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Contents October 2017 Edition
IN THIS ISSUE:
Preventing medical errors during transfer of care
1RYHPEHUĂ?Ă? Metro Convention Centre Toronto, Ontario
â–˛ Cover story: Making the invisible visible
OCTOBER 2017 HOSPITAL NEWS 17
â–˛ Health Achieve Special
â–˛ Reducing stigma, gaining compassion
COLUMNS Editorâ€™s note ....................4 In brief ..............................6 Hospital Security ...........31 Evidence Matters ...........34 From the CEOâ€™s desk .....39 HN Podium .................... 44 Safe Medication ............45 Careers ..........................46
â–˛ Withdrawal management care
â–˛ Trauma-informed practice
Provincial governments will bear the burden of
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legalized marijuana T
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By Malcolm Bird he Trudeau government is set on legalizing marijuana by the summer of next year. While they will enjoy the political payoff of appearing progressive on this matter, all of the associated problems and the logistics of legalizing pot will fall on the shoulders of the provincial governments. There are strong correlations between how a drug or a particular indulgence, such as gambling, is made available to the public and the propensity for individuals to indulge in it and the negative health and social outcomes associated with its use. In other words, it matters how we legalize marijuana not just that we legalize it. Canadian provincial governments might want to draw lessons from the last time an illegal substance was legalized – alcohol – following prohibition in the late 1920s, as well as insights from the current public health efforts to eliminate tobacco use. For starters, it might make sense to make acquiring recreational marijuana reasonably expensive and somewhat difficult. All provincial governments (except Alberta, which eliminated their liquor board), should consider selling only recreational marijuana in government liquor stores because they have the secure infrastructure in place to deal with a drug with narcotic properties. They also have well-trained and professional staff and secure logistical facilities to ensure it is distributed in a socially responsible manner. This will eliminate the potential
enormous political problem of licensing and determining where (and when) dispensaries will be permitted to open and operate. It will also eliminate the possibility of organized criminal elements establishing and operating dispensaries. Most critically, the government should not only control the retail end of marijuana, but the wholesale side as well. They should sell recreational marijuana as a “store brand” in plain packaging and offer only a few different types. This will prevent manufacturers from developing and promoting specific brands of pot through advertising campaigns. “Store brands” are more profitable for retailers largely because they gain more control over manufacturing and cut out supplier middlemen. As the sole wholesaler in a province, provincial liquor boards will be able to drive hard bargains with manufacturers. There must also be significant taxes imposed on marijuana. But taxes will not earn significant revenues as the government must also cover the costs associated with its (mis)use. Government revenues from the sale of pot will already be restricted given the decline in pot prices over the last 25 years: a gram of pot in the 1990s cost $15 while a gram today cost less than $10 on the illegal market. Contrary to popular belief, the legalization of marijuana will require an increase in police and legal efforts to stamp out the black market. Continued on page 7
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Monthly Focus: Technology And Innovation In Healthcare / Patient Experience/Pharmacology: Digital health advancements and new technology in healthcare. Programs and initiatives focused on enhancing the patient experience and family centred care. An examination of safe and effective use of medications in hospitals and clinical pharmacology.
Monthly Focus: Year In Review/Future Of Healthcare/Accreditation/ Hospital Performance Indicators: Overview of advancements and trends in healthcare in 2017 and a look ahead at trends and advancements in health care for 2018. An examination of how hospitals are improving the quality of services through accreditation. Overview of health system performance based on hospitals performance indicators and successful initiatives hospitals have undertaken to measure and improve performance.
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New study shows people with schizophrenia are dying younger eople with schizophrenia have a mortality rate that is three times greater each year than those without schizophrenia, and die on average, eight years earlier than people without schizophrenia according to a new Ontario study by researchers at the Centre for Addiction and Mental Health (CAMH) and the Institute for Clinical Evaluative Sciences (ICES). This study was published recently in CMAJ (Canadian Medical Association Journal). “Our study shows that individuals with schizophrenia are not benefitting from public health and health care interventions to the same degree as individuals without schizophrenia,” says Dr. Paul Kurdyak, senior author, CAMH and ICES Scientist and Director of Health Outcomes with the Medical Psychiatry Alliance (MPA), which
THE STUDY SHOWED THAT INDIVIDUALS WITH SCHIZOPHRENIA HAD HIGHER RATES OF DEATH FOR ALL CAUSES INCLUDING CARDIOVASCULAR DISEASES AND CHRONIC MEDICAL CONDITIONS supported the study. “As healthcare providers, it is our responsibility to work together across our healthcare system to provide these patients with better, integrated physical and mental healthcare. By not doing so, there are dire, tragic consequences and shortened lives.” Researchers studied all deaths during the 20-year period between 1993 and 2012 in Ontario and examined the deaths annually. They identified all people with schizophrenia
and categorized the deaths as occurring among those with and without schizophrenia. The study showed that individuals with schizophrenia had higher rates of death for all causes including cardiovascular diseases and chronic medical conditions. Cardiovascular disease, such as heart attack or stroke, is a leading cause of death in the general population. However, while the rest of Ontario has experienced a reduction in
cardiovascular deaths, the study shows that individuals with schizophrenia are not experiencing the same reduction. People with schizophrenia have many cardiovascular risk factors such as diabetes, obesity, smoking and sedentary lifestyle, but are more burdened by these risk factors than those without schizophrenia. Medications used to treat schizophrenia can cause weight gain and the development of diabetes. “It seems that people with schizophrenia haven’t benefitted from the advances that we have made for patients living with chronic physical illnesses in the general population,” says Dr. Kurdyak. “A healthcare system that can address the mortality gap we have observed in this study would truly be a high performing healthcare H system.” ■
One in five opioid overdoses involves alcohol espite a decline in alcohol involvement in opioid-related deaths over past decade, one in five fatal opioid overdoses still involved alcohol in 2013, according to a new study by researchers at the Institute for Clinical Evaluative Sciences (ICES), St. Michael’s Hospital and the Ontario Drug Policy Research Network (ODPRN). “While it is well known that patients receiving opioids should refrain from alcohol consumption, we found that 22 per cent of the opioid-related deaths
between 1993 and 2013 involved alcohol,” says Tara Gomes, a scientist at ICES and the Li Ka Shing Knowledge Institute of St. Michael’s Hospital and a principal investigator of ODPRN. The 20-year study of all opioid-related deaths in Ontario from 1993
legalized marijuana Continued from page 4
CONTRARY TO POPULAR BELIEF, THE LEGALIZATION OF MARIJUANA WILL REQUIRE AN INCREASE IN POLICE AND LEGAL EFFORTS TO STAMP OUT THE BLACK MARKET When government liquor commissions took over alcohol distribution bootleggers had to be eliminated or they would both undercut the state’s monopoly on sales and its ability to control how it was sold and consumed. Policies will also need to be developed to allow the police to determine which pot has been legally procured and which has not. Since federal legislation will permit individual Canadians to grow their own marijuana plants at home, verifying legally procured marijuana will be considerably more difficult. Provinces should also be wary about offering edible pot. Ingesting marijuana substantially increases its potency and is often sold as child-attractive products such as brownies, gummy bears and the like, substantially increasing the potential for accidental consumption – including by children. If provinces do decide to sell edibles, they should ensure that dosage amounts per item are consistent amongst different products, and are presented in a manner that is easy for consumers to understand.
declined from 38 per cent in 1993 to 22 per cent by 2013,” adds Gomes. The researchers add that the study showed a seven-fold increase in accidental opioid-related deaths over the study period. By 2013, nearly twothirds of all opioid-related deaths in Ontario were accidental and did not involve alcohol. “The steep increase in opioid-related deaths in Ontario has been driven by accidental deaths and coincided with the introduction of long-acting oxycodone to the public drug formulary in Ontario in 2000.” adds Gomes. This highlights the contribution of prescribed opioids on rising rates of fatal opioid overdoses in Canada, and demonstrates that the majority of these deaths may be avoidable. The study “Prevalence and characteristics of opioid-related deaths involving alcohol in Ontario, Canada,” was published in the journal Drug and H Alcohol Dependence. ■
WE FOUND THAT 22 PER CENT OF THE OPIOID-RELATED DEATHS BETWEEN 1993 AND 2013 INVOLVED ALCOHOL
The provinces will also need to establish a permit and purchase tracking system. Such a practice would allow the government to determine who is purchasing marijuana and if individual sales could be tracked to original purchases, this would aid in preventing marijuana ending up in the hands of minors. Persistent violators who resell marijuana, for instance, could have their permits revoked. Governments should consider restricting the purchase age to 21 as recommended by many medical practitioners, and in order to limit consumption and normalization of its use, there should also be no advertising or promotion of marijuana. I make these suggestions as a way for provincial governments to make the best of a very difficult situation. Consumption of marijuana will likely rise, as will the associated costs of dealing with its effects on individuals. Like many issues in Canadian federalism, this is a classic one where the federal government is wholly detached from the reality of implementing the policy, H and the real costs associated with it. ■
to 2013 showed that the rate of opioid-related deaths increased 288 per cent from 11.9 per million in 1993 to 46.2 per million in 2013. The rate of opioid-related deaths without alcohol involvement increased 388 per cent from 7.4 per million to 36.1 per million, while deaths involving alcohol increased by 125 per cent from 4.5 per million to 10.1 per million. The researchers identified 6,702 opioid-related deaths between 1993 and 2013, of which 1,496 involved alcohol. “An important finding of this study was that, while the annual number of opioid-related deaths involving alcohol rose, the proportion of opioid-related deaths involving alcohol
Innovation to Impact
Malcolm G. Bird teaches political science at the University of Winnipeg and is an expert advisor with EvidenceNetwork.ca. www.hospitalnews.com
OCTOBER 2017 HOSPITAL NEWS 7
Making the invisible visible: Mental health system performance By Paul Kurdyak “I had very little care for a lot of difficult symptoms (only a few walk-in clinic visits) until I was in crisis. My family took me to the ER, where I waited for many hours to see someone. After that wait I saw the ER doctor, but not a mental health professional. I was discharged in the early morning with no follow-up of any kind. My parents were told that I was just behaving badly. I later learned that there was a mental health team working at that ER, but was not referred to them. I had two more similar experiences in the ER over a couple of years, before I was referred to the appropriate type of care.” (Person with lived experience) tories of difficulty accessing services and fragmented care once services are accessed like the one above are all too common. There are repeated calls to address the shortcomings of the mental health system. However, as tragic as the stories are, it is
hard to respond meaningfully to them because there is not enough information to guide and monitor investments in the mental health system. In a recently released report entitled “Toward Quality Mental Health Services in Canada: A Comparison of Performance Indicators across five
Provinces” a team of researchers from five provinces (BC, Alberta, Manitoba, Ontario and Quebec) developed, analyzed and produced mental health system performance indicators. This is the first time that mental health system performance has been compared across provinces. There were six indi-
cators in total, measuring access to primary care for individuals with mental illnesses and addictions, the use of the Emergency Department as a first point of contact for mental illnesses and addictions, suicide attempts and completions, and overall mortality rates. A key finding was poor access to mental health and addictions care for children and youth. Individuals between the ages of 20 and 24 had the lowest rates of regular access to a family physician, and males had worse access than women. This is problematic given that this age group is experiencing their first onset of mental illnesses and addictions. We also measured the proportion of individuals who had mental health or addiction-related Emergency
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COVER Figure 4: First treatment contact is ED â€“ 3-year medians
MULTIPLE RESEARCH STUDIES HAVE DETERMINED THAT INDIVIDUALS FACE AN INCREASED RISK OF SUICIDE AFTER RECENT PSYCHIATRIC HOSPITALIZATION
Department visits with no outpatient (primary care or psychiatrist visits) in the preceding two years (Figure 4). This indicator is a measure of system access, with the Emergency Department as a place where people go because there is nowhere else. Here again, between the ages of 15 and 19 had the highest rates of no prior contact â€“ between 35 and 46 per cent â€“ suggesting that this age group has the greatest struggles with access to care. Youth between the ages of 15 and 19 had the highest rates of hospitalizations for suicide attempts. Continued on page 10
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Making the invisible visible Continued from page 9 In Ontario, the rate was three per 1000 in this age category, and the rate was approximately 10 per 1000 in British Columbia and Alberta, and as high as 18 per 1000 in Manitoba. Timely access can help reduce the impact of mental illness and addiction across the lifespan, including reducing the likelihood that children and youth will attempt suicide as a result of distress and mental illness. As important as results such as poor access for children and youth are, the ability to generate comparable performance indicators across multiple provinces is a milestone achievement. Measurement within the mental health system lags behind other areas of the healthcare system. Consider, for example, the sophistication of cancer care in most provinces. Organized and regionalized cancer care is a result of systematic feedback from ongoing
performance measurement. Across Canada, mental health system performance has been largely invisible, with the result being a persistence of anecdote and an absence of evidence to inform policy. If Canadians are to get the mental healthcare they deserve, we need to have a much better understanding of the status quo so that quality improvement is targeted and equitable. Measurement is the first step to a broader quality improvement agenda. It is time to make the invisible visible so that we map a way forward to addressing the barriers to care Canadians are describing as they try to access services for mental illnesses and addictions. What can we take from the results of our report? First, there is a lot of unmet need among individuals suffering from mental illnesses, particular in youth and young adults. Clinicians
WELL-DOCUMENTED RISK FACTORS FOR SUICIDE INCLUDE A HISTORY OF SELF-HARM, A HISTORY OF SUICIDE ATTEMPTS, BEING DIAGNOSED WITH A MENTAL DISORDER, AND HARMFUL USE OF DRUGS AND/OR ALCOHOL should have a high index of suspicion and inquire about mental health issues. And once detected, we clearly need to ensure that services are accessible, especially for children and young adults. This is particularly challenging since many young adults are mobile and have not had much connection to regular healthcare providers, as our report has shown. We need to continue to measure mental health system performance. You cannot change what you cannot measure. Moving forward, we need to
develop more relevant performance indicators, particularly those that are co-developed with individuals who struggle with mental illnesses. We also need to standardize data and measurement across provinces so that the effort we put into our report becomes routine. Finally, we need to include all provinces and territories so that, nationally, we develop the capacity to learn from one another as we bridge the gap between the current status quo and the future state of better acH cess and quality. ■
Paul Kurdyak is a psychiatrist and Medical Director, Performance Improvement at the Centre for Addiction and Mental Health. He also is a Core Senior Scientist and Lead of the Mental Health and Addictions Research Program at the Institute for Clinical Evaluative Sciences (ICES).
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Research project pilots new illegal drug alert warning system to help prevent overdoses By Tiffany Akins
Sara Young is the Regional Leader, Mental Health & Substance Use at Vancouver Coastal Health.
ancouver Coastal Health (VCH) Harm Reduction staff are working with the BC Centre for Disease Control (BCCDC) on a new research project to develop a more timely and accurate way to communicate information about clusters of drug overdoses and drug contamination alerts. “Vancouver Coastal’s pilot project will give medical health officers access to what’s happening when it’s happening,” says provincial health officer Perry Kendall. “This real time information will help them decide and put into place an immediate course of action to prevent overdoses.” The Real-time Drug Alert & Response (RADAR) project is starting to test several methods of reporting, including an online web form and a texting service at (236) 999-DOPE (3673). In both methods, people can report information such as the date of the overdose, what town and neighbourhood the substance was purchased in, types of substances thought to be used, and the physical description of the substances. Participants can also upload a photo of the drug and/or its packaging. Participants do not have to provide their names or contact information. Both methods are up and running currently and anyone can use them.
Currently, data from several sources, such as BC Emergency Health Services, emergency departments, Insite and overdose prevention sites, is analyzed to find any anomalies in overdoses, which could signal a contaminated batch of drugs on the street. The information is then forwarded to harm reduction service providers to communicate to people who use drugs but these alerts often lag one to two weeks behind the data.
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“253 people died in the VCH region from illegal drug overdose last year,” says Sara Young, Regional Leader, Mental Health & Substance Use at VCH, who is leading the project with Dr. Jane Buxton of the BC Centre for Disease Control. “We desperately need to find a better way to quickly get messages out about bad batches of drugs so that people can take added precautions, and prevent overdosing.” “When service providers relay the alerts to their clients they can also remind them about important harm reduction actions they can take: like not using alone, starting with a small amount, using Insite or an overdose prevention site, and ensuring a takehome naloxone kit is on hand,” says Dr. Mark Lysyshyn, medical health officer at VCH. “This timely and relevant information may help people who use drugs stay safe.” After eight months the project will be evaluated to determine possible future use. “We’re excited about the potential of this reporting tool to help people not just in Vancouver, but also across the
country,” says Buxton. “This pilot project will help us determine what works and what needs to be improved, after which we hope to roll it out in other areas. Information is powerful – it will help us save lives.” The research project is funded by the Vancouver Coastal Health Research Institute. It is one part of a comprehensive response plan focusing on attacking the issue from several angles – preventing overdoses, encouraging safer drug use, and providing treatment options for people with substance use disorders. VCH’s research project supports the work of the Joint Task Force on Overdose Response established in 2016. As part of the wide range of actions taken, partners across the health system continue to expand access to life-saving naloxone and opioid addiction medications and treatments such as Suboxone, operate overdose prevention sites, work with Health Canada on approvals to open additional supervised consumption sites and improve the H system of substance use services. ■
Tiffany Akins is Communications leader at Vancouver Coastal Health. www.hospitalnews.com
Making women visible in research By Lindsay Jolivet ost older people with dementia are women. However, we do not know how dementia medications affect women, specifically, because studies virtually never report data on men and women separately. Missing data means that doctors do not always know if they should prescribe lower doses to women, for example, or choose one drug over another for women or men. “For dementia, missing data means the primary population is receiving treatment based on evidence that does not always account for their needs,” says Dr. Paula Rochon, vice-president of research at Women’s College Hospital. Dr. Rochon’s research has found that a third of residents in long-term care have to split their pills to take the dose the doctor prescribed. A new study reinforces this point. Students Nishila Mehta, Craig Rodrigues and Manpreet Lamba, supervised by Dr. Rochon, reviewed 33 clinical studies of cholinesterase
AFTER YEARS OF ADVOCACY, CLINICAL TRIALS AND OTHER STUDIES NOW ROUTINELY RECRUIT WOMEN TO PARTICIPATE IN STUDIES. inhibitors, a class of dementia medications, for data presented about women and men. One study reported outcomes for both women and men. None reported how many women versus men had adverse events in response to the drugs being tested. After years of advocacy, clinical trials and other studies now routinely recruit women to participate in studies. But they seldom publish findings in a way that allows the exploration of the differences between women and men. These differences can include biological sex, but also gender. As a result of this gap, many women are overlooked and underserved in our healthcare system. An initiative at Women’s College Hospital called Women’s Xchange is working to close health gaps by en-
suring the impact of sex and gender is made visible in research. Women’s Xchange, a knowledge translation and exchange centre based at Women’s College Hospital, supports community research in women’s health and operates a consultation service to help researchers incorporate sex and gender into their research from the proposal stage through execution, analysis, and dissemination. Research has shown that scientists do not routinely incorporate and report on sex and gender in their studies. The Canadian Institutes of Health Research instituted a requirement that researchers integrate sex and gender into their research designs when appropriate, yet found in a follow-up study that many still fail to do so.
Women’s Xchange recently published metrics for researchers and funders to assess how well sex and gender are incorporated into research proposals. The metrics, published in the journal PLOS ONE, include questions, examples and assessment criteria for identifying and reporting on an array of sex and gender considerations in every stage of the research process. The team is working with the Ministry of Health and Long-Term Care on a follow-up project to test and validate the metrics. “For too long, too many researchers have neglected consideration of how sex and gender may influence research findings. Even when there are no differences between men and women, reporting that lack of difference is important,” says Robin Mason, PhD, the scientific lead for Women’s Xchange. “Developing the tools and supports to integrate sex and gender into research is one of the H aims of Women’s Xchange.” ■
Lindsay Jolivet is the Research Communications Advisor at Women’s College Hospital. www.hospitalnews.com
OCTOBER 2017 HOSPITAL NEWS 13
New CCSA resource aims for a recovery-oriented system of care eptember was Recovery from the Disease of Addiction Month (Recovery Month) in Canada. The fact that recovery from addiction to alcohol and drugs is possible, achievable, and a part of everyday life for thousands of Canadians is an important reminder for us all â€“ and especially those working in healthcare today. In celebration of this month, the Canadian Centre on Substance Use and Addiction (CCSA) and the National Recovery Advisory Committee (NRAC) released Moving Towards a Recovery Oriented System of Care: A Resource for Service Providers and Decision Makers.
14 HOSPITAL NEWS OCTOBER 2017
The resource provides examples of policies and practices that service providers can integrate into their practices to help increase understanding about recovery, reduce barriers, and,
ultimately, help those served achieve a better quality of life. The experiences of individuals detailed in Canadaâ€™s first ever Life in Recovery from Addiction in Canada
survey and report are used throughout the resource to explore the first-hand successes and challenges of recovery. While expert consultations with a range of recovery service providers and the guiding principles in A National Commitment to Recovery from the Disease of Addiction in Canada inform the actionable examples. Importantly, the resource is based on the concept that there is no one pathway in recovery that works for all those struggling with addiction and, as a result, a successful journey can be different for each person. This approach to treating the whole individual means collaboration at all service levels is critical. Across the continuum of care, services should re-
The five key components a recovery-oriented system of care: 1. Collaboration between service providers 2. Coordinated community-based services and protocols 3. Measures of long-term recovery outcomes 4. Shared language and messages 5. Lessening of stigma
flect the individual’s needs and goals when addressing his/her problematic substance use. Dedication of this kind – to supporting the whole individual – is expressed as Recovery Capital: a combination of personal, interpersonal and community resources that can be drawn upon in recovery. What is inside a person – their inner strengths – can be as important as the external care and supports they receive. These are important insights for service providers, decision makers and the recovery community today as they work together to increase the capacity of the system to provide a comprehensive response that is based on collaboration, community services and long-term supports, and to reduce the stigma associated with substance use, addiction and recovery through greater awareness and understanding.
Recovery requires collaboration: A recovery-focused system of care includes collaboration between service providers and community support systems, as well as between professionals across healthcare and social service sectors. Recovery is a personal journey toward wellbeing: Recovery is unique to the individual with optimal services tailored to strengths, needs, perceptions and experiences, including trauma and mental health issues. Recovery extends beyond the individual: The recovery process includes not only the individual, but the individual’s family, friends, workplace and community. Everybody can play a role in supporting an individual’s recovery. Recovery is multidimensional: Recovery involves addressing the multiple dimentsions of a person’s health in addition to their substance use.
ACROSS THE CONTINUUM OF CARE, SERVICES SHOULD REFLECT THE INDIVIDUAL’S NEEDS AND GOALS WHEN ADDRESSING HIS/HER PROBLEMATIC SUBSTANCE USE
Life in recovery from addiction in Canada CCSA, in partnership with the National Recovery Advisory Committee, is focusing on changing the conversation about addiction — away from the problem, toward celebrating the solution. This change includes conducting the first-ever Canadian Life in Recovery survey, which explored the life experiences of individuals in recovery from addiction to alcohol and other drugs in Canada, including information on personal journeys and different pathways to recovery.
laboration, community supports and long-term outcomes, and to reduce the stigma associated with substance use, addiction and recovery. To help share practical examples of success, the resource also includes short profiles of programs like Oxford House, the Calgary MESH Program
and the Sunny Book Family Navigation project. A living document, CCSA will be accepting feedback on the resource via an online survey, and will update further editions of this document to include examples and stories from serH vice providers. ■
This article was submitted by the Canadian Centre on Substance Use and Addiction.
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PRINCIPLES OF RECOVERY
The full resource contains a list of suggestions, or, actionable examples, for use in healthcare settings There are many pathways in recovery: A variety of interventions and approaches can lead to successful long-term recovery. There is no one pathway in recovery that works for all those struggling with addiction and as a result, a successful journey can be different for each person.
Recovery involves everyone: Everyone can contribute to creating a culture and society that is compassionate, understanding and supportive of people in recovery and those struggling with addiction. This begins with overcoming stigma and dispelling the common myths that are associated with both having a substance use disorder and being in recovery. In embracing the principles, service providers, decision-makers and the recovery community can increase the capacity of the system to address col-
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OCTOBER 2017 HOSPITAL NEWS 15
Turning patient safety improvement ideas into reality through better training By Kathryn Young ospital staff have great ideas for changes that will improve patient safety, but turning those ideas into reality can be daunting. Where do you start? That’s how Jonathan MacLeod, Andrée Vincent and Lynn Kachuik – from The Ottawa Hospital – felt before they discovered the training, tools, tips and support from the hospital’s Quality Improvement (QI) team that has helped launch their projects faster and with more success. “When I walked in I didn’t know where I was going to start with this process,” says MacLeod, Manager of Safety and Prevention. His project will improve the violence risk assessment by incorporating better quantitative and staff survey data earlier in the process. “By ensuring we’re implementing recommendations sooner, we’re creating a safer environment for staff and patients, the patients around them (such as roommates) and their family members.” Likewise, Kachuik is also leading a patient safety project: pilot-testing a discharge checklist to be used throughout the hospital for palliative patients for end-of-life care. Even though she’s a veteran of QI and research projects, she found the training helped her team clarify its goals and objectives, and quickly identify any key missing pieces. “It’s forcing us to take a step back and look at all the pieces, the order, how to simplify the checklist and make it easier for other teams to use,” says Kachuik, Advanced Practice Nurse in Supportive and Palliative Care. “They’re very vulnerable patients who require a lot of supports and access to services in the community. If the services aren’t quickly accessible and set up when they go home, they’re going to end up back in our Emergency Department. Safe discharges mean everything is there to keep the patient safe.” The QI team launched two training courses earlier this year – a one-day in-
The Ottawa Hospital’s Jonathan MacLeod, Andrée Vincent and Lynn Kachuik found the new quality improvement training offered by the hospital’s QI team is making a huge difference in the success of their projects, which ultimately improve patient safety. troductory course and a four-day program to take staff through a structured step-by-step improvement framework so they can successfully design and lead QI projects. Trainees learn how to: • Effectively write their problem statement. • Understand their role. • Learn why local fixes are not always best. • Apply various quality improvement tools, handpicked from the best methodologies, such as project charters, measurement plans, audit tools, process maps and more. • Identify outcome, process and balancing measures. • Develop effective plan-do-study-act cycles. • Make the improvements stick.
The QI team took the best from various other programs (such as LEAN, Six Sigma and the Institute for Healthcare Improvement model) and combined them into one simple, five-step how-to framework. The team offers an applied, just-in-time training program geared to this unique Ottawa Hospital approach. “By the end of the first morning, I felt better,” says MacLeod, who took the four-day course. “The tools and framework they provide help you assess your current state and identify your problem and places for improvement. It doesn’t take long to get focused and get started.” “Identifying the problem can be daunting because you don’t know where to begin, but when you use
these tools you know exactly where you’re going at all times,” says Andrée Vincent, Quality Lead for employee scheduling services in Human Resources. She had led QI projects before, but found this time was much easier. “The steps are there, the tools are there and the team is there to help,” says Vincent. “They gave us tons and tons of tips on how to measure data, how to get information from your stakeholders, techniques to help us really analyze what the issues were and give us a baseline so we could look in the future to see what the improvements were.” Her favourite tool was the swimlanes diagram for process mapping, which helps identify all the people who need to be involved in the solution. Kachuik says it’s important for a whole project team to do the training together. “It gives you a common language,” she adds. “It’s clear and logical and you have something to guide you. It provides the rationale for why you need to do certain things, and keeps you on the straight and narrow instead of going off on tangents.” The Ottawa Hospital earned ‘exemplary’ status from Accreditation Canada last spring, in large part because of its commitment to continuous quality improvement, which in turn improves patient safety – an essential component of quality health care. “Quality isn’t something we should recognize only for one month during the year,” says Samantha Hamilton, Director of Quality and Patient Safety. “Continuous improvement is, in fact, the core of what quality means.” In that vein, the QI team is doing QI on its own courses, using feedback from trainees to make the courses even better. “You’re spending four days in this program but the value and return on the time you spend – you can’t quantiH fy it,” says MacLeod. ■
Kathryn Young is Publications Officer, Editor-in-Chief of the Journal at the Ottawa Hospital Research Institute. 16 HOSPITAL NEWS OCTOBER 2017
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How to decode the cohorts By Dr. Mary Donohue hat if I told you that you could reduce your stress by 34 per cent and be 11 per cent happier just by making an effort to try to understand the people around you? We are the product of our environment and of the time in which we were born, and we act and react to each other based on those variables. Baby Boomers, Generation X and Millennials all communicate differently, and there is a certain peace that comes with understanding that you are part of a cohort that responds to the world around you in the same way due, in large part, to your relationship with technology. We all want to use our talents to make the world a better place, so finding out how to interact with other generations more effectively is priceless. Having a clearer insight into why
others respond to you the way they do, particularly if they are from different cohorts, can actually improve your efficiency. You could theoretically end up with an â€œextraâ€? hour in the day because youâ€™ve figured out how to communicate with your coworkers in a way that allows them to truly understand the message youâ€™re trying to impart. Engagement increases when managers focus on employeesâ€™ strengths, when employees build positive workplace relationships and when employees feel valued and trusted. Thatâ€™s why it makes sense to put in the effort. The premise of all my research and my programs is the fact that we all process information differently. When people say there is no generation gap or that Millennials should just â€œsuck it upâ€? and work they way we do, theyâ€™re wrong. Our brains have developed dif-
Dr. Mary Donohue ferently because of the technology we were born into, and that affects the way we interact. We canâ€™t expect oth-
er cohorts to simply process information exactly like we do, because they canâ€™t â€“ they arenâ€™t wired the same way we are. Every generation has a different relationship with technology, and behaviour patterns change because of it. For example, weâ€™ve really only been using typing for work communication since the advent of the iPhone. Thatâ€™s just about 10 years, and yet this kind of communication has changed everything â€“ even personal relationships. According to the Wall Street Journal, Millennials often wonâ€™t ring or answer a doorbell. They are far more apt to text, â€œalmost thereâ€? or â€œoutsideâ€? rather than ring the bell because they are always connected to their smartphones and doing something other than texting simply doesnâ€™t occur to them. Some even admit that
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18 HOSPITAL NEWS OCTOBER 2017
Like many health systems, Horizon Health Network was faced with a challenge: A growing number of patients with heart conditions was leading to longer wait times to get treatment. Horizon Health Network partnered with Medtronic Integrated Health Solutions to tackle wait times and improve some other key services at the New Brunswick Heart Centre (NBHC). $IWHUWKHĆŹUVW\HDUWKHUHVXOWVDOUHDG\H[FHHG H[SHFWDWLRQV1%+&LPSURYHGLWVFDUGLDFVXUJHU\ internal processes, providing the capacity to be more productive and see more patients. Learn more at www.medtronic.ca/NBHC. 'DWDRQĆŹOH ÂŠ 2017 Medtronic. All Rights Reserved.
HEALTH ACHIEVE 2017
TECHNOLOGY HAS CHANGED THE WAY WE COMMUNICATE ON EVEN THE MOST BASIC HUMAN LEVELS
the sound of a doorbell ringing is so foreign to them that it’s terrifying.1 Technology has changed the way they communicate on even the most basic human levels. Think about it: they were brought up on technology, so they think and work very differently than Boomers and GenXers who were introduced to technology much later in their lives. Millennials have never had to memo-
rize anything, so we shouldn’t expect them to. They were micromanaged by their parents, so we need to give them clear instructions and specific tasks, and let them ask a thousand questions. They were brought up to communicate and respond exactly the way they are. You plant corn to get corn, after all, but some people forget that Millennials are the people that we trained them to be.
Of course Millennials need to take responsibility to manage up and learn how to communicate effectively with the other cohorts as well. The point is, understanding each other can completely change our work environment. We all want to talk about what matters to us, and we all want to share our ideas and the way we think things should be done. But what good is that if no one is really listening? Ev-
erything changes when we take the time to understand why we do what we do, and why others respond to us the way they do. I will be explaining the framework of cross-generational friction, and how to use the traits of every cohort to transform what many consider a communication and societal gap, into productive strengths at HealthAchieve in H Toronto on November 6. ■
Dr. Mary Donohue is CEO of Donohue Learning™ and Adjunct Professor, Graduate School of Management, Dalhousie University.
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OCTOBER 2017 HOSPITAL NEWS 19
HEALTH ACHIEVE 2017
Discharge planning: The pathway to innovation By Carol Hatcher and Mehdi Somji
n a perfect world, every patient leaving the hospital would simply pack up and go home. But not every pa-
tient’s hospital journey ends that way. For those who need to go home with additional community services, or who are heading off to a rehabilitation fa-
Canada’s Leading ED Administration Conference November 28-29, 2017 – Toronto This two-day conference will focus on current issues facing ED administration, with a second full day dedicated to medical-legal issues and quality improvement.
cility, a retirement residence or a longterm care facility, discharge-planning intervention is a necessity. It’s part of a discharge planning assessment completed on admission that divides patients into those who need planning and those who don’t. But up until now that process has been fraught with challenges due to gaps in processes that resulted in delays and frustration.
and management of patients that require discharge planning. Humber River Hospital embedded this pathway within an in-house app designed to address the need for a smoother discharge process. Once our LHIN partner hospitals saw the app, the idea started to pick up traction beyond our walls because there simply wasn’t anything like it out there – and they wanted in. CL-
THE DISCHARGE PLANNING DASHBOARD WILL BE GOING LIVE IN CENTRAL LHIN HOSPITALS STARTING OCTOBER 2017, WITH THE POTENTIAL FOR FUTURE COMMUNITY ENGAGEMENT
Featured Speakers: Dr. Chris Carpenter Director, Evidence-Based Medicine Washington University Division of Emergency Medicine
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20 HOSPITAL NEWS OCTOBER 2017
It’s a cliché, but necessity is truly the mother of invention, and the need for a process that streamlined discharge to enable patients requiring intervention to get to the next level of care as soon as possible is the reason our new Discharge Planning Pathway and Dashboard was created. It began with the Central Local Health Integration Network (LHIN) ALC Collaborative, Central LHIN Hospitals, and Central LHIN Home and Community Care developing the Discharge Planning Pathway to allow for early identification, engagement
HIN funded development and collaboration played a tremendous role in the current incarnation of the Discharge Planning Dashboard, which will be going live in Central LHIN Hospitals starting October 2017, with the potential for future community engagement. Essentially, we have taken the Pathway we developed and embedded it within technology that pulls in patient information and pushes out notifications designed to ensure that there is consistency in communication, that all teams have clear accountability, and that no patient falls through the cracks. Continued on page 28 www.hospitalnews.com
HEALTH ACHIEVE 2017
Gaining a win from a loss By Michele Lindsay esearch and experience tells us that a hospital error can be serious or even fatal for a patient, and potentially career ending for staff members involved in the incident. In fact for everyone impacted by the error, healing from the resulting trauma may take years, and in some cases the impact never fully goes away. An event like this occurred at Southlake Regional Health Centre on a typical day in a busy procedure room where a highly skilled and adept team performs dozens of procedures every week. Things came to an abrupt halt when a recovery nurse discovered that the wrong device had just been implanted into a patient. The error
AS WITH MOST INCIDENTS, THERE WERE MULTIPLE, SEEMINGLY INSIGNIFICANT CAUSAL FACTORS THAT LED TO THE ERROR was disclosed to the patient, and within a few hours it was corrected and the patient was safely discharged home. It amounted to a few extra hours spent at the hospital and no discernable harm to the patient, but despite a positive outcome, the team was left reeling from an error during a seemingly routine but safety-significant procedure. In the wake of the incident, over the course of a year several changes
were made to the systems and processes around this procedure to further ensure the right outcome for our patients. As with most incidents, there were multiple, seemingly insignificant causal factors that led to the error. Any one of those factors may not have caused the error, but unfortunately the culmination of all of them and their root causes did. More than a dozen recommended actions designed to mitigate the risk of recurrence were
developed with input from the team involved. The team fully embraced the data culled from the investigation and analysis of the incident, and were empowered to help create a more robust system. The systems and processes are still functioning as designed, which is a testament to a dedicated team focused on quality care for their patients. However, the error still stings deeply, and now more than two years later some staff members are still having a difficult time putting the error behind them. There was no finger pointing or scolding, because at Southlake we recognize caring, hardworking people can make mistakes, and they need to be supported. Continued on page 28 OCTOBER 2017 HOSPITAL NEWS 21
November 6 & 7 Metro Toronto Convention Centre, South Building healthachieve.com
Learn to be an agent of change from those who already are. Seek new ways to push boundaries that move the health care system forward by learning from industry leaders who are determined to create a high-performing health care system ƥĺîƥɫƙĲūČƭƙĚēūŠƎƭƥƥĿŠĳƎîƥĿĚŠƥƙǶƑƙƥɍ MONDAY, NOVEMBER 6, 2017
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HEALTH ACHIEVE 2017
Developed by the Ontario Hospital Association (OHA) together with the Ontario College of Family Physicians (OCFP) this Ideabook showcases the many creative and successful initiatives designed to strengthen relationships between family physicians and hospitals, and their positive impact on patient care.
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The Ontario Hospital Association’s health policy journal Designed to support our hospitals and partners, this biannual publication will provide in-depth perspectives and analysis of the issues, trends, research, and best practices in health care.
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Ultraray Group Inc. is proud to announce the acquisition of Techlem Medical Corp. The acquisition of Techlem reinforces Ultraray’s position as a leading manufacturer and distributor of medical products. About Ultraray Group Inc Ultraray’s journey began in 1985, providing medical radiation protection apparel to local customers. Today, Ultraray has expanded to provide products for diagnostic imaging, radiation protection, sterile processing, surgical operations, and patient handling. Ultraray Group Inc. now has ﬁve divisions; including Ultraray Medical, Ultraray Radiation Protection, Ultraray Metals, Ultraray Motorsports, and Techlem Medical. Each division is uniquely positioned to bring custom manufactured products to the market. About Techlem Medical Corp Techlem Medical Corporation is a Canadian manufacturer of Patient Handling and Patient Transportation Equipment located in Mississauga, Ontario. For over 50 years, Techlem has provided a full range of top rated medical stretchers, stretcher mattresses, I.V. poles and other related equipment.
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OCTOBER 2017 HOSPITAL NEWS 23
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HEALTH ACHIEVE 2017
Dignity in death: Giving the marginalized compassionate end-of-life care By Dr. Naheed Dosani ore often than not, the first response we get when tending to the needs of a terminally ill homeless or vulnerably housed person is, “Why are you doing this? Why do you care about me?” It’s not uncommon for them to be taken aback by the care we’re willing to offer them or the time we’re willing to spend with them. They find it strange that a social worker or health care provider wants to know how they feel about their quality of life, because no one has ever cared to ask before. Unfortunately, our experience shows us that there is a profound lack of self worth and dignity within this group of people, but it’s not surprising when you look at the stigma and
discrimination this segment of the population faces within our healthcare systems. Sometimes they are treated as though they are not deserving of the same kind of dignity and care that many may take for granted every day. This inequity – and the heartbreaking stories of the marginalized people lost in the system that I have seen and heard firsthand – is the reason why our team at the Inner City Health Associates in Toronto, founded Palliative Education and Care for the Homeless (PEACH). PEACH is a mobile, street and shelter-based outreach service aimed at meeting the supportive and palliative care needs of the homeless and vulnerably housed. Through PEACH, we are able to provide To-
PEACH IS A MOBILE, STREET AND SHELTERBASED OUTREACH SERVICE AIMED AT MEETING THE SUPPORTIVE AND PALLIATIVE CARE NEEDS OF THE HOMELESS AND VULNERABLY HOUSED ronto’s most marginalized populations with compassionate care and a dignified approach to their palliative care journeys. PEACH functions as a program of the Inner City Health Associates (ICHA), a network of more than 80 healthcare providers working in over 40 street and shelter-based settings to provide frontline physical and men-
tal healthcare. Because PEACH is embedded within this grassroots network of frontline health providers and functions in partnership with Toronto Central LHIN’s Home & Community Care Palliative Care Team (in addition to many other community-based partnerships), we are able to see patients quickly and give them access to the care they need, where they need it.
YOUR LEAN LEARNING JOURNEY Ready to advance and supplement your Quality Improvement initiatives and implementation efforts? The following Lean health care learning programs, developed by the Ontario Hospital Association (OHA) and KPMG, are designed to support you in small- to largescale transformation initiatives. White Belt - Online Equipping you with the practical skills to participate in and support Lean projects. Yellow Belt - Online or In-person Educating you on the practical skills to implement Lean projects. Green Belt - Online or In-person Providing you with an in-depth overview of Lean thinking principles and their application in a health care environment.
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26 HOSPITAL NEWS OCTOBER 2017
Executive Green Belt for Leaders In-person Training on how to lead an organization so it meets its ﬁscal constraints while still able to improve on quality for the patients, residents, clients and customers without reducing services or staff. Black Belt - In-person Preparing you to be the expert in Lean within an organization. A Black Belt typically sets the strategy for a Lean system transformation implementation.
HEALTH ACHIEVE 2017 PEACH operates as a low threshold and low barrier program, which means there are minimal obstacles for a patient to receive care from the team. In fact, often our patients are referred to us by social workers, concerned citizens, and even other individuals with lived experiences of homelessness in the community. One of the underpinnings of community-based palliative care delivery is the in-home care experience; but right within the name “home care” there’s bias and an inherent sense of discrimination. Our home care systems often make clear assumptions that the patient has caregivers or family to supplement the care provided by professionals – and that they have a home at all. In fact, many argue that we have structured a healthcare system that excludes 150,000 to 300,000 homeless people each year, and to me and many others, that’s an unforgivable and intolerable flaw. As frontline healthcare providers and as a healthcare system, we need to
shift our thinking to meet the unique needs of the various populations that we serve. It is true that the manner in which we handle particular marginalized and vulnerable patients may require a different approach, however, it can really make a tremendous difference in the outcome for that patient. In addition to adjusting our thinking, we need to continue to work on our understanding of the populations
we serve and the data we collect to help us with that. It troubles me that we really don’t know the socio-economic demographic of patients who die in our Palliative Care Units and Hospices. Many frontline providers and researchers have postulated that we are likely serving particular segments of the population and perhaps, neglecting others. As health providers, we are afforded
privilege to care for and support those in need. Our hope is that we can utilize that privilege to support our most vulnerable populations in Canada. During my session at HealthAchieve in Toronto on November 6 and 7, I will be speaking about how we can improve both access to care for the homeless and vulnerably housed in Toronto, and collaboration and coorH dination amongst service providers. ■
Dr. Naheed Dosani, is a Palliative Care Physician, Project Lead and Founder of the PEACH (Palliative Education and Care for the Homeless) program, Inner City Health Associates.
OCTOBER 2017 HOSPITAL NEWS 27
HEALTH ACHIEVE 2017
The pathway to innovation Continued from page 20 It also enables healthcare providers to share information with their patients, making them part of their own recovery journey in a way that simply wasn’t feasible before. During the creation process we were able to leverage the different areas of expertise of the Central LHIN, Central LHIN hospitals and Central LHIN Home and Community Care, because we had the input of clinical and tech subgroups populated by representatives from each one. Pulling all the organizations together allowed us to understand the unique challenges they faced, and to recognize the pockets of excellence within each one. This enabled us to work together to create a standard across all the different organizations. While our goal was to create a standardized tool to streamline discharge planning, in the process we have also created a valuable information tool for the Central LHIN.
THE DASHBOARD WILL GIVE THE LHIN A COMPREHENSIVE VIEW OF WHAT’S GOING ON ACROSS ALL HOSPITALS BY PROVIDING AGGREGATE DATA The Dashboard will give the LHIN a comprehensive view of what’s going on across all hospitals by providing aggregate data. This will allow the LHIN to see how many patients require discharge intervention at any given time, how many of those patients are ALC, and what barriers to transitions within the community there may be. It provides a real-time view of what’s happening with the LHIN, so in addition to being able to identify areas where challenges exists and to see where things are working, it’s great for decision-making and guiding where funds or services could be allocated.
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28 HOSPITAL NEWS OCTOBER 2017
We’re proud of the Pathway and the resulting technology, of course, but we are also proud of the collaborative
effort made to leverage the expertise of several different organizations in building a transferrable system that works well for everyone, and most importantly, helps us put our patients first. We will be talking more about the Discharge Planning Pathway, including running a demonstration of the new technology, at HealthAchieve on H November 6 in Toronto. ■
Carol Hatcher is Vice President Clinical Programs and Mehdi Somji is Manager Clinical Process Optimization at Humber River Hospital.
Gaining a win from a loss Continued from page 21 That’s why the immediate debriefing was not focused on blame, but was instead focused on learning, looking for system weaknesses and supporting the team. The team needed to go away feeling as though they were part of a solution, not part of a problem. And that’s exactly what happened. But despite the spontaneous outpouring of support from other hospital staff, and the team’s ability to share their feelings with each other, the guilt some team members still carry today is cruel and unforgiving. Tears still form when the nurse from the procedure rooms talks about “that day.” This incident is an example of the caring and learning approach we have toward patient safety incidents at Southlake. That approach includes the expanded role of the Quality of Care Committee (QCC) beyond critical incidents, hospital-wide safety alerts, a formalized approach for the investigation and management of patient safety incidents that incorporates considerations for wounded caregivers, forums for discussing the incidents, and an initiative for eliminating never events at Southlake.
We are breaking through the paradigm of perfection. It’s an unfortunate fact that there are cracks and niches in the system, and mistakes do happen no matter how exceptional your team is and how hard they try to be perfect. High performing people don’t tend to deal with errors of this magnitude that often, so the incident was a huge opportunity for us all to learn and to formalize a new approach to the management of patient safety incidents, and to create a systematic, comprehensive and compassionate approach to the investigation and review of incidents. It truly was gaining a win from a loss, and the process has clearly demonstrated that we embrace transparency, accountability, transferability, shared learning in a culture of care and concern at Southlake. Join us at HealthAchieve in Toronto on November 7th, to learn more about Southlake Regional Health Centre’s approach to Quality of Care reviews, the expanded role of our Quality of Care Committee, and our culture of care with staff that have made learning from incidents and near misses a sucH cess on the journey to high reliability. ■
Michele Lindsay is Quality Improvement Specialist, Quality & Risk Dept., at Southlake Regional Health Centre. www.hospitalnews.com
HEALTH ACHIEVE 2017
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November 6 & 7 Metro Toronto Convention Centre, South Building healthachieve.com
The Centre of it all: HealthAchieve’s Exhibit Floor Learn from inspiring innovations, engage with industry leaders and network with thousands of health care professionals who come to HealthAchieve to be empowered by the potential that changes holds. Here are some of the attractions you can look forward to: Garden H2Oh! Booth #509
Intelligent Health PavilionTM Booth #1627
Book Store and Book Signing Booth #1721/1723
Come and see what is growing in the future of health care. It’s about green space, peace of mind, meditation, virtual reality, easy growing, forest bathing, and local food contributing to a healthy lifestyle. Demonstrating a best practice combination at HealthAchieve and a play on the garden from last year, this year we have a new version, Garden H2Oh! Take in some “forest bathing”, meditation, virtual reality, the smell of fresh vegetables, and some food tasting mixed with technology.
Voted winner of the People’s Choice Award at HealthAchieve 2016, the Intelligent Health Pavilion™ (IHP) will be an even greater experience for delegates at this year’s HealthAchieve. ×ĿƙĿƥūūƥĺɌȂȇȃȈƥūƙĚĚǶƑƙƥɠĺîŠēɈ fully integrated, multiple vendor solutions, and understand why and ǅĺĚƑĚƥĺĚǋǶƥĿŠƥūǋūƭƑūǄĚƑîŕŕĺĚîŕƥĺ care strategy.
Several HealthAchieve keynote speakers’ books will be available for purchase at the book store located on ƥĺĚĚǊĺĿċĿƥǷūūƑîƥċūūƥĺȂȉȃȂɓȂȉȃȄɍ We will be offering special onsite pricing for books, so come prepared to take advantage of the special offers and get your books signed by some of the authors!
InnovationEX Displays Booth #1703 The Joint Centres is a partnership between six large community hospitals that collaborate on spread of innovation and leading practices to improve quality, safety and performance of the health care system. Stop by this sixhospital display showcasing Mackenzie Health, Markham Stouffville Hospital, Michael Garron Hospital, North York General Hospital, Southlake Regional Health Centre, and St. Joseph’s Health Centre.
TELUS Health Lounge Booth #1015 See your #healthachieve tweets and Instagram posts live on our social media wall while staying hydrated at our water stations. This lounge area will have two large charging stations, allowing you to lock up your mobile device for recharging, while you can ƑĚŕîǊîŠēƥūƭƑƥĺĚǷūūƑɍ
HealthAchieve Go By participating in our mobile app scavenger hunt game, you’ll earn points for a chance to win a grand prize valued at $1,000 and will be entered in draws for a chance to win prizes valued at over $500! Visit the app store and type in MYHA2017 to download the app today!
Complimentary Services and Products • • • • • • •
Ask the Expert: Medical Cosmetics and Nutritionist Consultation (Booth #729) Charging stations (Booth #1015) Complimentary drinking water (Booth #1015) Flu Shot Clinic (Booth #1329) Massage Chairs and $3,000 Massage Chair Wellness Prize (Booth #500/502) Seated Massage, Assistive Devices Consultation (Booth #729) Tim Hortons Coffee (Booth #535/634)
Emergency Department Ambassador Project
reduces violence By Jeff Young iolence in the workplace has always been a very real area of concern for healthcare environments, and the issue has increasingly drawn the attention of unions, workers, regulatory bodies and the public due to its profound impact on patients, visitors and staff. While the ever-present potential for violence is an unfortunate reality in hospitals, and emergency departments in particular, it is critical that healthcare providers seek opportunities to prevent and respond to incidents of aggression. Looking for possible solutions to this issue, Integrated Protection Services (IPS) piloted the Client Services Ambassador program in partnership with Paladin Security Group Ltd. in late 2014. The program is designed to promote proactive, positive interaction with hospital visitors, by posting emergency department Ambassadors trained to recognize and deescalate potentially aggressive behaviour early; with the goal to reduce violent incidents by building trust and positive rapport between security staff, patients, visitors, and clinical staff. As Ambassadors are also fully trained as Security Officers, they are able to intervene if violent incidents do arise. The Lower Mainland IPS program is responsible for security management for four health organizations serving the Vancouver, BC area: Fraser Health, Providence Health Care, Provincial Health Services Authority and Vancouver Coastal Health. With a combined operating budget of +$7B and approximately 65,000 staff members, the health authorities serve a population of over three million people. Paladin provides a complete range of security services to all four organizations. An inner-city facility in Vancouver, St. Paul’s Hospital (SPH), was selected for the initial trial, following with two
THE PROGRAM IS DESIGNED TO PROMOTE PROACTIVE, POSITIVE INTERACTION WITH HOSPITAL VISITORS, BY POSTING EMERGENCY DEPARTMENT AMBASSADORS TRAINED TO RECOGNIZE AND DEESCALATE POTENTIALLY AGGRESSIVE BEHAVIOUR EARLY additional locations, Royal Columbian Hospital (RCH) and Surrey Memorial Hospital (SMH) in 2015. The specific hospitals were chosen due to high levels of documented aggression and repeat clientele suffering from addiction and mental health issues. These trials introduced the specialized Ambassador position for 12 hours/day (7 days/week), focused on proactive and positive interactions with all persons utilizing the ED. The ED Ambassador is dressed in a “softer” uniform than other security staff and takes a practical approach to engaging patients who may seem agitated, and is empowered to help, for example, by bringing water, getting the patient a blanket, etc. As well, Ambassadors check on the general wellbeing
of patients in the waiting room and report any concerning observations to clinical staff. Ambassadors are provided with smartphones equipped with a specialized reporting program to document different interaction types with patients, staff and visitors falling within one of four categories: Customer Service/Hospitality; Health/Medical Support; Discharge/Social Support; and Behaviour Mitigation. The findings from the initial trials were overwhelmingly positive. The ED Ambassador works closely with the ED clinical and Social Work team and since the program’s inception, there have been fewer involvements by the regular Security team for evicting discharged patients, and fewer responses to aggression in the ED.
More specifically, the hospitals have seen up to a 40 per cent reduction in physical aggression and 31 per cent reduction in total aggression. Additionally, ED staff have reported an enhanced feeling of safety, with survey scores of staff’s perceptions of their personal safety during the trial period increasing an average of 32.3 per cent amongst the three sites. In all instances of the three pilot projects, it is noteworthy that there were no appreciable decreases in ED patient visits that might otherwise account for some of the observable reductions. Feedback from staff, patients, and visitors has also demonstrated a notable impact. One Registered Nurse observed that “The ambassador program in RCH ED has changed the quality and efficiency of de-escalation and code whites here! This is essential to increase quality of care.” Non-clinical staff have also benefitted, with one BC EHS Paramedic noting that the Ambassador position, “has been a highly clever add on; always professional, courteous, and polite. Speaking on behalf of EHS, we couldn’t do without the Ambassador and only have positive feedback to offer.” This project has garnered much attention and received multiple awards since its inception. In 2016 it received the highest award for workplace health innovation from the Health Employers Association of B.C. (HEABC) and the program was presented during the 2016 world conference for violence in the health sector in Ireland. As well, both Ambassadors at RCH and SMH received awards for quality service from the B.C. Emergency Health Services agency. All three programs are approved for funding through 2017/18, and the project has caught the attention of the Health Authorities’ senior executive team and is now expanding to other sites in BC at the request of exH ecutives and ED staff alike. ■
Jeff Young is Immediate Past-President of the International Association for Healthcare Security & Safety (IAHSS) and VP, Healthcare for PalAmerican Security. www.hospitalnews.com
OCTOBER 2017 HOSPITAL NEWS 31
FOCUS Pat Larson has enabled systemwide improvements in Withdrawal Management Services (WMS) thanks to the Urban Telemedicine Initiative in WMS, a program that embeds her – a nurse practitioner – into five non-medical withdrawal management sites across Toronto. Photo credit: Michael Garron Hospital
Merging ‘medical’ and ‘non-medical’ expertise in
withdrawal management care By Erica Di Maio hile Pat Larson is a nurse practitioner by trade, she wears many hats in her role supporting clients and staff in five non-medical withdrawal management sites across Toronto. Although many Withdrawal Management Services (WMS) clients have increasingly complex medical complications, these sites are traditionally staffed by unregulated care providers, without access to primary care or medical services on-site. The integration of Pat’s clinical expertise for individuals requiring crisis support for withdrawal and substance use has led to transformational changes in the sector. This shift began five years ago when the Toronto Central Local
32 HOSPITAL NEWS OCTOBER 2017
Health Integration Network created the Urban Telemedicine Initiative in Withdrawal Management Services. The project funds a Nurse Practitioner, Pat, to support the medical needs of five non-medical WMS, including: Michael Garron Hospital’s (MGH) Withdrawal Management Centre and Aboriginal Day Program, the University Health Network’s Women’s Own and Ossington WMS and St. Joseph Health Centre’s Glendale WMS. Although Pat’s home base is at MGH’s Withdrawal Management Centre, she travels across WMS sites multiple times per week to offer clients medical expertise in their communities and provide enhanced support to non-medical WMS providers. This
also includes consultations with clients and staff via telemedicine.
‘SOMETIMES, WE NEED TO BE A BIT OF A DETECTIVE AGENCY’
When individuals with addictions try to abstain from using alcohol or other addictive substances, they might experience painful and uncomfortable physical and psychological symptoms, known as withdrawal. Depending on the substance, symptoms might include: nausea, vomiting, tremors/ shakes, anxiety, and restlessness. In the most severe cases of alcohol withdrawal, individuals might experience seizures or delirium tremens. “Individuals in withdrawal often want to make a change and it’s our
job to help them safely though their journey. Our clients might be homeless or come from homes where others around them are using and they need a safe environment to stabilize,” says Pat, who has worked with individuals with addiction for more than 30 years. Depending on the individual, withdrawal can continue for up to seven days for alcohol or 10 days for opioids. Clients are referred to a WMS by Central Access or the Emergency Department, and are placed in the next available bed. “Sometimes we need to be a bit of a detective agency. We have clients come to us without medications and might not know the name of their pharmacy or family doctor. We begin our search with very limited informawww.hospitalnews.com
tion and try our best to connect the dots to help these individuals navigate the system and access the appropriate care or treatment,” says Pat. The MGH Withdrawal Management Centre houses 30 beds, with eight dedicated to clients in crisis. WMS staff facilitate client intake and transfers and act as frontline counselors to offer oneon-one and group facilitation. Pat works closely with staff to coordinate medication reconciliation, complex client care, and focuses on the development of system-wide improvement strategies in collaboration with WMS supervisors.
PREVENTING UNNECESSARY VISITS TO THE EMERGENCY DEPARTMENT
Maria Spirkoski, Program Supervisor, Withdrawal Management Centre at MGH describes the integration of a
INDIVIDUALS IN WITHDRAWAL OFTEN WANT TO MAKE A CHANGE AND IT’S OUR JOB TO HELP THEM SAFELY THOUGH THEIR JOURNEY nurse practitioner into a non-medical setting as one of the most significant shifts in WMS she’s observed in 20 years working in the field. “With a changing population and in the midst of an opioid public health crisis, we have increasingly complex clients who might not only be dependent on multiple substances, but also have chronic medical conditions including liver disease, heart disease or diabetes.” “Typically, we would send these clients to the emergency department given non-medical staff do not have the clinical expertise to manage these
conditions. But with Pat on-site, she’s able to facilitate care for these complex clients and prevent unnecessary visits to the ED.” According to a 2016/17 report for the Urban Telemedicine Initiative in Withdrawal Management Services, the total number of crisis and residential clients seen across WMS sites was 4,860, with 80 per cent – mostly male – seeking support for multiple reasons, including substance abuse, mental health, medical issues or challenges navigating the healthcare system. Of those clients, Pat was able to support close to 25 per cent. The report antici-
Erica Di Maio is Senior Consultant, Corporate Communications at Michael Garron Hospital.
pates 11 per cent of clients were diverted from the ED as a result of successful consultation with a nurse practitioner. As part of the Initiative, a Practice and Quality Steering Committee has been formed, including Pat and Supervisors across the WMS sites to standardize best practices and create guidelines to enable system-wide improvements. For example, creating a standard withdrawal management referral form for EDs, whereas previously, WMS sites would often not know whether a client had already been treated elsewhere or been given medication for withdrawal. “The most vital part of this initiative is being embedded within the system,” says Pat. “By being on the frontlines, I can see where the difficulties and complexities are, and in turn, transform that into real system H change.” ■
Worth a shot? A new way to treat opioid addiction By Dr. Janice Mann
hen it comes to treating opioid addiction, preventing the severe symptoms of withdrawal – including drug cravings, anxiety, restlessness, diarrhea, sweating, and rapid heartbeat, is one of the keys to preventing relapse. That’s where opioids like methadone and buprenorphine are helpful. While they act on the same receptors in the body as opioids like morphine and heroin to prevent withdrawal symptoms, they don’t lead to the “high” or sense of euphoria experienced with opioids we associate with addiction. But there is a whole other type of medication that might also be helpful when treating people with opioid addiction. A drug called naltrexone actually blocks the opioid receptors in the body, blocking the effects of any opioids that are taken. This drug can’t be used immediately in someone currently taking opioids, as it would cause very severe withdrawal symptoms. But once a person has successfully stopped taking other opioids with the help of methadone or buprenorphine, naltrexone could potentially be the next step in helping to prevent a relapse. Naltrexone is also used in the treatment of alcohol dependence. Until recently, naltrexone was available only in a formulation to be taken by mouth, and had to be taken
at least twice a week, if not every day. This made it difficult for some patients with opioid use disorder or addiction to stick to their treatment. And without taking their naltrexone, these patients could feel the high or euphoria again from any opioids taken and potentially experience a relapse. However, now an injectable form of naltrexone exists, which is injected into the muscle only once a month. This extended-release form of naltrexone, which is significantly more costly than the oral formulation, is known by the brand name Vivitrol. Currently in Canada, this injectable, extended-release form of naltrexone is available only through Health Canada’s Special Access Programme, and most recently, through a new Health Canada regulation which allows the bulk importation of drugs into the country for urgent public health needs. Given the current opioid crisis in Canada, the need to effectively treat people addicted to opioids is crucial. But what role could injectable, extended-release naltrexone play? Does it help to prevent relapse? And how does it compare with naltrexone taken by mouth and other available treatments? When the need arises for answers to important questions such as these, the healthcare community turns to CADTH – an independent agency
that finds, assesses, and summarizes the research on drugs and medical devices. CADTH searched for medical studies that would help to answer questions about the role of extended-release naltrexone to treat opioid addiction. In total, 23 reports met the strict criteria to be included in the review of the evidence. The CADTH review found that for patients with opioid addiction, extended-release naltrexone increases the length of time they are abstinent from opioids and helps keep them in treatment, compared with no active treatment, usual treatment, or treatment with buprenorphine. By contrast, oral naltrexone doesn’t appear to have the same results, although it could be useful in transitioning patients to treatment with extended-release naltrexone. No differences in patient safety were seen between the various treatment options. And although it is more expensive, extended-release naltrexone may still offer good value for the cost compared with treating patients with methadone or buprenorphine, according to studies from other countries. Clinical practice guidelines included in the review generally recommend naltrexone if other treatments can’t be taken or if patients have already stopped taking opioids for long enough
to be unlikely to experience withdrawal symptoms. In guidelines since 2015 oral naltrexone is not recommended, but the extended-release formulation is recommended if drugs like methadone or buprenorphine cannot be used, or if there are concerns that patients might not be able to stick to a more demanding treatment schedule. Knowing the evidence on extended-release naltrexone is important for determining its role in helping to address the opioid crisis in Canada. While significant efforts are underway to decrease the amount of opioid prescriptions in Canada and explore non-opioid treatment options for pain, effective treatment of all patients already addicted to opioids is essential. It is important to identify alternative, effective drugs that can help address the challenges presented by buprenorphine or methadone treatment for opioid addiction – and based on the CADTH review of the evidence, extended-release naltrexone may offer just that. If you’d like to learn more about the CADTH review of extended-release naltrexone or find more evidence to help address the opioid crisis in Canada, please visit: www.cadth.ca/opioids and www.cadth.ca/pain, follow us on Twitter @CADTH_ACMTS, or speak to the CADTH Liaison Officer H in your region. ■
Dr. Janice Mann MD, is Co-lead of the CADTH Opioid Working Group. 34 HOSPITAL NEWS OCTOBER 2017
New sweat lodge offers traditional healing for mental health patients By Kristi Lalonde ugust 23, 2017 was an historic day for Waypoint Centre for Mental Health Care with the celebration of the first sweat lodge ceremony in a provincial mental health hospital; a remarkable achievement allowing centuries-old traditional ceremonies to take place with respect and equity beside western medical practices. According to Austin Mixemong, Waypoint’s Traditional Healer, 3rd Degree Midewiwin of the Three Fires Midewiwin Lodge, “This ceremony is one of deep spiritual significance. It has healed our people since the beginning of time and it’s important that our indigenous patients have the choice to incorporate ceremony into their healing journeys.” Recognizing traditional healing methods is important to use,” adds Glenn Robitaille, Director of Ethics and Spiritual Care. “Our team is deeply committed to supporting the cultural traditions of all of our patients as they move through their recovery journey. The sweat lodge is a dome-shaped structure that when you enter, it’s said you are entering the womb of mother earth. The rocks used to heat the lodge are called grandmothers and grandfathers and songs and prayers are offered during the ceremony. Cedar medicine is then poured on the Grandmothers steam that brings healing and balance. It’s a very sacred place. “When indigenous people are on their healing journey, the sweat lodge is a good starting point in helping them find peace and balance and to talk to their Creator,” says Glenn Robitaille. “The sweat lodge has been called the most powerful structure in the world and can vary in purpose: cleansing, healing and loss are just some examples. It is said the ceremony responds to what the participants need.” Construction of Waypoint’s sweat lodge took place earlier this summer under Austin’s leadership. He was assisted by John Rice, also 3rd Degree Midewiwin, a former Healer at Way-
Kelly Brownbill, Ziigwen Mixemong and John Rice work together to construct the sweat lodge at Waypoint Centre for Mental Health Care. point and the First Nation Métis and Inuit Healer with the Barrie Branch of the Canadian Mental Health Association (CMHA), along with community members Kelly Brownbill and Ziigwen Mixemong. All four returned August 23rd to participate in first ceremony with a patient, with Austin conducting the sweat and John serving as fire keeper. Austin adds, “There is an indigenous teaching that recognizes people are made up of four equal parts: the mental, physical, emotional and spiritual. We need to ensure we are providing supports to our clients in all four of those quadrants to ensure the best outcomes for them.” I am deeply grateful to Austin Mixemong for the many hours of personal time he has given to see this day arrive and to John Rice, our former Healer, for his ongoing support of our indigenous patients.” Waypoint Centre for Mental Health Care is a 301 bed specialty mental health hospital with a 113 year history of providing mental health ser-
vices in the province of Ontario. The hospital is committed to providing culturally safe and informed care and
is a member of the Aboriginal Health Circle in the North Simcoe Muskoka H LHIN. ■
Kristi Lalonde is a Communications Officer at Waypoint Centre for Mental Health Care.
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Black health matters Health leaders say racism and discrimination need to be addressed in healthcare
effort to mandate the standardized collection of demographic data from patients and clients. Currently, all hospitals and community health centres within this LHIN are mandated to participate in this initiative.
By Ryan Joyce n a world where we regularly wake up to headlines announcing innovations that break down scientific barriers in healthcare, it can be hard to comprehend why some communities still face barriers to access basic care solely based on their race. To help address this inequity, Sinai Health System and the Black Experiences in Health Care committee (which includes the Black Health Alliance, the Wellesley Institute and TAIBU Community Health Centre), hosted the Black Experiences in Health Care Symposium earlier this year. The symposium aimed to identify and raise awareness of issues relating to health inequities faced by black Ontarians, and over 130 healthcare providers, academics, advocates, patients/ clients and members of the community participated. The event received support from Toronto Central LHIN, one of 14 provincial planning and funding agencies.
IT’S IMPORTANT WE ALL UNDERSTAND THAT INEQUITY AND RACISM ARE DISEASE EQUIVALENTS IN TERMS OF THEIR IMPACT The health needs are unique for this population and other racialized groups. Black communities have high rates of diabetes, mental health, HIV/ AIDS, heart disease, sickle cell, stroke and hypertension. If not adequately addressed, these challenges can lead to poor patient outcomes, and strain the healthcare system. Serena Thompson, a sickle cell patient, brought these challenges to life
EQUITY ACROSS THE CONTINUUM OF CARE
Attendees at the Black Experiences in Health Care Symposium. when she spoke at the symposium. “On a number of occasions, I have felt that I am not treated like other patients because of my race,” says Serena. “My disease causes me extreme pain and the only relief is medication, but healthcare providers often take one look at me and assume I am only there for drugs. So, while I am in pain I have to advocate for myself and I feel pressure to act or dress a certain way to be taken seriously.” Racism and other social determinants of health exacerbate the issues Serena and others face. “When we think of complex patients, we picture an aging population with multiple chronic diseases,” says Dr. Gary Newton, Sinai Health System’s President and CEO. “It’s important we all understand that inequity and racism are disease equivalents in terms of their impact. They contribute to complexity and poor outcomes in the same way diabetes and hypertension do.” A new report that emerged from the symposium suggests these challenges can be greatly reduced with targeted solutions, and makes recommendations for hospitals, community health
centres, primary care providers, the Ministry of Health and Long-Term Care, LHINs, Health Quality Ontario and police.
SYSTEM LEVEL APPROACH
The report recommends that Ontario’s Ministry of Health and LongTerm Care sets system-level accountability, together with LHINs and Health Quality Ontario. Proposed solutions include the development of a fully funded black health strategy, a separate strategy for more funding for black community mental health services, and funding to create culturally safe spaces for this community. The report also recommends that Ontario’s Ministry of Health and LongTerm Care and its LHINs can hold local healthcare providers accountable for the collection of socio-demographic data and race-based health-related data, and mandate health equity training across the province. Some are ahead of the curve. On behalf of the Toronto Central LHIN, Sinai Health System leads a transformative and first-of-its-kind Canadian
The report recommends addressing racism in hospitals, community health centres and primary care providers. “Healthcare providers can mitigate racial health inequities by being aware of how unconscious bias can affect diagnoses and treatment, and involving diverse groups of patients in designing our services and spaces,” says Marylin Kanee, Sinai Health System’s Director of Human Rights and Health Equity. “Hiring staff that represent our population and offering training around health equity, cultural safety and anti-oppression at all levels within healthcare organizations will also help move the marker on improving health outcomes for marginalized communities.”
IMPACT OF POLICING AND MENTAL HEALTH
The report also calls for continuous education for police officers about racism and mental health, accountability for police violence, and the development of mental health and trauma response teams to correspond with 911 calls. Sinai Health System’s and the Black Experiences in Health Care committee’s first symposium is just the beginning of an important, ongoing conversation. In the future, participants from the symposium would like several other topics to be discussed, such as barriers faced by black youth and black LGBTQ+ people, and intersections between black and Indigenous experience. The full report is available on Sinai Health System’s website at sinaihealthsystem.ca. ■ H
Ryan Joyce is a Communications Specialist at Mount Sinai Hospital, part of Sinai Health System. 36 HOSPITAL NEWS OCTOBER 2017
What lies at the core of Canadian Patient Safety Week? By Chris Power
sking someone why they do the things that they do can lead to a variety of responses. Some people might give you simple, closed answers, letting you know that their mind has been made up and their course is set. Still others might give you their entire life story as a preamble to why they do what they do in their lives, be it hobbies or working at a certain job. However, asking an organization why it does what it does isn’t as simple. At that point, you’re not asking the organization, you are asking every person who works within it why they do what they do. This question becomes all the more poignant when
Be sure to take full advantage of all the planned activities during Canadian Patient Safety Week: • Tune in to our brand-new PATIENT podcast series – a nonfiction medical drama about people trying to fix modern healthcare from the inside out. • Be sure to watch and share two new patient and provider videos. These personal stories remind us all why patient safety is so vitally important. • Test your medication safety knowledge and play the new medication safety quizzes for both patients and healthcare providers at asklistentalk.ca • Join in the fun and engaging contest for Canadian Patient Safety Week – Catchy Phrase Contest: Question Your Meds. If you have an idea for a catchy phrase to remember the 5 Questions, I want you to share it with us at asklistentalk.ca www.hospitalnews.com
you’re asking about why we at the Canadian Patient Safety Institute (CPSI) host our annual Canadian Patient Safety Week (CPSW). Over the years, CPSI has championed our vision of safe care for all Canadians. For me, this vision has a special place in my heart. I have worked in healthcare for a long time, beginning my journey as a nurse, and many years later, serving as CEO of Capital Health in Nova Scotia. I have always focused on moving forward with new practices that can help drive awareness and improvement of patient care. Believe me, I want people to be able to trust the healthcare system as much as we at CPSI do. This circles back to why we host Canadian Patient Safety Week. The week is an annual campaign created in 2005 to inspire and celebrate extraordinary improvement in patient safety and quality. Over the years, it has been a relevant resource for anyone who participates in the healthcare system, from organizations to providers to patients and citizens. However, this campaign is more than just a week of activity for participants. What Canadian Patient Safety Week provides is a voice for patients, healthcare providers, and their families. It provides an opportunity for people who have been negatively impacted by the healthcare system with a chance to share their stories and their experiences. This year, the act of giving patients, providers, and families a voice is particularly relevant. Our theme, Take With Questions, highlights the importance of encouraging healthcare providers, patients, and their families to speak up and ask the Five Questions to Ask About Your Medications. These questions, crafted by CPSI, Patients for Patients Safety Canada, the Canadian Pharmacists Association and the Canadian Society for Hospital Pharmacists, have been tailored to get to the heart of how medication should be handled. They are:
• Changes – Have any medications been added, stopped or changed, and why? • Continue – What medications do I need to keep taking and why? • Proper Use – How do I take my medications and for how long? • Monitor – How will I know if my medication is working, and what side effects do I watch for? • Follow-up – Do I need any tests and when do I book my next visit? These five questions provide a starting point from which to start a
conversation about medication safety. It is this conversation which expresses the core values that Canadian Patient Safety Week strives to uphold. I encourage you to get involved with our campaign this year. You can check out the online resources at asklistentalk.ca and participate on social media. I would love to see what your organization is doing on social media as well. Tweet using the #asklistentalk and follow CPSI @ H Patient_Safety. ■
Chris Power is CEO, Canadian Patient Safety Institute.
OCTOBER 2017 HOSPITAL NEWS 37
Opioid strategy puts patient and public safety first by ensuring appropriate opioid prescribing by physicians
By Dr. David Rouselle he opioid epidemic has been described as the biggest drug safety crisis of our time. The College of Physicians and Surgeons of Ontario (CPSO) is concerned about the devastating consequences opioid abuse, misuse and diversion are having on patients, their families, and communities, with an escalating number of overdose poisonings and deaths – this problem touches us all. Opioid abuse and misuse are highly complex issues involving both illicit and prescription drugs, and there are no quick solutions to this problem. While prescription opioids are an important and useful therapeutic tool for select patients with certain conditions, prescription opioids carry risks, even when prescribed and used appropriately. There are many contributing factors to the opioid crisis, however, well-meaning prescribing by physicians has contributed to the problem, and improvements to prescribing practices must be part of the solution. As the regulatory body for physicians in Ontario, the CPSO is mandated to serve and protect the public. This includes ensuring that physicians appropriately prescribe opioids. Our Opioid Strategy comprises a four-pronged approach reflecting our mandate, namely to: Guide; Assess; Investigate; and Facilitate Education for Ontario’s doctors. The strategy is contingent on effective communication and collaboration with physicians, the public and health-system partners, and using data and analytics to inform prescribing practices and our regulatory responsibilities. Patient and public protection are at the forefront of the CPSO’s Opioid
THERE ARE MANY CONTRIBUTING FACTORS TO THE OPIOID CRISIS, HOWEVER, WELLMEANING PRESCRIBING BY PHYSICIANS HAS CONTRIBUTED TO THE PROBLEM, AND IMPROVEMENTS TO PRESCRIBING PRACTICES MUST BE PART OF THE SOLUTION Strategy. Our objectives are to facilitate safe and appropriate opioid prescribing by physicians to patients; protect patient access to care; and reduce risk to both patients and the public. Key College activities and elements of our Opioid Strategy which promote appropriate opioid prescribing include: Guidance – Our Prescribing Drugs policy articulates principles of good practice that apply when prescribing any drug and includes specific expectations for appropriate prescribing of narcotics and other controlled substances. The physician’s role is emphasized in preventing and addressing the risk of abuse, diversion, addiction, and overdose that may arise when opioids are prescribed. The policy also reflects the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain, and includes updated guidance on alterna-
tive treatment options; selecting appropriate doses; monitoring patients for signs of addiction; and tapering. Assessments – Our assessments of family physicians and other specialty practices have always looked at prescribing practices when applicable, and will include a new emphasis on opioid prescribing. We are also exploring an alternative approach to responding to potentially moderate-risk prescribing by conducting focused assessments. Our goal is to support continued prescribing when it is appropriate and informed by both clinical guidelines and CPSO policy. Investigations – We will continue to work with the Ministry of Health and Long-Term Care to identify levels of opioid prescribing and investigate prescribing practices that may be harmful to patients. We recently provided an update on the status of
investigations that arose from potentially concerning data received from the province’s Narcotics Monitoring System. While investigations may identify instances of risk of harm to patients when opioid prescribing is continued, there is also a very real risk of harm to patients when opioid prescribing is discontinued. That’s why we have taken a remedial approach, whenever appropriate, to help physicians practise to current standards. Our goal is to support education and continued prescribing under supervision, where the physician’s capacity for remediation is apparent. We are also urging physicians to not suddenly cease prescribing to patients currently on opioid therapy. Opioid-use disorder and chronic pain are health conditions like any other, and treatments should include all the elements of good practice including treating patients with respect and compassion. For some, this may include several tactics including a slow taper or opioid replacement therapy/ referral to a substitute treatment program for methadone or suboxone. Facilitating education – We are collaborating with many partners to ensure that physicians receive the education, training and resources they need to appropriately prescribe opioids. Our role is to identify and connect physicians with learning needs to educational resources to improve their prescribing practices. We stress that health system-wide solutions and collaboration amongst government and government agencies, health-care educators, regulators, doctors and other health professionals, and patients are required to address the opioid crisis. All of the CPSO’s efforts are grounded in a steadfast commitment to improved patient and H public safety. ■
Dr. David Rouselle is President, College of Physicians and Surgeons of Ontario. 38 HOSPITAL NEWS OCTOBER 2017
FROM THE CEO’S DESK
Culture matters By Dr. Bob Howard imon Sinek, in his book, Start with Why said, “Customers will never love a company until the employees love it first.” Like any organization, a hospital’s culture is the glue that helps hold everything together, the compass that provides direction. It drives decision-making and priority setting. It helps attract and retain employees. It frames how people are treated and sets the stage for how we treat our patients. When teams or organizations integrate, it’s important to understand each other’s cultures. Like taking a patient’s vitals, assessing your culture helps determine the health of your organization and where you need to focus to improve. That’s why in exploring the voluntary integration of Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital, we decided to conduct a cultural assessment. All three hospitals were founded by the Sisters of St. Joseph, so we already knew we had been left a similar legacy in our missions and values. The goal of the review was to talk to front-line staff, physicians, volunteers, senior leaders and board members to get a deeper understanding of what was intrinsically valued and sacred from a cultural perspective for each organization.
Through an engagement process conducted by an outside consultant, we asked a series of questions about organizational culture, what qualities and supports are unique to each organization, what is valued and fundamental, the role of leadership in influencing culture, communications, learning and development, organizational capacity, and staff retention, recognition and wellness. We wanted to learn what was valued and should be preserved. Given that we were all founded by the Sisters of St. Joseph, it is not surprising that the consultant’s report showed we are more alike than different, that we are a “good fit.” But each of the cultures has evolved in unique ways that needed to be understood and respected. The culture assessment found we have common values, but one that stood out was the intrinsic value and dignity of every human being and our commitment to care for the most marginalized or disadvantaged in the community. Our employees said they are also proud of the way we support our colleagues – we go above and beyond to help each other. And that recognition events and initiatives are important and should be preserved. We also heard, across all three sites, that people appreciated being
Dr. Bob Howard. given the opportunity to be heard and asked their opinions during the planning stage.
Not surprisingly, then, another recurring theme was the request for the new senior leadership team to be transparent in its communications. “Keep us posted about development – even if there aren’t any or even if you don’t have a plan.” By understanding what each organization values, the leadership team can now strive to preserve what legacy each hospital finds culturally significant, while also creating an innovative direction for the future. It’s also told us we have some work to do on building relationships across the sites to build networks and opportunities to collaborate.
THE CULTURAL ASSESSMENT WAS THE FIRST STEP IN OUR INTEGRATION JOURNEY
August 1 was the first day for our newly amalgamated organization. It’s still early days for us with many more lessons to be learned. Given the fierce loyalty within each organization, and some understandable anxiety over the change, the cultural assessment process set a demonstrated standard that employees’ opinions are valued, and will continue to be valued, as the integration moves forward. For more information on the integration between Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital, visit OurSharedPurpose.com. ■ H
Dr. Bob Howard is president and CEO of the health network uniting Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital.
OCTOBER 2017 HOSPITAL NEWS 39
High rates of antipsychotics prescribed to adults with developmental disabilities By Yona Lunsky n August, we published the first Canadian population based study on antipsychotic prescription patterns for adults with developmental disabilities, based on over 50,000 Ontario adults. Our study, a collaboration between the Ontario Drug Policy Research Network (www.odprn.ca) and the Health Care Access Research and Developmental Disabilities Program (www.hcardd.ca) revealed that over a six year period (between 2010 and 2016), 39.2 per cent of these adults had at least one antipsychotic prescription filled. This proportion rose to over 50 per cent of adults living in group home settings. These medications are not prescribed in isolation. The median number of drugs dispensed per person in the year prior to the study was seven. One in six adults with developmental disabilities prescribed antipsychotics had diabetes, and one in five
40 HOSPITAL NEWS OCTOBER 2017
had hypertension. Hospitalizations in this group were common. Importantly, not all of the individuals who filled these prescriptions had a psychiatric diagnosis. Forty per cent of them had a major mental illness diagnosis and 29 per cent did not have a current psychiatric diagnosis of any type. Those with and without a psychiatric diagnosis differed from one another clinically, and in terms of their health service use. Knowing about high medication use in this population is important for all hospital staff. The first time individuals get prescribed these medications may be during an inpatient or outpatient hospital visit. Complications related to these medications, including falls, diabetes, cardiovascular adverse events and drug interactions, whether they are prescribed inside or outside of hospital, can also lead to hospital visits. This is because individuals with developmental disabilities can have
multiple medical concerns, combined with difficulties self-reporting, monitoring and managing side effects.
ANTIPSYCHOTICS IN CRISIS
Hospital staff may be the prescribers of antipsychotic medications. Individuals with developmental disabilities may present to the hospital emergency department as agitated or aggressive. This may be due to a serious mental illness, but it can also be due to unrecognized medical issues or situational factors. Therefore, understanding how to assess mental health problems and knowing best practices with regard to medication prescribing and developmental disabilities is crucial. Guidelines here and from other jurisdictions emphasize that antipsychotics should not be the first line treatment for â€œchallenging behaviour.â€? According to NICE guidelines from the UK, anti-
psychotics should only be offered after other interventions targeting challenging behaviours have failed, when treating coexisting health problems does not improve behaviour, and when the risk to the person or others is severe. In practice, this means that we should be careful not to offer an antipsychotic medication as a first line treatment for behaviour when someone comes into hospital, and if it is being used in a crisis situation, it should only be done so on a short term basis.
THE IMPORTANCE OF MEDICATION MONITORING TO PREVENT FURTHER HEALTH ISSUES
Antipsychotic medications, without proper monitoring, can lead to serious health complications, which may even lead to hospital visits and admissions in the developmental disabilities popwww.hospitalnews.com
ulation. One H-CARDD study reported, for example, that adults with developmental disabilities and diabetes were 2.6 times more likely to be hospitalized for a diabetes related complication than other adults with diabetes. Diabetes could be caused by or exacerbated by antipsychotics use. A second H-CARDD study reported on high rates of several adverse outcomes after starting antipsychotics, including death, in a cohort of men and women with developmental disabilities. In the UK, a recent study reported that movement disorder side effects were more commonly observed in those with developmental disabilities than other adults prescribed these same medications. Knowing how to monitor antipsychotic medications and their role in contributing to other health issues is crucial. At the very least, it is essential that any new prescriptions
UNDERSTANDING HOW TO ASSESS MENTAL HEALTH PROBLEMS AND KNOWING BEST PRACTICES WITH REGARD TO MEDICATION PRESCRIBING AND DEVELOPMENTAL DISABILITIES IS CRUCIAL of antipsychotic medications or any medications provided in hospital must include plain language information about why the medication is being prescribed, and what to look for in terms of side effects. Canadian hospitals have several initiatives already in place when it comes to medication reconciliation, medication monitoring, and pharmacy consultations. The challenge is to think about how these efforts apply to individuals with developmental disabilities. It may be difficult for some
individuals with developmental disabilities to describe which medications are being taken and why, for example, during the medication reconciliation process, especially when there are multiple medications prescribed by different providers over a long period of time. Collateral information can be very helpful in these situations. Hospital staff can use this opportunity to engage with outpatient prescribers and pharmacies to understand their history with the medications and assess if they are all needed. Medication passports
can also be valuable. Dr. Barry Jubraj, a pharmacist and parent of someone with a developmental disability, has spoken to the ways in which pharmacists can better support patients with developmental disabilities, including how medication passports (also available as a free app) can be incredibly useful. Hospitals can also play an important role around medication education and medication monitoring for those with developmental disabilities. Colleagues from the UK have developed resources to assist healthcare providers, pharmacists, patients and carers to more carefully review and monitor antipsychotic medications, as part of the STOMP initiative. Moving forward, it is important that Canadian hospitals work together with patients and carers to explore the resources currently available, and to develop resources where there are gaps. â– H
Yona Lunsky, Ph.D., C.Psych. is H-CARDD Director and Senior Scientist at The Centre for Addiction and Mental Health; Professor and Developmental Disability Lead, Department of Psychiatry, University of Toronto.
BC Ministry of Health Substance Use Services’ patients expressing themselves through art as a way to work on their emotional healing, awareness and development.
Trauma-informed practice improves care and promotes safety at Forensic Psychiatric Hospital By Carol Swan ore than three quarters of Canadians report they’ve experienced some potentially traumatic event in their lifetimes. At the Forensic Psychiatric Hospital in Coquitlam, BC, researchers found that ALL of the hospital’s patients had experienced some form of trauma and many reported multiple childhood adversities and victimization or violence across their lifetimes. “Trauma” is defined by the BC Ministry of Health as “an experience that overwhelms an individual’s capacity to cope”. Since the ministry released its Trauma-Informed Practice Guide in 2013, BC Mental Health and Substance Use Services (BCMHSUS), the agency responsible for the Forensic Psychiatric Hospital (FPH), the Burnaby Centre for Mental Health and Addiction and other adult mental health and substance use program, has introduced a trauma-informed approach.
42 HOSPITAL NEWS OCTOBER 2017
TRAUMA-INFORMED CARE IS MUCH LIKE TAKING UNIVERSAL PRECAUTIONS TO PREVENT INFECTIONS – WE ALWAYS NEED TO TAKE TRAUMA INTO CONSIDERATION “At the hospital we care for people involved with the criminal justice system who have been found Not Criminally Responsible Due to Mental Disorder,” says Angela Draude, the hospital’s Executive Director. “This can be a challenging patient population, but when we operate with the assumption that patients have some form of trauma in their backgrounds we can approach them with more understanding.” Research shows that the majority of the hospital’s patients, 67 per cent,
have experienced four or more traumatic events in childhood and adulthood. A history of more than four events is seen as a “tipping point” for a significant increase in mental, physical and lifestyle problems. “Trauma-informed care is much like taking universal precautions to prevent infections – we always need to take trauma into consideration,” says Dr. Tonia Nicholls, a professor in psychiatry at UBC who is co-leading the research at BCMHSUS. The awareness that so many patients have experienced trauma has
had a profound impact on how the hospital delivers care. BCMHSUS’ trauma-informed practice steering committee includes a working group dedicated to using a trauma-informed approach at the hospital. The hospital takes a “four pillar” approach to trauma-informed practice. The first pillar involves building awareness of how common it is to have traumatic experiences. Last year, BCMHSUS hosted a workshop on how to bring a trauma-informed, compassionate lens to interactions with patients and colleagues. Dr. Maggie Bennington-Davis, chief medical officer for Health Share of Oregon, presented on the importance of brain health in infancy and childhood, the implications of the Adverse Childhood Experiences Study, as well as strategies for lowering stress and heart rates, building resilience, and ensuring safety for clients, physicians and staff. www.hospitalnews.com
FOCUS The second pillar emphasizes safety and trustworthiness. Dr. Nicholls says this is especially important when working with clients with a trauma history because they have often experienced unsafe relationships and living situations which can make it difficult for them to trust others. “It’s important to follow through. Do what you say you will do, when you say you will do it. Be consistent and predictable in meeting appointments and expectations,” says Dr. Nicholls. “If you’re not trustworthy it can reinforce a client’s damaging belief that they don’t matter.” The third pillar is to offer the opportunity for choice, collaboration and connection. This is put into action by engaging patients in decisions about their care and trying to create a non-hierarchical and supportive atmosphere. Care providers who recognize their own triggers can role model emotional intelligence for patients. At FPH, there are ongoing discussions with patients
about what might upset them and how they can cope. At the intake assessments, nurses ask patients about what sets them off and what helps them to ground themselves. The fourth pillar is about building strengths and skills. Clients with a history of trauma often experience self-loathing and guilt. A trauma-informed approach helps them to identify their strengths and build resilience. For example, BCMHSUS uses a tool called the Short-Term Assessment of Risk and Treatability (START) to assess
patients. Unlike traditional approaches to risk assessment, the START considers the patient’s strengths as well as risk factors. A trauma-informed approach, combined with a clinical program redesign, has led to a notable decline in the use of seclusion for psychiatric patients. The Canadian Patient Safety Institute sees seclusion as a last resort to control behaviour in an emergency. The rate of seclusion per 1,000 patient days at FPH has dropped from 88 to 58 in the past three years. The number of
new episodes of seclusion has dropped from 70-80 new seclusions a month in 2015/16 to an average of about 40 a month in 2016/17, with further reductions expected. At the same time, staff safety is also improving. Over the last few years, violent injuries resulting in time loss WorkSafe BC claims have been reduced from 94 in 2015 to a forecasted estimate of 54 by the end of 2017. These improvements are seen as a result of the hospital’s approach to care and preventative measures established with management and union representatives. BCMHSUS, an agency of the Provincial Health Services Authority, integrates trauma-informed practice in all of its services, including all of its adult mental health and substance use programs. It will also bring a trauma-informed approach to the provincial prison system as it begins to provide health services at all BC provincial correcH tional centres on October 1, 2017. ■
Carol Swan is the Communications Manager, BC Mental Health and Substance Use Services.
OCTOBER 2017 HOSPITAL NEWS 43
Investing in innovation
to make life better for chronic kidney disease patients By Stephen Thompson he Kidney Foundation of Canada estimates that one in 10 Canadians has kidney disease, with millions more at risk. When the kidneys fail, patients require either a transplant or dialysis to clean the blood of toxins and remove extra fluid. Dialysis treatment at a hospital or clinic can sometimes take up to four hours each session, depending on the dialysis prescription, and these sessions can be required up to three times per week. The Canadian Institute for Health Information reports that each year, more than $2 billion is spent providing dialysis to Canadians, with approximately 15 per cent of this cost due to complications arising from dialysis that result in patients needing to be hospitalized.
uncertainty of the future. The wait for a transplant can be very long (the current average wait time for a kidney in Ontario is seven years, according to the Trillium Gift of Life Network) and there are no guarantees. Kidney failure is a difficult journey for patients from all walks of life. For some chronic kidney disease patients, however, there is an alternative to dialysis in a clinic or hospital setting. Patients undergoing Peritoneal Dialysis (PD) therapy, which works by cleaning the blood of toxins and removing extra fluid through the body’s peritoneal cavity, can be performed at home. Home dialysis allows patients to direct their own care, keeping them out of hospitals and clinics. It can proceed while
DIALYSIS UNDERTAKEN AT HOME COSTS THE HEALTH SYSTEM UP TO 50 PER CENT LESS THAN WHEN IT IS PERFORMED IN HOSPITAL In many cases we can assume that, all else being equal, patients want to receive care at home. We know that clinicians and healthcare providers want to offer the best, most effective care. The future of healthcare in Canada will be to facilitate both, through remote patient management and twoway technology. Dialysis is not only costly to the Canadian healthcare system; it also comes with a personal cost for patients. In addition to the time spent in treatment, patients can feel drained following their session, both physically and mentally. There are dietary restrictions and limitations on normal activities of living, all while facing the
the patient sleeps and can even be adjusted according to work, school or travel schedules. According to The Kidney Foundation of Canada, dialysis undertaken at home costs the health system up to 50 per cent less than when it is performed in hospital. With new technology and therapy options available to renal patients today, physicians can better determine the right therapy for the right patient at the right time in their treatment journey. In 2016 there were over 5000 home dialysis patients in Canada. Baxter’s AMIA with SHARESOURCE, launched in Canada this year, is the first peritoneal dialysis (PD) system in Canada to provide two-way con-
Stephen Thompson nectivity between patients at home and healthcare providers. AMIA was designed to allow patients to administer their own PD therapy in the home setting with intuitive features such as voice guidance, a touchscreen control panel and the SHARESOURCE remote patient management platform. SHARESOURCE allows healthcare providers to securely view their patients’ home dialysis-related treatment data that is automatically collected after each PD session. Healthcare providers can then act on this information, if required, by remotely adjusting their patients’ home device settings without requiring them to travel to the clinic. The SHARESOURCE system also provides a patient’s healthcare team better visibility to their missed treatments. The healthcare provider can then proactively follow up with their patient to address any potential issues. AMIA with SHARESOURCE is just the latest example of Baxter Canada’s commitment to improving the lives of patients through innovation, research and development. Celebrating 80 years in Canada this year, we look forward to how we can continue to build on our legacy of making lives better for patients. Since 1937 Baxter has been responsible for introducing some extraordinary medical breakthroughs to
Canadian patients and healthcare professionals. Our Alliston manufacturing facility, marking their 60th anniversary in 2017, is the only large-scale plant in Canada to produce life-sustaining intravenous and dialysis solutions. It was there in 1977 that the world’s first peritoneal dialysis solutions were produced in plastic, rather than glass, containers, making continuous dialysis therapy a possibility. To advance hospital care, we were the first to introduce a needle-less system for IV therapy, protecting healthcare workers from needle-stick accidents, and the first to produce a commercially available slow setting fibrin sealant used to adhere skin grafts in burn patients. Today, you can find Baxter products and services touching the lives of patients at every step of their healthcare journey, in hospitals and dialysis clinics across the country. In 2016 over 800 Canadian hospitals procured products from Baxter. Our mission to save and sustain lives inspires our commitment to elevate standards of care and deliver care more efficiently. We will continue to invest in research and development to support advancing healthcare practices and treatments. Baxter is proud to be a partner in Canadian healthcare. We look forward to another 80 years. For more H information: www.Baxter.ca. ■
Stephen Thompson is President, Baxter Canada 44 HOSPITAL NEWS OCTOBER 2017
What are the key features in pharmacy practice? By Puja Modi and Certina Ho ecently, there has been a growing interest in measuring safety culture, as it can impact patient outcomes and healthcare costs. Safety culture is not just a mere compilation of safety initiatives. It is the shared beliefs and values at a workplace that inspire all workers to give their attention to safety. In healthcare, we must evaluate the safety culture to help ensure that we have an adequate risk management system in place for delivering quality care and patient safety. There are four main features, according to the Agency for Healthcare Research and Quality (AHRQ), to consider when optimizing a healthcare organization’s safety culture. These features will be discussed below, with the support of a case example: A patient normally takes two pills in the morning, but this time she was dispensed eight pills for the morning in her blister pack. The patient realized this difference and contacted her doctor to see if any changes in her medications were made. The doctor clarifies that no changes had been made. The pharmacy dispensed the wrong medications, as they were intended for another patient with the same first name. Personal and medical information for this other patient was also given with the blister pack. The patient identified the discrepancies before any dose was taken.
1. ACKNOWLEDGE THE HIGH-RISK NATURE OF HEALTHCARE AND ATTEMPT TO ACHIEVE CONSISTENTLY SAFE OPERATIONS
A healthcare organization should attempt to become a highly reliable organization (HRO). An HRO has a system, which has been developed to minimize risk and prevent errors, yet still anticipating unexpected errors and system failures. HROs proactive-
Levels of Error
At Risk Behaviour
Clear ignoring of the required steps for safety
Response to Error
Figure 1. Three Levels of Error in Just Culture ly look for possible areas of risk, and quickly resolve the issues detected. In the case scenario above, the pharmacy reflecting on the error would be considered retrospective. To be an HRO, the pharmacy should have previously identified the high-risk processes in blister pack preparation, and proactively addressed potential risks before the incident occurred.
2. CREATE A BLAMEFREE ENVIRONMENT WHERE INDIVIDUALS FEEL COMFORTABLE REPORTING ERRORS OR NEAR MISSES
For any error that occurs, most individuals would immediately want to blame someone. This blaming culture in healthcare may make people uncomfortable and prevent them from reporting, which can result in impairment of safety culture advancement. Though we may encourage organizations to have a blame-free culture, some accountability should be required. Therefore, a blame-free culture and the need for accountability have been integrated to what is called “just culture”. The main goal of just culture is to identify and address issues at the system level that may lead individuals to engage in unsafe behaviour. In just culture, there are three levels of errors to consider (Figure 1). The response to the error or the corresponding method of management will depend on the type of behaviour, and
not the severity of consequences due to the error (Figure 1). In case example above, a possible human error would be unintentionally missing the fact that the last name of the patient was incorrect; an at-risk behaviour could be poorly completing the technical and therapeutic checks of a prescription; and reckless behaviour would be skipping the checking steps altogether. Even if the patient was not harmed in this case, it is important to take the required action and learn from this incident.
3. ENCOURAGE COLLABORATION TO SEEK SOLUTIONS TO PATIENT SAFETY ISSUES
When seeking solutions to patient safety issues, it is important to involve all individuals who are in the circle of care of the patient, as it can lead to better patient care, safety optimization, and work efficiency. This can help create a mutual support structure that can coordinate and resolve safety culture problems. Also, shared learning is imperative. Once problems have been identified and resolved, dissemination of information as well as potential risks or contributing factors of the incident is very important. In the case example above, the pharmacy should be discussing the incident and potential contributing factors and subsequent solution as a team, allowing participation from all.
This is a learning opportunity, which can help ensure a similar mistake will not happen again.
4. COMMIT RESOURCES TO ADDRESS SAFETY CONCERNS
This commitment can entail of pledging more resources or staff time towards patient safety, providing more safety related education, improving system-based processes, creating an anonymous or blame-free reporting culture, using advanced technology, and evaluating patient safety in the organization. System-based commitments are more impactful in mitigating risks than person-based strategies. This is due to a lack of requirement for individual attention and vigilance. Under the circumstances of limited budget and resources, system-based changes may not be always feasible. Hence, person-based strategies should not be ignored either. For the above case scenario, the pharmacy may consider dedicating more resources to improve safety culture of the work environment. An example of a person-based strategy is to provide the pharmacy team with education and standard operating procedures in blister pack preparation. System-based changes may include the implementation of advanced technology in blister packing or outsourcing blister-pack preparation to an off-site H automated dispensing system. ■
Puja Modi is a PharmD Student at the Leslie Dan Faculty of Pharmacy, University of Toronto; Certina Ho is a Project Lead at the Institute for Safe Medication Practices Canada (ISMP Canada). www.hospitalnews.com
OCTOBER 2017 HOSPITAL NEWS 45
What doctors can do to prevent medical errors during transfer of care By Michael Wong and Stephen Routledge edical errors can be costly for both patient and hospital. As defined by The Joint Commission: ‘Transitions of care’ refer to the movement of patients between healthcare practitioners, settings, and home as their condition and care needs change. For example, a patient might receive care from a primary care physician or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she may receive care from a visiting nurse or support from a family member or friend. A 2012 Joint Commission report focusing on transitions of care estimated that 80 per cent of medical errors involve miscommunication between caregivers during handoff between medical providers. In a 2016 presentation Helen Haskell, President, Mothers Against Medical Error and Consumers Advancing Patient Safety showed that medication errors are the leading cause of medical harm and extended stays in hospital patients. Patients are estimated to be exposed to one medication error each day, and one in four hospital errors occur during prescription or administration. According to the World Health Organization, global costs associated with medication errors are US$ 42 billion annually. In order to keep patients safe, clinicians should focus on three key points along the patient’s continuum of care: 1. Upon admission to the healthcare facility 2. During patient recovery at the healthcare facility 3. Upon discharge from the healthcare facility
oid-related respiratory depression. A key study by Melissa Langhan (Melissa Langhan, MD (Assistant Professor of Pediatrics, Emergency Medicine, Yale School of Medicine), quantified this as an average of 3.7 minutes quicker than pulse oximetry monitoring.
Patient admission is a critical time for risk assessment. Clinicians should
PATIENT TRANSFER AND DISCHARGE
80 PER CENT OF MEDICAL ERRORS INVOLVE MISCOMMUNICATION BETWEEN CAREGIVERS DURING HANDOFF BETWEEN MEDICAL PROVIDERS employ screening tools to identify high-risk patients before procedures. As examples of screening that should occur on admission, according to recommendations released by expert panels brought together by the Physician-Patient Alliance for Health & Safety, assessments should be done particularly for: • Maternal patients • Stroke patients Moreover, because we are in the midst of an opioid epidemic, patients potentially receiving opioids can be assessed using the Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose (RIOSORD), an analytical model designed to define elevated risk of overdose or life-threatening respiratory depression. It is crucial that the results of these tests be quickly communicated to all clinician teams responsible for the patient through their stay. This includes special
attention to the patient’s current medication and any existing conditions.
As patients recover from procedures, it is common for Patient Controlled Analgesia (PCA) pumps to be employed to manage pain. For the opioid naive, incorrect dosages can lead to opioid-related respiratory depression. Research published in Anesthesia & Analgesia suggests that an electronic checklist may help, especially during intraoperative transfers of care. The PPAHS PCA Safety Checklist is a free downloadable resource developed by a panel of experts to reduce the risk of opioid-related adverse events. Continuous electronic monitoring should also be employed for all patients receiving opioids. This includes the use of pulse oximetry and capnography monitors. Intermittent spot checks are not sufficient to detect the signs of opi-
Patients’ non-adherence to physician-recommended medical treatment remains a persistent problem. It is estimated that 50 per cent of patients do not take their medications as prescribed. Consequently, clinicians should take steps to actively engage patients and their families as partners in their health. Most importantly, before transfer and discharge clinicians should ensure that patients have the information they need to use their medications safely. Clinicians should make sure that their patients understand the answers to the following five questions about their medications: 1. Have any medications been added, stopped, or changed, and why? 2. What medications do I need to keep taking, and why? 3. How do I take my medication, and for how long? 4. How will I know if my medication is working, and what side effects do I watch for? 5. Do I need any tests and when do I book my next visit? We encourage clinicians to download a PDF version of these five questions and share with their patients here. The tool was jointly developed by several organizations aiming to improve communication between patients and their caregivers with prescribers. It is available in over 22 languages and can be customized with a logo for implementation in a healthcare facility. For more resources dedicated to patient safety, please visit the CPSI and H PPAHS websites. ■
Michael Wong, JD, is the Founder & Executive Director of the Physician-Patient Alliance for Health & Safety and Stephen Routledge, MPH, is Patient Safety Improvement Lead, Canadian Patient Safety Institute. 46 HOSPITAL NEWS OCTOBER 2017
Reducing stigma, gaining compassion By Courtney Morgan he Canadian Mental Health Association defines stigma as a negative stereotype. Individuals who live with a mental health condition are often afflicted by stigma and discrimination. This negative stereotyping behaviour is a sad realism for those living with a mental illness, and it can ultimately prevent them from seeking the help they need. For Catholic Central High School student Mari Pullman, stigma has been completely eliminated from her perceptions after volunteering at Southwest Centre for Forensic Mental Health Care.
Catholic Central High School student Mari Pullman smiles in Southwest Centre for Forensic Mental Health Careâ€™s Sunset Variety store.
HEREâ€™S HER STORY:
Mari has always had a strong interest in forensic psychiatry. To help her explore this passion, she decided to volunteer at Southwest Centre for Forensic Mental Health Care, where she was assigned to the Sunset Variety store. For three to four hours every Thursday, Mari helps to manage the cash, restock shelves, sell a variety of goodies and â€“ her favourite part of the job â€“ spend as much time as possible connecting with patients. However, before Mari started, she had some fears about what her experience would be like. Movies, television and media had created preconceptions
about people living with mental illness and although Mari felt confident starting at Southwest Centre, she knew she was holding onto a few hesitations and worries that she would need to overcome. Today, nine months into her experience at Southwest Centre, Mari no longer carries the burden of stigma towards the patients she serves. Through volunteering her time, she has established friendships with some of the patients who visit her regularly to chat and share their stories. â€œI have had an amazing time getting to know, and trying to understand, the patients I have had the privilege to meet,â€? says Mari. â€œTheir friendliness and kindness has allowed me to overcome ignorance and wrongful perceptions.â€?
Itâ€™s been a true life lesson for Mari who explains that she understands the importance of getting to know people before judging them â€“ a lesson she can apply across all areas of her life. This experience will also help prepare her for the future since she has recently accepted her offer of admission to Kingâ€™s University College where she will study Social Sciences with a special focus on Criminology. â€œI have gained a sense of understanding and compassion,â€? says Mari. â€œPsychiatric patients, especially those who have committed acts deemed criminal, are often, unfortunately, left at the outside of society. I hope the work I do in the future can help create a change for those living with mental H illness.â€? â–
Courtney Morgan is a Communications Assistant at St. Josephâ€™s Health Care London.
RN, RPN, PSW & Therapists for Full time and Part time roles across Ontario
Saint Elizabeth is a national health care provider that has been opening the door to new possibilities and care experiences for more than a century. Recognized as Canadaâ€™s largest social enterprise, we employ 8,000 people and visit 18,000 clients every day. Through the Saint Elizabeth Research Centre, our Health Career Colleges, our commitment to person and family centered care and the Saint Elizabeth Foundation, we are helping to make the future of health care brighter and stronger. -FBSONPSFBUXXXTBJOUFMJ[BCFUIDPNPSmOEVTPO5XJUUFSBU!4U&MJ[BCFUI4&)$ *GZPVKPJOPVSUFBNZPVXJMMCFDPNFBQBSUPGBEJTUJOHVJTIFE$BOBEJBO OPUGPSQSPmU organization with a century of experience. â€˘ You will have access to a total rewards t:PVNBZIBWFnFYJCMFXPSLJOHIPVST program which includes group â€˘ You will be provided with an extensive CFOFmUTBOEQFOTJPOQMBO paid orientation and preceptorship program â€˘ You may be eligible for our education bursaries and tuition assistance â€˘ You will be eligible for subsidized program RNAO/RPNAO memberships JOIN OUR All applicants must have a valid driverâ€™s license and HEALTH access to a car and current CNO registration CARE TEAM TODAY!
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OCTOBER 2017 HOSPITAL NEWS 47
Anita R A D I AT I O N T H E R A P I S T
We Represent We are proud to be the largest and most respected union of health-care professionals in Ontario. Why? Because we focus exclusively on improving working conditions for the nurses and health-care professionals who provide quality care to patients. We’re known leaders in collective bargaining and a prominent voice in the ﬁght for better care. Everything we do is about health care, always has been, always will be.
Let’s stand strong together. W W W. O N A . O R G
Focus: Patient Safety, Mental Health + Addiction and Research. Special: Health Achieve Guide Supplement