seniors are not the only population where there is unnecessary and potentially harmful medication use. The report shows a disturbing 300 per cent
Blood is a vital, and limited resource. Choosing Wisely Canada recommendations highlight where blood transfusions are wasteful, and don’t improve patient care. Reactions to blood transfusions are common, and can increase morbidity and mortality in very ill patients. Yet, the rates of blood transfusions vary across provinces with patients with similar diseases and treatments having different blood transfusion rates. For example, transfusions for hematology patients in Canada vary from 13 to 54 per cent depending on the hospital where they are receiving care. Some hospitals profiled in the report are working to reduce unnecessary transfusions, and to conserve limited blood products by introducing new transfusion orders that remind providers of Choosing Wisely Canada recommendations around using blood resources wisely. www.hospitalnews.com
Variation in practices demonstrates opportunities to reduce unnecessary care
An important finding of the report that should cause Canadians to take notice is wide variation across regions and between provinces. Variation means major differences in medical practice, some of which are not evidence-based and can be potentially harmful to patients. Reducing variation improves quality for all Canadian patients and can reduce waste. A good example of this is pre-operative testing. In Ontario, nearly one in three patients having eye surgery had a preoperative test, compared to one in five in Alberta. Medicine has evolved and so has medical practice. It used to be standard that patients needed to undergo a battery of tests to ensure that they were ‘fit for surgery’. However, as surgical and sedation practices have improved, this
is no longer needed for certain low-risk surgeries, like hip or knee replacements or cataract surgery. These tests could include blood work, electrocardiograms and chest x-rays. Research shows that preoperative tests before low-risk surgeries do not improve patient care and that results of these tests waste resources and cause needless anxiety to patients.
So what can you do?
The national conversation about unnecessary care has started to spark changes. The report provides several examples of how healthcare providers are working hard to put in place better practices or protocols to reduce waste, which may also harm patients. For example, with preoperative tests, a simple change to pre-surgical checklists or order sets can help to reduce unnecessary tests. We know patients are aware of this problem too. Ipsos Reid survey data
SUBSTANTIAL VARIATION EXISTS AMONG REGIONS AND FACILITIES IN TERMS OF THE NUMBER OF UNNECESSARY TESTS AND PROCEDURES PERFORMED. THIS SUGGESTS THAT THERE IS ROOM TO REDUCE UNNECESSARY CARE shows that one in four Canadians say they personally have experienced unnecessary care in the past year: 67 per cent of Canadians surveyed believe patient demand is also responsible for unnecessary care, rather than decisions made by healthcare providers alone. Nearly half (42 per cent) of Canadians surveyed said they expect a test ordered, or a prescription written, when they visit a doctor’s office. But the vast majority (92 per cent) of Canadians surveyed also said they need more information to help make decisions and ask the right care questions.
Choosing Wisely Canada, a national, clinician led campaign has over 220 recommendations of ‘things clinicians and patients should question.’ The campaign emphasizes that patients and clinicians need to together question whether that test, treatment or procedure is really necessary. There are four key questions that a patient can ask, or a clinician can introduce, to help start a conversation about unnecessary care: Do I really need this test, treatment or procedure? What are the downsides? Are there simpler, safer opH tions? What happens if I do nothing? ■
Karen Born, PhD is the Knowledge Translation Lead, Choosing Wisely Canada and Assistant Professor, Faculty of Medicine, University of Toronto Wendy Levinson, MD, OC is the Chair, Choosing Wisely Canada and Professor of Medicine, University of Toronto.
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JUNE 2017 HOSPITAL NEWS 17
Dr. General Leung, one of the co-founders of MIMOSA, inspects the device designed to detect poor blood circulation in the feet. Photo credit: Katie Cooper, Medical Media Centre
Early-detection tool improves foot surveillance for patients with diabetes By Kelly O’Brien ore than three million Canadians have diabetes, a number that has nearly doubled since 2002 and continues to grow. They have tools to manage their glucose levels, but not to manage foot wounds that often lead to infection and amputation. MIMOSA (Multispectral Mobile Tissue Assessment Device) is an early-detection tool developed by Dr. Karen Cross, a surgeon-scientist at St. Michael’s Hospital, and Dr. General Leung, a magnetic resonance physicist at St. Michael’s. The device detects poor blood circulation in the feet, which can lead to diabetic foot ulcers, by photographing the skin with near-infrared light. “It’s just beyond the range of human
vision , so it’s safe, but also it has deep penetration into the skin, so it’s going to get below that top layer,” says Dr. Cross. “It can see things that we can’t.” Dr. Cross likened the light MIMOSA uses to the technology used to discover that Leonardo da Vinci was the artist behind The Adoration of the Magi, the painting most often attributed to Filippino Lippi. The light allowed art historians to view the different layers of the painting without damaging it. “We’re doing the same thing,” saysDr. Cross. “Before, to see how much hemoglobin you have, you’ve got to take blood. You’re damaging something by putting a needle in there. We can actually do it without damaging anything.” Between 15 and 25 per cent of people with diabetes will have a foot ulcer
at some point. These ulcers often become infected and as a result, diabetics are 23 times more likely than the general population to have a lower limb amputation. The technology MIMOSA uses to monitor wounds was originally developed as an early detector and triage tool for determining burn depth. But what has changed is the size of the tool. “Because of the way the technology’s changed, and because we have so much computing power in our pockets with our cell phones, we’re able to shrink it down,” says Dr. Leung. “So now it’s evolved from being 10 or 12 feet tall to being a little clip-on device.” The device is designed to work for all diabetics, no matter their age or level of mobility.
“This is something you could put on a selfie stick and put it down below and take a picture,” says Dr. Cross. The team has already seen success using MIMOSA to monitor wound development in a recently completed pilot study, and will soon begin work on a two-year, multicentre randomized controlled trial. Evidence has also shown prevention strategies such as MIMOSA can result in a 20 to 40 per cent reduction in treatment costs. “Diabetes is a global tsunami,” she says. “More than 300 million people worldwide have diabetes, and that number is only growing. So something that can be made quite simply and can reduce those costs is an easy sell. That’s H what we want to do.” ■
Kelly O’Brien works in communications at St. Michael’s Hospital. 18 HOSPITAL NEWS JUNE 2017
Transforming and innovating
to meet patient needs
By Roxanne Hathway-Baxter
t goes without saying that every patient who comes through the doors of Runnymede Healthcare Centre is different. Often the path to recovery is filled with challenges along the way, and a hospital’s ability to accommodate patients’ specific needs is incredibly important. To support their treatment journey, Runnymede’s programs and services have been designed with one goal in mind – excellent patient-centered care. In turn, this is supporting the wider healthcare system by admitting patients who are Alternative Level of Care (ALC) – those who no longer need the type of care provided by an acute care hospital, but are unable to be discharged because there are no beds suited for their needs in other facilities. A pilot project for stroke patients, The Innovative Journey for Stroke Recovery, was introduced at Runnymede in 2016 in collaboration with Trillium Health Partners (THP) in response to an identified need in the community. Patients admitted to THP who have suffered a severe stroke are transferred to Runnymede once they are ready to start rehabilitation. This offers patients the advantage of slower stream rehabilitation through the hospital’s Low Tolerance Long Duration Rehabilitation (LTLD Rehab) program. Once the patients have reached the identified rehabilitation goals at Runnymede they return to THP to undergo active rehabilitation, which is performed at a faster pace. LTLD Rehab is ideally suited to severe stroke patients, because at the beginning of their treatment, many are unable to tolerate the intensity of rehabilitation provided at acute care hospitals. By taking rehabilitation at a slower pace initially, patients are able to build up their strength, and can either transition into a more active and intense rehabilitation program, or complete their
treatment at Runnymede and return to the community. The hip fracture initiative at Runnymede is another partnership designed to put patient needs at the forefront and address a pressing system challenge. Made possible through collaboration with THP and St. Joseph’s Health Centre, Runnymede is focused on standardizing and enhancing access to rehabilitation for patients post-hip fracture, while reducing the average length of stay for patients in acute care hospitals – an all too common problem in the current system. By getting patients out of acute care and into a rehabilitation facility like Runnymede, they can jumpstart their treatment journey by getting the right level of care that they need for their recovery. Unfortunately, finding spaces for patients in rehabilitation facilities is becoming more and more of a challenge, as the demand for them increases throughout the healthcare system. In 2016, there were over 4000 ALC patients in Ontario acute care hospitals waiting for beds in other facilities, and of these patients, 19 per cent were waiting for rehabilitation beds. In this time of increased demand, Runnymede is more than ready to help address system challenges. In November 2016, the hospital marked a major turning point in their history by receiving a reclassification as a Group “E” general rehabilitation hospital, under Regulation 964 of the Public Hospitals Act. With this new designation, Runnymede has transformed from a complex continuing care hospital into a rehabilitation hospital, with 70 of the 206 beds specifically classified as “rehabilitation beds.” “At Runnymede, we’re always looking for ways to provide an exceptional patient experience and improve the quality of patient-centred care. Our reclassification as a rehabilitation hospi-
tal will allow us to continue to provide patients with the best possible care, and also help our system partners to address the challenges being faced by the healthcare system at large,” says Runnymede President and CEO, Connie Dejak. Runnymede’s reclassification as a rehabilitation hospital and the continued
addition of new patient-centred programs, like the hip fracture initiative and Innovative Journey for Stroke Recovery, are demonstrating its commitment to both its patients and system partners. These measures will have a positive impact on the individuals and on the wider healthcare system at this H crucial point in time. ■
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Roxanne Hathway-Baxter is a Communications Specialist at Runnymede Healthcare Centre. www.hospitalnews.com
JUNE 2017 HOSPITAL NEWS 19
Participants at a creative problem solving session at NBRHC
Using creative problem solving for healthcare transformation By Lindsay Smylie Smith an you imagine the next time you are up against a problem in your organization, bringing all the stakeholders together in one room and leaving with a solution that works for everyone? That’s exactly what staff at the North Bay Regional Health Centre (NBRHC) have done. By using creative problem solving, staff are able to take challenging situations and turn them into well-defined problems with an action plan – created by and for the stakeholders – in a short time frame. Amazingly, they are able to do all this while also creating buy-in from staff, improving patient care, patient flow, interdisciplinary teamwork and, in some cases, improving the financial well-being of the hospital. Paul Heinrich, NBRHC President and CEO says he was first introduced to the idea of creative problem solving from Min Basadur, Founder of Basadur Applied Creativity, when Basadur
20 HOSPITAL NEWS JUNE 2017
BASADUR TEACHES CREATIVITY IS A PROCESS THAT INCLUDES THE FOLLOWING (IN THIS ORDER) – PROBLEM FINDING, FACT FINDING, PROBLEM DEFINITION, IDEA FINDING, EVALUATION AND SELECTION, PLAN, ACCEPTANCE AND ACTION spoke to a class Heinrich was taking at McMaster University. “I thought it was such a simple concept, but so powerful,” Heinrich says. Basadur teaches creativity is a process that includes the following (in this order) – problem finding, fact finding, problem definition, idea finding, evaluation and selection, plan, acceptance and action. Most people want to jump from problem finding (step 1) to action (step 8), but skipping ahead in the process would mean missing out on identifying the cause of the problem before getting to the solution. Heinrich went on to work with Basadur to use creative
problem solving at four different organizations – including NBRHC. Heinrich admits this way of thinking and problem solving can seem too difficult from the outside. “Divergent and convergent thinking can be very challenging for adults,” he says. “We have learned there is a ‘right’ answer for everything. Over time, we have learned to be uncreative.” It was at NBRHC that Heinrich decided to try a different approach. “Instead of relying on others to help us solve our problems,” Heinrich says, “We thought ‘why not train our own staff with these skills?’” Heinrich liked
the idea of tailoring the tools and tactics specific to a healthcare audience, while also creating the capacity within the organization to use these methods on an ongoing basis. So they did just that – training dozens of staff at the Health Centre in the theory of creative problem solving, encouraging them to take them back to their areas and teams, adapting them for the specific problems and audiences. That’s exactly what two members of the organizations’ Quality Team, Karin Dreany and Kristen Vaughan, did when faced with the task of making improvements to the Health Centre’s clinical documentation processes. This complicated problem involved a number of stakeholders across numerous departments. Essentially, a lack of standardization and incomplete charts meant the Health Centre was potentially missing out on important funds to match the true costs of a patient’s stay. There were additional concerns around turnaround times and a backlog for inwww.hospitalnews.com
FOCUS putting that required substantial staff overtime to keep up. Using key elements of creative problem methodology, they tailored the quality improvement to their audience by streamlining the group process from two days to two hours. Once they had everyone in the room – including physicians, frontline administrative and clinical staff, managers and senior leaders – as a group they came up with the top five problems and together brainstormed potential solutions. Subgroups were assigned to each solution, with representatives from physicians, clinical and coding staff on each. The result? Almost 90 per cent of physicians have adopted the new standardized documentation practices, clinical records has eliminated their overtime, and the turnaround time for chart coding has decreased from 60 days to 23 days. Improved, timely documentation allows the health centre to accurately capture the acuity and treatment of our patients.
BRINGING EVERYONE TOGETHER IN ONE ROOM IS ARGUABLY THE MOST IMPORTANT FACTOR IN THE SUCCESS THESE PROJECTS HAVE SEEN Another example of how creative problem solving was used with impressive results is the review of the leave of absence (LOA) process in NBRHC’s Regional Specialized Mental Health Programs. Laurie Wardell, Director, Mental Health, explains how there was an opportunity early last year to review some of the practises with the discharge process, particularly with respect to how LOA’s were functioning. “We thought there might be a way we could improve how this was executed to help improve our patient flow, better support our patients in their transition to the community and at the same time strengthen our relationships with some of our community partners.” To accomplish this, as with the Clinical Documentation Project, they
needed to get everyone together in one room. This included the psychiatrists, front line staff, health centre leadership and community partners. Groups that weren’t able to attend the session in person were able to remotely participate by Ontario Telemedicine Network (OTN). “Bringing everyone together and having the ability to engage everyone in the process from the very beginning was so important,” Wardell says. “Everyone had a voice and was able to understand the problem. The session helped us narrow the scope of work and clearly identify the problem we were trying to solve.” An unexpected benefit was the impact to the relationship with community partners. “They appreciated being
Lindsay Smylie Smith is a Communications Specialist at North Bay Regional Health Centre.
involved in the creative problem solving session. It increased their trust in the process and they were able to see for themselves the Health Centre’s level of support for these changes,” Wardell says. The group was able to improve wait times by reducing the length of the leave of absences by 55 per cent. Wardell credits the group session to the success the group has had with the process change. “Front line staff were a part of the process identifying and creating the solution to the problem – so they were ready to implement it on the units without anyone else having to create buy-in.” Bringing everyone together in one room is arguably the most important factor in the success these projects have seen. By bringing together everyone who don’t think it can be done or should be done, and by engaging them in the problems solving and allowing them to have a voice – good things are accomH plished together. ■
Dialysis at home: By Eftyhia Helis ne of the most vivid memories of my teenage years is that of my dad, in his late 30s at the time, leaving the house early in the morning to go to a hospital in a bigger city 100 kilometres from our hometown for his dialysis treatment. I will never forget the agony our family felt on “dialysis days” as he was heading out in the morning or the relief when he was finally back home late in the evening – a routine we repeated three days each week. But our story is not unique and probably sounds familiar to many people with end stage kidney disease (ESKD); especially those who do not have access to a dialysis facility in their area. Our kidneys are responsible for filtering our blood to remove excess fluid, salt and waste products from our body as urine. Kidneys also play a role in regulating blood pressure and the levels of certain minerals in the body. Kidney disease often shows no symptoms for a long time until the disease has progressed to a point where kidney function is quite low. ESKD is the final stage of the disease progression when kidneys can no longer filter enough waste out of the blood to meet the body’s daily needs. Treatment options focus on replacing the kidneys’ function and include dialysis or kidney transplantation. Unless a patient receives a kidney transplant, lifelong dialysis is usually required. According to data from the Canadian Institute for Health Information (CIHI), over 35,000 Canadians were living with ESKD in 2015. Approximately 60 per cent of these patients were on dialysis. Hemodialysis (HD) and peritoneal dialysis (PD) are the two main types of dialysis provided by Canadian kidney care programs. In HD, the patient’s blood is circulated through an external dialysis machine that filters the blood before returning it to the body. HD can be done in a clinical setting (i.e. hospital, community dialysis unit) with the assistance of a medical professional, but it can also be done at home by
22 HOSPITAL NEWS JUNE 2017
the patient and/or a trained caregiver without professional assistance (selfcare HD). Several options for HD delivery frequency are available (ranging from two to nine hours per session) and treatment must be repeated several times a week. PD requires a permanent catheter in the abdomen. During treatment, a cleansing solution (dialysate) is circulated through the catheter inside part of the abdominal cavity to absorb waste and fluid from the blood. In this process, the peritoneum (abdominal lining) acts as a filter and waste and extra fluid are discarded from the body. PD is usually done at home (can also be done at work or while traveling), and can be performed while the patient is asleep or awake and with assistance or without (self-care). Given the life-long aspect of dialysis treatment, home-based options may allow for greater flexibility in eligible patients’ daily lives. In 2009, The Globe and Mail featured an article with the title: “At-home dialysis touted as the next best thing”. However, currently in Canada, most patients needing dialysis are treated with HD offered in a clinical setting with the assistance of a healthcare professional. Should homebased options be considered more frequently for eligible patients? Is this feasible? How would an increased uptake of home-based dialysis affect patients’ quality of life and the healthcare system? CADTH, an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures, conducted an evidence review on different options for dialysis, including home-based HD and PD. The review did not find differences in clinical benefits, such as quality of life or survival, between patients who are treated with HD in a clinical setting and those who are treated with HD or PD at home. It was noted, however, that younger patients on home HD and PD may have better survival outcomes compared with elderly patients. From an economic perspective, the review also concluded that home-based therapies are less costly than in-centre dialysis for the health care system, however, some costs associated with homewww.hospitalnews.com
Should this be an option for more patients? based treatment (e.g. cost of water and electrical power needed for home HD) may be significant for patients. If such expenses are not covered by healthcare plans, the financial burden for patients choosing this type of treatment is an important consideration. CADTH also identified evidence showing that patients value treatment conditions that are the least disruptive to their daily activities and their caregivers’ lives. This means that homebased dialysis would work better with some patients’ lifestyles while for other patients the preferred choice would be in-centre treatment. While patients trust their doctors to help them make a treatment decision, they also report that having information about all treatment options (e.g. what to expect, impact on quality of life) and being involved in their dialysis decisions helps them feel more comfortable with
HOME-BASED THERAPIES ARE LESS COSTLY THAN IN-CENTRE DIALYSIS FOR THE HEALTH CARE SYSTEM, HOWEVER, SOME COSTS ASSOCIATED WITH HOME-BASED TREATMENT MAY BE SIGNIFICANT FOR PATIENTS their treatment. Another important component of the decision-making is sharing information with the patients’ caregivers; caregivers play a significant role in supporting patients’ treatment and are also affected by the choice of dialysis modality, in-centre or homebased. Home-based dialysis can be particularly useful for patients living in rural or remote areas with limited access to urban centres. Often, these patients, and in some instances their families as well, have to relocate to be closer
to treatment facilities. While several infrastructure conditions must be satisfied for having dialysis at home (e.g. space and storage for treatment supplies, transportation access for supply delivery, reliable water supply and electricity), at home treatment is feasible in these areas. Comprehensive training (for patients, caregivers and nursing support staff), well-established procedures addressing challenges specific to care in rural or remote settings, and the use of technology (i.e. teledialysis) may facilitate the successful implementa-
tion of home-based dialysis, eliminating the need for these patients to move to urban centres for treatment. In summary, according to available evidence, for eligible patients (as assessed by their healthcare provider), home-based dialysis could be considered as a first choice for treatment. However, implementation factors, including the local kidney care environment and infrastructure, as well as patient preference, and education about dialysis options need to be addressed in the treatment decision-making process. In some parts of Canada, significant work to support home-based dialysis is taking place. Sharing this information and connecting healthcare professionals and patients with these experiences is important. To learn more, visit www.cadth.ca/ dialysis or speak to a CADTH liaison H officer in your region. ■
Eftyhia Helis, MSc, is a Knowledge Mobilization Officer at CADTH
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JUNE 2017 HOSPITAL NEWS 23
TRENDS IN TRANSFORMATION
Process improvements in medicine achieve significant results By Maurice Williams and Sarah Muto, Process Improvement Consultant, LHSC & Sarah Muto, Project Consultant, LHSC n F2013/14, London Health Sciences Centre (LHSC) data indicated that on average the health care centre was continually running over census, with 115-120 per cent capacity most days, and with surges of up to 130 per cent. These capacity issues directly affected climbing lengths of stay in the Emergency Department. Staff and physicians were burned out from the bed pressures, and work needed to be done. Patients in the emergency department waiting for a medicine bed were one of the largest factors contributing to long emergency department lengths of stay. “We recognized that something needed to change,” says Dr. Jim Calvin, Chair Chief Medicine, LHSC. “But we lacked the clear data to understand where the bottlenecks in the system were.” The Department of Medicine created a strategic plan, trained their physicians and clinical staff on Lean Six Sigma and held a retreat to develop an improvement plan for long lengths of stay on the medicine inpatient unit. The understanding was that a number of initiatives needed to be trialed in PDSA (Plan-Do-Study-Act) cycles to try and address the issue. “The goal of the work wasn’t to simply turn beds over faster, it was about making quality improvements to the patient’s journey of care,” says Sherri Lawson, Director, Inpatient Medicine, LHSC from 2012–2017. In the fall of 2015, a series of Kaizen events were held with inpatient medicine staff and physicians, and supported by hospital process improvement consultants. Value stream maps were created and a significant amount of wastes in their processes were identified. Opportunities were then prioritized to reduce patient days through a number of initiatives which began in 2016, including; white board usage, bed assignment
Members of the Medicine Discharge Kaizen Team at London Health Sciences Centre.
THE DEPARTMENT OF MEDICINE CREATED A STRATEGIC PLAN, TRAINED THEIR PHYSICIANS AND CLINICAL STAFF ON LEAN SIX SIGMA AND HELD A RETREAT TO DEVELOP AN IMPROVEMENT PLAN FOR LONG LENGTHS OF STAY ON THE MEDICINE INPATIENT UNIT. process, bullet rounds, seven day a week Allied Health, patient education, medicine post discharge support including follow-up phone calls, patient mobility, and pharmacy medication reconciliation done at admission and discharge. Patient Oriented Discharge Summary (PODS) and discharge checklists were also piloted. To manage these concurrent initiatives, hospital leadership and physicians continued to engage in house project management, process improvement, and decision support resources to keep initiatives on track, ensure sound process improvement methodologies were used, and to validate outcomes. The result of implementing each of these initiatives have been measured
independently, but the collective result in the University Hospital (UH) Medicine program was a reduction of the average acute length of stay by 1.1 days and a concurrent reduction in the 30-day all cause urgent readmission by one per cent. Overall the 90th percentile for Emergency Department length of stay at UH went from worst performing in F2014/15 (34.73 hours) to best in F2016/17 (16.40 hours) amongst peer teaching hospitals in Ontario. Victoria Hospital also saw remarkable improvements from 29.97 hours in F2014/15 to 24 hours in F2016/17. Impact to patient access and flow has been significant, and the overall quality of care for patients has also
been enhanced. “Through our efforts, our discharges are better prepared and transitional care is improved,” says Calvin. The Medicine program still recognizes that they have more to do. “I always think we can do better,” says Calvin. “These efforts have been instrumental in demonstrating what can be done with a little effort, open minds, and teamwork.” Next up for the department is a focus on; a balanced scorecard by department, division, team and the individual, moving patient oriented discharge summary (PODS) and physician checklists to electronic formats with the support of our Information Technology Infrastructure department, and finally, a renewed focus ion Quality Based Procedures (QBPs) throughout the department. “Our focus needs to be on continuing to create innovations in quality and process improvement,” says Calvin. “Patience is necessary, but you need to set a high standard for yourself and H your organization.” ■
Maurice Williams is a Process Improvement Consultant, and Sarah Muto a Project Consultant at London Health Sciences Centre. 24 HOSPITAL NEWS JUNE 2017
FROM THE CEO’S DESK
Broadening the role of a hospital By Sarah Downey have a passionate belief that hospitals need to do more than treat sick people (and deliver babies). Hospitals reside in real communities, serve and employ its neighbours, fundraise locally, and have adapted over years to changing needs. We all need to care about the health of our communities. There are many approaches required to measure and qualify the health of those we serve. First we pull up health indicators such as birth, premature mortality and smoking rates. We also look at system level indicators like cancer screening, access to family doctors and Emergency Department usage. We also look at socio-economic statistics that bear the most weight on the health of a community – like income, education, housing, and immigration. For many years, we have published a profile of our community on our website.
the Michael Garron Hospital in memory of their son who died of cancer. Across the Toronto East Health Network, we serve 22 distinct neighbourhoods, totaling 400,000 residents. While the overall population is not growing, its inequities are. Elevated rates of chronic disease, premature mortality and mental health and addiction challenges are predominant in a diverse population comprised of 40 per cent immigrants and many newcomers who speak over 50 languages. We serve one neighborhood with an incredibly high birth rate where the neighbourhood beside it has a high proportion of isolated seniors. “The Hospital Care for All Report” published by the Centre for Urban Health Solutions in 2012, in fact, identified Michael Garron Hospital as serving the largest proportion of low income patients relative to high when compared to all other Toronto Central Local Health Integration Network (LHIN) hospitals.
TO HELP IMPROVE THE LIVES AND HEALTH OF THOSE IN OUR COMMUNITY, THE HOSPITAL MUST WORK OUTSIDE OUR WALLS AND WITH OUR PARTNERS In addition to the numbers, it’s important to capture the stories and struggles of those we serve. We, do this in a variety of ways from Patient Experience Panels, Community Advisory Council, Patient Video Program and by incorporating patient stories into daily huddles on units. We have an inventory of 1,950 stories from patients and their families collected over three years. It was this deeply held belief that led us to our new vision to: Create Health. Build Community. This new vision is an explicit recognition of the need to shift in direction for this hospital and local health system. In recognition of the more expansive role of a hospital in our community and a large philanthropic gift, we renamed ourselves from the Toronto East General Hospital to the Toronto East Health Network. And, to recognize the generosity of the Garron Family who donated $50M to our cause we renamed the hospital at the heart of the Network, www.hospitalnews.com
It is clear. In order to help improve the lives and health of those in our community, not just treat their illnesses, the hospital cannot do it alone. We must work outside our walls and with our partners in health care and beyond, to improve underlying economic and social inequities. And, as hospitals, we need to be seen as enablers of population health and community building. Two large community housing complexes in our catchment area result in 4400 visits annually to our emergency room – that’s one person every two hours. It is clear an inspectoral approach is needed. As one example, noticing an increase in patients’ with hepatitis C virus (HCV), Michael Garron Hospital set up a HCV clinic within the hospital. The intent was to help patients improve access to anti-viral medications in hopes of curing their HCV, improving their health and preventing hospitalization. However, the traditional structure of a hospital-based clinic
didn’t work well. The patients were some of the most marginalized in our community. Many had substance abuse challenges, underlying mental health conditions or were under-housed. Many had all of the above. These are the statistics that don’t get captured in a funding formula or aggregate statistics. A unique program had to be developed for these people. In this case, the South Riverdale Community Health Centre, Regent Park Community Health Centre and Sherbourne Health Centre had the counseling services, housing workers, peer support services and primary
care that these people were looking for. They just needed infectious disease medical services to complete the package. And so the Toronto Community Hepatitis C Program was born. Some of our more recent work has been as a hospital resources partner for the East Toronto Sub-Region to advance the work of Ontario’s Patient First Act in improving access to primary care and connections in the community. One of their first initiatives was to develop comprehensive maps that show hotspots – areas with concentrated populations at risk of higher emergency department utilization and/or limited primary care. Based on these maps, the group then began working directly with providers in the area to work on teambased solutions tailored to the stories and needs of the community. MGH is committed to working with community members and partners to understand the stories and underlying issues that need to be addressed in order to deliver excellent care and improve people’s overall health and well-being. We will however need policy and funding to recognize this too. Only then will we be able to create the equitable healthcare system we all want. Only then will we be able to creH ate health and build community. ■
Sarah Downey is President & CEO at Michael Garron Hospital.
JUNE 2017 HOSPITAL NEWS 25
Medical assistance in dying Is it ethical for residential hospices to opt-out?
By Jonathan Breslin
y now the general public is probably well aware that religiously-affiliated health care organizations in Ontario will not provide medical assistance in dying (MAiD). But these are not the only facilities that are opting out. Over the past year several media stories have reported decisions by various hospice organizations to opt out as well. Some of these are individual residential hospices, while others are hospice organizations that include residential hospices and professionals who provide home palliative care services. In the case of religious organizations, such as Catholic hospitals, the rationale for opting out is fairly obvious. These organizations are required to provide service consistent with the religious beliefs of their tradition, and if the religious beliefs clearly forbid the intentional ending of a human life, they don’t have much wiggle room. In the case of hospice, however, the rationale isn’t quite as obvious. Why is it that
THE SIMPLE REASON IS THAT MANY WHO WORK IN HOSPICE SEE MAiD AS DIRECTLY CONFLICTING WITH THE PHILOSOPHY OF HOSPICE AND PALLIATIVE CARE
some hospice organizations are deciding not to provide MAiD? The simple reason is that many who work in hospice see MAiD as directly conflicting with the philosophy of hospice and palliative care. Consider this statement from the website of Hospice Palliative Care Ontario: “Quality hospice palliative care neither hastens death nor prolongs life. The goal of hospice palliative care is to improve the quality of life for patients and their families facing problems associated with life-threatening illness” (emphasis added). This is borrowed directly from the World Health Organization’s definition of palliative care.
On its own this reason isn’t very convincing. After all, medicine has evolved a great deal over its history and palliative care can evolve too (there was once a time, not too long ago, when withdrawing life-sustaining treatment was considered in direct conflict with the philosophy of medicine). The argument “because this is how we’ve always done things” is never a convincing reason for why things have to continue to be done that way. On a more practical level, however, the concern of many in hospice and palliative care is that providing MAiD would further the already problematic association many people make between hospice/
palliative care and death. The concern is that the public may become fearful and avoid hospice and palliative care (more than they already do) because “that’s where they end people’s lives.” We can accept this as a legitimate concern but still inquire as to the ethical considerations on the other side of the ledger – and there are several. For one, a decision by a residential hospice to opt out of MAiD does impede access to the service. It is simply not easy for dying patients to shop around for a willing provider, especially since there a very limited number of residential hospices in Ontario. In some cases a transfer to another facility may not be feasible, which would directly violate the patient’s right to access MAiD. This is especially true if a critical mass of residential hospices choose to opt out. Second, while there is a concern that some people may avoid hospice out of fear of being put to death, it is at least equally likely that a policy to opt out of MAiD will hinder access to hospice for
Jonathan Breslin PhD, is an ethicist for Southlake Regional Health Centre and Mackenzie Health. 26 HOSPITAL NEWS JUNE 2017
Learning to let go
RN-turned-author Yvonne Heath helps others understand the importance of end-of-life planning
By Victoria Alarcon
many patients. At last check approximately 80 per cent of Canadians support the right to seek MAiD. An opt-out policy essentially forces an unfair choice on dying patients: to access residential hospice you may have to give up your right to access MAiD. It is not difficult to imagine that there will be patients who decide against admission to residential hospice because they don’t want to risk not being able to access MAiD. Third, there is the impact on patients in residential hospice to consider. These are patients at the end of their lives who have been fortunate to access a comfortable and supportive environment in residential hospice, who will be required to transfer to another facility to carry out their final wish. This may mean spending their last hours in a hospital, or traveling quite a distance to another residential hospice if there even is one with an available bed. This can result in added discomfort and anxiety for the patient, not to mention the impact on H the patient’s significant others.■
vonne Heath RN remembers the day she came across a woman in her 60s while working at a chemotherapy/infusion clinic in central Ontario. She could not believe what she was seeing. The woman was short of breath, and her feet, legs and abdomen were swollen as she waited to be seen, unaware she was nearing the end of her life. “She wasn’t even going to make it through her next chemotherapy treatment,” says Heath, who, after 27 years of nursing, saw the signs. Heath called the woman’s oncologist to confirm she was not told of her condition. She found out the oncologist was not good at discussing death. “I was devastated because I naively believed that every oncologist should and would be great at having these brave and honest conversations,” she says. Heath told the woman the reality of her situation and encouraged her to ask her doctor about her options in terms of palliative care. She answered the woman’s questions and reassured her that she would receive the best care possible. Within two weeks of that visit, the woman died at home. “That was an eye-opener for me,” Heath admits, saying the encounter in 2014 made her realize just how ill-prepared many healthcare professionals are to have those difficult conversations with their patients, which can result in excessive suffering. Looking back, that experience, coupled with a career full of similar experiences, set her on the path to write a book about how to embrace death, and how to approach conversations about end-of-life wishes, quality vs. quantity of life, and tips for self care. Love Your Life to Death was published in 2015 and includes the stories of patients Heath has met, and what they have taught her. Heath graduated from the nursing program at Centennial College in 1987. Over the past 30 years, she has worked in several hospitals and healthcare organizations in Canada and the U.S. Her first position was at Toronto East General Hospital (now Michael Gar-
ron Hospital) on the medical unit in 1988, where she cared for patients with chronic diseases. Within a few years, Heath relocated to the U.S., where she worked for the Roswell Cancer Institute in Buffalo, then became a traveling nurse in Louisiana before moving back to Canada and working at Huntsville District Memorial Hospital in 1997. She says that during this time she saw patients suffer anxiety and fear because they avoided discussing death. In 2001, when she was offered an opportunity to cover a maternity leave in the chemotherapy clinic, Heath saw first-hand the benefits of having an endof-life care plan for patients and families. At the clinic, she met a patient named Kevin, a man in his 40s who had gone through chemotherapy for two years. He knew he was nearing the end, and Heath recalls his gracious and positive attitude right up until his death. After he died, she spoke with his mother, asking how she was able to cope with her child’s death. She learned it was because Kevin took the time to speak openly about his fate, and what he wanted the end of his life
to look like. The experience made her realize that we all need to talk about death more openly. Heath was still working in chemotherapy when she accepted a job at the South Muskoka Memorial Hospital in 2010. Despite knowing how important it is to talk about end-of-life, she noticed many patients and families still were not having those conversations. “One thing after another just kept confirming I needed to do something,” she says about the push to begin writing her book. In 2015, Heath put her nursing career on hold to promote the book and raise awareness of her message. She also works as an inspirational speaker and host for Rogers TV, interviewing people she says are grieving well, living well and dying well. Her goal is to spread her message beyond her home province in hopes of changing the way we view death in society. “My big message is to empower communities and professionals to live life to the fullest, learn to grieve and support others, and have “the talk” about endof-life long before it arrives,” says Heath. H This will help “…to diffuse the fear.” ■
Victoria Alarcon is editorial assistant for The Registered Nurses Association of Ontario. This article was originally published in the March/April issue of Registered Nurse Journal, the bi-monthly publication of the Registered Nurses’ Association of Ontario (RNAO).
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Shared learning to advance medication safety:
A multi-incident analysis on metformin-related medications By Mi Qi Liu and Certina Ho s the first line pharmacological therapy for type 2 diabetes, metformin plays a crucial role in disease management, and it is among the top 10 prescription medications in 2015. With advancement in the pharmaceutical industry, newer classes of diabetes medications have been developed, with examples including the sodium-glucose
METFORMIN PLAYS A CRUCIAL ROLE IN DISEASE MANAGEMENT, AND IT IS AMONG THE TOP 10 PRESCRIPTION MEDICATIONS IN 2015 co-transporter 2 (SGLT2) inhibitors and dipeptidyl peptidase-4 (DPP-4) inhibitors. Considering factors such as
Table 1. Theme 1 – Therapeutic role in diabetes management In order to achieve optimal therapeutic effect and the goal of managing diabetes, metformin treatments often involve dosing adjustments and the continuous efforts of dosing maintenance. Furthermore, tablet-splitting is often necessary to ensure correct dosing. Combination products containing metformin may be utilized, considering factors such as disease progression, patient adherence, convenience, and cost.
disease progression and patient adherence, products combining metformin and other classes of oral diabetes med-
ications including the newer classes aforementioned have been utilized. Yet, metformin and combination products containing metformin can also be a double-edged sword. Listed in the Institute for Safe Medication Practices (ISMP) High-Alert Medications in Community/Ambulatory Healthcare, metformin, if used incorrectly, can pose significant threats to patient safety.
Table 2. Theme 2 – Choice of agent Incorrect choice of agent, which can encompass the inappropriate selection of drug, formulation and strength, can either result in sub-optimal management of diabetes potentially leading to metabolic complications in the worst case scenario or expose patients to risks such as hypoglycemia. Subtheme – Drug selection
Subtheme - Dosing adjustment and maintenance Potential Contributing Factors
Therapeutic management itself is associated with a fair amount of dosing adjustments, based on patients’ response/ tolerance to the medication or the control/progression of the medical condition
Actively engage patients in their health/disease management, as patient’s awareness and understanding of dosing regimen changes can serve as an independent double check; remind and train pharmacy staff to check with patients for further information when they present to the pharmacy with prescriptions of possible dosing adjustments, or proactively contact patients via phone if they are not physically present in the pharmacy before preparing the prescription.
Copying of previous prescriptions on patient profile Mixing up of the old and new dosing regimens at the prescribing stage
The “copy” functionality is readily available in most pharmacy software systems to improve pharmacy workflow. Policies may be considered within the pharmacy to limit the use of the “copying” function from previous prescriptions (where applicable). Emphasize to pharmacy staff and remind them of the importance of timely and effective communication with prescribers when encountering concerns related to dosing adjustment and maintenance.
Subtheme – Tablet-splitting Potential Contributing Factors
Tablet-splitting may be required/needed when patients undergo dosing adjustments or have difficulties swallowing tablets
Perform independent double checks during prescription preparation, especially for medications with special prescriber/patient requests such as tablet-splitting.
28 HOSPITAL NEWS JUNE 2017
Potential Contributing Factors Look-alike/sound-alike medications Mixing up of metformin, metformin-containing combination products and other classes of oral diabetes medications
Recommendations Create a section on the shelf where the most commonly dispensed metformin related products, formulations and strengths are organized and away from the products dispensed less frequently (creation/organization will be based on each pharmacy’s individual product demand) – in an effort to minimize the chance of accidentally selecting the wrong one out of a pool of look-alike/ sound-alike products, when all are kept in close proximity.
Subtheme – Formulation Provide regular educational updates and training selection and Subtheme – to pharmacy staff regarding new drug information Strength selection (including new formulations and available strengths of existing medications). Potential Contributing Offer patient education and counselling for both new Factors and refill prescriptions to serve as the final independent Environmental factors such as distractions from double check for production selection and therapeutic appropriateness before the medications are handed other pharmacy staff/ over to patients. patients, heavy workload and staff shortage
Lack of knowledge or awareness of pharmacy staff on the availability of various formulations and strengths of a medication Confirmation bias
SAFE MEDICATION In order to identity potential contributing factors and improve medication safety via possible error-reduction strategies, ISMP Canada conducted a multi-incident analysis on metformin-related medications. Relevant incidents in 2015 were extracted from the ISMP Canada’s Community Pharmacy Incident Reporting (CPhIR) program (http://www.cphir.ca). Three main themes were identified, with sub-themes extending from each main theme, as presented in Tables 1, 2 and 3. Learning from medication incidents is a critical step in safety enhancement. It is hoped that findings from this multi-incident analysis can provide a platform for healthcare professionals to reflect upon previous errors and facilitate shared learning. The potential recommendations provided in this article attempt to aid with the adoption of system-based error reduction strategies, which would then contribute to a safe medication practice environment and H safety culture. ■
Table 3. Theme 3 – Prescription preparation As the mainstay in type 2 diabetes management, metformin is dispensed frequently; combination products containing metformin are used often as well. Prescription-preparation incidents involving technical errors often include incorrect data entry and blisterpack (or multi-medication compliance aids) preparation. Subtheme - Data entry of prescription and patient care information Potential Contributing Factors Recommendations External influences such as distractions Incorporate independent double checks into workflow whenever possible. and heavy workload, potentially leading to an increased chance of technical errors Confirmation bias Subtheme – Blister pack (or multi-medication compliance aids) preparation Potential Contributing Factors Recommendations Complexities and vulnerabilities Create a list of high-alert medications that are frequently used or dispensed in blister associated specifically with blister pack packs (or multi-medication compliance aids) based on the pharmacy’s individual (or multi-medication compliance aids) product demand. This list can be displayed in the dispensary area as a reminder for all preparation staff members. Adopt a checklist that outlines the procedures of blister pack (or multi-medication compliance aids) preparations, with an extra section of precautions/tips specifically for high-alert medications. Consider redesigning the work environment, so that there is a specific workspace for blister pack (or multi-medication compliance aids) preparation, in order to minimize distractions and mixing up with other prescription-preparation procedures.
Mi Qi Liu 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.
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QJune 3, 2017 Canadian Nursing Informatics Association 2017 Conference Toronto, Ontario Website: www.cnia.ca QJune 4–7, 2017 eHealth Conference & Tradeshow Toronto, Ontario Website: www.ehealthconference.com QJune 12–13, 2017 National Health Leadership Conference Ottawa Conference & Event Centre, Ottawa Website: www.nhlc-cnls.ca QAugust 8–10, 2017 FIME – Largest Medical Trade Exhibition Orlando, Florida :HEVLWHZZZÀPHVKRZFRP QAugust 20–23, 2017 CMA 150th Annual Meeting & General Council Québec Convention Centre, Québec City Website: www.cma.ca QS eptember 26-27, 2017 5th Annual National Forum on Patient Experience Holiday Inn Toronto International Airport, Toronto Website: www.patientexperiencesummit.com QSeptember 28, 2017 EMR: Every Step Conference Toronto Congress Centre, Ontario Website: www.ontariomd.ca QOctober 22–24, 2017 CAPHC Conference Montreal, Québec Website: www.caphc.org QOctober 26-27, 2017 Paediatric Emergency Medicine Conference Peter Gilgan centre for Research and Learning, Toronto Website: www.sickkids.ca Q November 6–7, 2017 HealthAchieve Toronto, Ontario Website: www.healthachieve.ca Q November 13-16, 2017 MEDICA – World Forum for Medicine Düsseldorf, Germany Website: www.medica-tradefair.com To see even more healthcare industry events, please visit our website www.hospitalnews.com/events
30 HOSPITAL NEWS JUNE 2017
Multitom Rax (Robotic Advance X-ray) iemens Healthineers has received approval from Health Canada for the Multitom Rax (Robotic Advance X-ray), a universal diagnostic imaging system that enables a wide range of examinations in multiple clinical areas – from emergency medicine and interventional, to pain management and orthopedics, and from conventional 2D radiography to fluoroscopy examinations and angiography applications – all in one room using one X-ray system. The world’s first Twin Robotic X-ray system, the Multitom Rax boasts a unique design that enables, for the first time, the acquisition of 3D natural weight-bearing images “With the Multitom Rax, Siemens is proud to introduce the world’s first Twin Robotic X-ray system,” says Richard Newman, Business Manager, X-ray Products. “This universal X-ray system delivers unprecedented versatility for healthcare facilities. Now, clinicians can perform a multitude of imaging exams in one room without moving the patient. With the Multitom Rax, we’re opening a new chapter in X-ray technology.” The unique open design of the Multitom Rax Twin Robotic X-ray system features a height-adjustable patient table and two independent, ceiling-mounted robotic arms for the X-ray tube head and the flat-panel detector for almost unlimited positioning freedom anywhere in the room. Both ro-
botic arms can be moved into position automatically or manually with servo motor support to make fine adjustments. While one robotic arm moves the X-ray tube, the other arm carries the 43cm x 43 cm flat panel detector, which can acquire static, dynamic, and Real 3D sequences. The operator is always in control of the system’s movement and able to position both robotic arms precisely and safely around the patient. The Multitom Rax Twin Robotic X-ray system enables, for the first time, the acquisition of 3D imagesunder the patient’s natural weight-bearing condition. With Multitom Rax, you have unique options for determining the malpositions and the cause of pain. Acquire Real 3D images, in the position where your patient feels pain: lying, sitting, or standing. Real 3D helps you gain new insights, increase the accuracy of your diagnosis and treatment planning, and spare your patients additional pain – while accelerating your procedures. Conventional 2D X-rays do not always reveal fine hairline fractures in the bone. In cases of a suspected bone fracture, the patient historically has required a computed tomography (CT) 3D image to confirm the diagnosis. With the Multitom Rax Twin Robotic X-ray system, a 3D image can be acquired on the same system, so the patient does not have to wait for a future appointment or be transferred to a CT H system. ■ www.hospitalnews.com
The MolecuLight i:X
A Canadian invention revolutionizing wound care hen Dr Ralph DaCosta, a cancer scientist at the Princess Margaret Cancer Centre in Toronto, first discovered that his optical fluorescence camera could detect bacteria, almost 11 years ago, he may not have anticipated the impact his invention would be having in wound care today. He founded the company, MolecuLight Inc. in June 2012 and after a few years of product development and clinical trials, the product received Health Canada Approval in October 2015. Today, the patented technology Dr DaCosta developed, MolecuLight i:X, allows clinicians to visualize the presence and distribution of potentially harmful bacteria in and around wounds without patient contact or need for contrast agents, in addition to providing quick and easy wound area measurement. The deviceâ€™s handheld size and intuitive user interface are designed for use by clinicians of all skill levels as well as across hospitals and
wound care clinical settings. Real-time fluorescence information on bacterial presence and distribution obtained via bacterial fluorescence imaging, in combination with best clinical practices, can guide early interventions (i.e. wound debridement) to reduce bioburden, promote wound healing, and decrease wound care costs associated with delayed wound healing and ineffective treatments. The MolecuLight i:X is a state-ofthe-art fluorescence imaging device that provides instant visual detection and documentation of bacteria in wounds that would otherwise be invisible. When excited by a specific wavelength of light, tissues (i.e. collagen) emit a characteristic green fluorescence and bacteria emit either a red fluorescence colour (caused by endogenous porphyrin molecules) or a cyan-fluorescence colour (caused by endogenous pyoverdine molecules), the latter attributed specifically to Pseudomonas spp. The MolecuLight i:X Wound Intelligence Device also allows for stan-
dard wound images to be captured and wound areas to be quickly and accurately measured for documentation. Pathogens detected by the MolecuLight i:X include, the following clinically relevant bacterial species: Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus), Pseudomonas aeruginosa, Escherichia coli, Staphylococcus lugdunensis, Enterococcus spp, Proteus spp, Klebsiella pneumonia, Beta-hemolytic Streptococci (Group B), and Enterobacter spp. Clinicians around the world are using the MolecuLight i:X for fluorescence image-guided sampling and debridement, informing antimicrobial stewardship practices and treatment selection monitoring and documentation of treatment effectiveness and facilitation of patient education and engagement in their care. Though the link between bioburden and delayed wound healing is universally accepted innovations have overwhelmingly focused on methods to de-
crease bioburden (e.g. antimicrobials) while (technology) innovations in actual diagnosis of bioburden have lagged behind. With the emergence of handheld bacterial fluorescence imaging at the bed side, wound care clinicians can finally benefit from medical imaging advances that have been sorely lacking in this field. The MolecuLight i:X represents a new frontier in wound care in which bioburden can be visualized in real-time and evidence-based treatment selections made to specifically target bioburden on an individualized patient level. Treatment effectiveness can now be evaluated in real-time, and wound care costs associated with inappropriate selection of therapies decreased. The MolecuLight i:X is currently approved by Health Canada and has CE marking. It is pending FDA De Novo approval. The MolecuLight i:X product and related accessories are distributed H by Smith & Nephew. â–
New mobile device disinfection solution:
Diversey Care rolls out SKYÂŽ 7xi ealed Airâ€™s Diversey Care division recently introduced the SKYÂŽ 7xi, a mobile device disinfection solution for healthcare environments. In one minute or less, SKY safely disinfects tablets and smartphones with high-intensity ultraviolet (UV) light that penetrates the cells of pathogens such as viruses, bacteria and spores. â€œPhones and tablets, which are being used with increased frequency within healthcare facilities, are extremely high-touch surfaces and potential sources of healthcare associated infections,â€? says Carolyn Cooke, Vice President Healthcare North America, Diversey Care. â€œSKY is portable and easy to use, enabling fast and effective disinfection of facility-owned, healthcare worker and visitor devices and allowing organizations to create safer and more satisfying environments of care.â€?
The SKY 7xi disinfects devices with targeted UVC light rather than fumes or chemicals, making it a safe and effective method for reducing handheld device pathogen transmission. It achieves up to a 5-log reduction in harmful pathogens including MRSA, VRE, MDR-Gram negative, norovirus and C. diff spores. With desktop, wall mount and mobile cart options, SKY can be placed in multiple locations. The unique design provides 360-degree coverage and can accommodate devices up to 1 inch thick by 8 inches wide and 12 inches H long. â–
Registered Nurses Registered Practical Nurses Wound Care/Enterostomal therapy For Clinical and Virtual roles across Canada
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JUNE 2017 HOSPITAL NEWS 31
Focus: Health Care Transformation, eHealth, Mobile Health and Medical Imaging.