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Testing new ways to screen for loss of sensation in diabetic patients FOCUS IN THIS ISSUE

INSIDE

CARDIOVASCULAR CARE/ RESPIROLOGY/DIABETES

www.hospitalnews.com JULY 2016 EDITION | VOLUME 29 | ISSUE 7

High-tech heart-valve heals seniors too weak for open-heart surgery

Ethics .................................................... 7 From the CEO’s desk .........................12

Developments in the prevention and treatment of vascular disease, including cardiac surgery, diagnostic and interventional procedures. Advances in treatment for various respiratory disorders, including asthma and allergies. Prevention, treatment and long-term management of diabetes and other endocrine disorders.

Evidence Matters ...............................18 Nursing Pulse .....................................19 Long Term Care ..................................20 Careers ...............................................23

When more isn’t better Up to one third of medical care adds no value to patients

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Helping COPD patients

breathe easier By Melissa Di Costanzo

he Sumac Creek Health Centre will soon roll out a halfday health promotion program to help patients with chronic obstructive pulmonary disease to breathe easier. Chronic Obstructive Pulmonary Disease (COPD) is a lung disease that includes chronic bronchitis and emphysema, and develops over time. Symptoms include an ongoing cough that produces mucus, shortness of breath, wheezing and chest tightness. Registered nurse Carolene Garcia is a COPD champion who “quickly recognized this specific population has extensive needs – especially following discharge from hospital.” Garcia noted the COPD patients she works with are mostly low income, live alone with no social support, and have multiple co-morbidities. That’s why she is creating a program with a team-based approach: she will work with a pharmacist and dietitian, as well as other healthcare professionals, to assist with managing the disease and, most importantly, to improve patients’ quality of life. Patients with COPD are fearful of becoming short of breath and often arrive in the Emergency Department with an exacerbation, or a sudden worsening of symptoms. “I see patients with COPD struggle every day,” she says. The dietitian will work with patients to prevent or reverse malnutrition by implementing strategies to minimize weight loss and improve the ability to eat. The pharmacist will help with medication reconciliation, treatment optimization and patient education. Garcia, who will be the COPD resource, and the Sumac Creek RN team

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Letter to the Editor Re: Nursing Pulse Column June

Building up one group by tearing down another is never the right answer n May 9, the Registered Nurses Association of Ontario (RNAO) published a position paper called ‘Mind the Safety Gap: Reclaiming the Role of the RN’. This document and the ensuing campaign to promote it has been viewed by many in healthcare as an unapologetic attack on Ontario’s registered practical nurses (RPNs) and, in particular, their work in the acute care sector, where they have provided excellent care for many years. Our association avoids engaging in intra-professional conflicts in the press. Given the contents and recommendations of this document, however, there is no other alternative but to respond on behalf of the province’s 39,000 RPNs. This document contains inconsistencies, contradictions and misleading statements. It is based on questionable assumptions and uses partial statistics to support its premise. And while purporting to put patients first, in reality, this document questions the decision-making abilities of Ontario’s nursing leaders, prioritizes turfism at the expense of collaboration and seeks to elevate RNs by tearing down their RPN colleagues (who are regulated by the same college as RNs, the College of Nurses of Ontario, and required to practice to the same standards). RNAO uses the term ‘RN Replacement’ to imply a systematic campaign aimed at replacing RNs with RPNs. And while ‘RN Replacement’ makes for tantalizing headlines, this is an incredibly oversimplified label for the complex changes taking place in healthcare. The document compares the growth rates of RN and RPN positions but refers to them as ‘shares’ of nursing, with no definition of what a ‘share’ is. If a ‘share’ refers to a nursing position, the comparison would be inaccurate, since RPNs have a much lower full-time employment rate than RNs. Comparing positions in this manner would be ‘apples to oranges’. The document also promotes the idea of PSWs, RNs and NPs working to full scope of practice. Yet, when hospitals work to allow RPNs to work to their full scope of practice, they are accused of engaging in ‘RN replacement’. Ontario needs more of all categories of nurses working to their full scope of practice to service its healthcare needs. Among its recommendations, RNAO proposes that the MOHLTC develop a Health Human Resources

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Registered nurse Carolene Garcia is a COPD champion will manage patient cases, ensure patients have a good understanding of the disease process, refer patients to other allied health professionals, and connect patients to available community resources/ services such as pulmonary rehabilitation and home care. “Having a well-thought out collaborative plan of care can have a direct impact improving health outcomes and possibly decrease readmission to the hospital,” she says. Jacqueline Chen, the clinical leader manager at Sumac Creek, says Garcia and the rest of the primary care team are well-positioned to provide tailored care to this patient population. “With good, co-ordinated care and patient engagement, we can help prevent unnecessary visits to the Emergency Department,” H says Chen. n Melissa Di Costanzo works in communications at St. Michael’s Hospital in Toronto.

(HHR) plan to align healthcare needs with the various types of care providers. They propose their document should be the building block for that process. While we agree that it’s time to develop such a plan, it needs to be built from the ground up with input from all nursing groups as equal and respected partners. The document proposes that the Ministry issue a moratorium on nursing skill mix changes until the completion of the HHR plan. Yet, on the following page, it proposes sweeping and immediate skill mix changes. The document calls for the elimination of RPNs from Ontario hospitals. It is true that the majority of hospital patients require care by an RN. However, there are many patients in acute care (e.g. well moms, well babies and patients in continuing care, rehabilitation and less complex medical and surgical patients) for whom RPNs provide excellent care. In addition, 14 per cent of hospital patients today are classified as alternate level of care (ALC), or no longer requiring acute care, a patient population well within the appropriate practice of an RPN. RPNs absolutely have roles to play in acute care hospitals. For an outside group to suggest otherwise is offensive. The document uses the term ‘diploma-prepared’ to refer to RPNs. RNAO also refers to RPNs as ‘less qualified personnel’. Their document fails to mention that both categories of nurse have a wide range of educational backgrounds within their designations and there are fabulous nurses from both categories who are diploma-prepared. That is not to say that RPNs and RNs are the same – they are not. The point is that using RPNs’ education to attempt to diminish their effectiveness as care providers is wrong. An Ontario RPN’s education is comprehensive, grueling and, as is the case with many other health providers, has evolved immensely over time, providing these nurses with the expertise to do their jobs in all sectors of healthcare. Ontario is facing significant healthcare transformation. All of us need to be invested in addressing this challenge. However, holding back one group from practicing in the manner that they’ve been educated in order to advance another group is completely counter to that goal. Building up one group by tearing down another is never the right anH swer. We’re stronger together. n Sincerely, Dianne Martin, Executive Director The Registered Practical Nurses Association of Ontario (RPNAO)

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In Brief

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Cancer:

Wrong care in the wrong place Unnecessary hospitalizations due to chronic disease are reaching the tipping point of seriously harming this country’s healthcare system and do not meet the needs of patients and their families, according to a report by the Canadian Foundation for Healthcare Improvement (CFHI). According to CFHI, diseases such as chronic obstructive pulmonary disease (COPD) are placing a growing strain on Canada’s healthcare system. Of all chronic diseases, COPD is the number one reason for hospitalizations in Canada, accounting for the largest number of return visits to emergency departments. COPD also generates the highest volume of hospital readmissions. CFHI announced new results from a national initiative that shows hospitalizations due to COPD can be decreased by up to 80 per cent when healthcare is provided to patients and their families at home. This transformational approach not only improves quality of care, but would also avoid 68,500 emergency department visits, 44,100 hospitalizations and 400,000 bed days – saving $688 million in hospital costs over the next five years.

A conservative estimate finds that about 800,000 Canadians live with COPD, yet people with advanced COPD are among the highest users of Canada’s hospital resources. One in four Canadians over age 35 are expected to develop the disease in their lifetime, meaning the situation is forecast to worsen in coming years.

Of all chronic diseases, COPD is the number one reason for hospitalizations in Canada

“We knew this was coming,” says CFHI Vice-President, Programs, Stephen Samis. “Rising rates of chronic disease are straining our healthcare resources and staying the course is not an option. Canada continues to operate a healthcare system designed in the 1960s

THE IMPACT OF COPD ON HOSPITALS Province Territory

Canada

that focuses on expensive acute care rather than helping people manage their chronic diseases in the community.” CFHI, in collaboration with Boehringer Ingelheim (Canada) Ltd.,supported 19 hospitals from every Canadian province to provide more effective, efficient and coordinated care to patients living with advanced COPD and their families. The program, known as the INSPIRED collaboration, has enrolled 885 patients across Canada. For 146 of those patients who had participated in the program for a three- month period, their hospitalizations decreased by 80 per cent. Patients also reported greater selfconfidence, improved symptom management and a return to daily activities such as climbing stairs, exercising, travelling and returning to work. An independent analysis carried out by RiskAnalytica concluded that further expanding the CFHI/BICL INSPIRED collaboration would benefit 14,000 Canadians a year and save $688 million in hospital costs over the coming five years. For every $1 invested in the program, $21 in hospital-based costs could H be prevented. n

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QC

ON

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Rank as Chronic Disease Most Responsible for Inpatient hospitalization

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Number of inpatient Hospitalizations Average Length of Stay (Bed Days) of Inpatient Hospitalizations

87,975 1,777 554 2,989 3,161 25,285 27,749 2,929 3,795 9,149 10,341 99 95 82 7.6 8.6 8.7 9.3 8.9 8.3 6.4 9.4 7.4 8.2 7.6 6.5 3.5 6.9 Source: Hospital Morbidity Database, 2013_2014, Canadian Institute for Health Information

OTN creates app review partnership There’s more than one app for that – whatever “that” is. In fact, as recently reported in Hospital News, there are about 165,000 health or wellness apps out there. However, only a very small percentage of those apps are actually created by healthcare or science-based organizations. “For primary care providers who’d like to complement the care they provide to their patients – especially patients with chronic conditions – the difficulty is knowing which apps are evidence-based, userfriendly and secure,” says Dr. Ed Brown, CEO, Ontario Telemedicine Network (OTN). “OTN can make an important contribution by acting as a reviewer for apps,” he says, “using our experience and working with our partners to provide an assessment of how well apps fill the need they’re meant to serve.” www.hospitalnews.com

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To help OTN develop its app review – dubbed Practical Apps – Dr. Brown enlisted the help of Dr. Payal Agarwal, an Innovation Fellow at Women’s College Hospital Institute for Health System Solutions and Virtual Care (WIHV), who has a self-confessed passion for healthcare innovations. “The field of virtual healthcare is moving quickly. We want to be able to do rapid but reliable assessments to identify the tools that will actually help improve patient outcomes,” says Dr. Agarwal. “Apps and digital health tools should be engaging and very easy to use for patients, but they must also produce meaningful data for physicians.” Along with OTN Chief Medical Officer Dr. Rob Williams, Dr. Brown, Dr. Agarwal and a team of researchers at WHIV are developing a review of apps that address persistent patient conditions.

Each monthly review will address one topic, for example headaches and migraine, insomnia, hypertension or prediabetes, reviewing three to five of the best available apps for clinical evidence of effectiveness, usability, reliability, accessibility and privacy and security. “These are fairly common long-term primary care issues often tied to things like diet, exercise, lifestyle and medication compliance,” says Dr. Williams. “Useful apps can drive the focus of care back to the patient, helping them better understand the dynamics that influence their problems, and provide advice on ways to manage.” Practical Apps – available to healthcare providers, administrators and consumers – will be published online (www.PracticalApps.ca) beginning in H September. n

New Ontario cases have tripled since 1981

While the last three and a half decades have seen the number of new cancer cases nearly triple, survival from cancer has also steadily increased, according to a new report – Ontario Cancer Statistics 2016 – released by Cancer Care Ontario. In this first comprehensive look at the state of cancer in the province, Cancer Care Ontario has compiled data from the Ontario Cancer Registry to provide a clear picture of cancer, focusing on the incidence, mortality, survival and prevalence of the disease. The number of new cancer cases in Ontario is increasing and can largely be attributed to an aging population and population growth. At the same time, cancer survival for nearly all cancer types is improving and mortality rates are declining, particularly from breast, colorectal and lung cancers. The five-year relative survival for all cancers combined in Ontario is 63 per cent, which is a significant increase from 48 per cent in the mid-1980s. The report, which is a definitive source for cancer surveillance information for Ontario, will be published every two years. It is intended to support decision-makers, the public health community, healthcare providers, researchers and others in planning and evaluating population-based cancer control efforts, including those related to cancer screening, prevention and treatment. “This data emphasizes the importance of the work we’re doing with our partners to reduce the burden of cancer in the province,” says Dr. Prithwish De, Director, Surveillance and Cancer Registry, Cancer Care Ontario. “Moving forward, this report will serve as a resource for us and others to reference when making informed decisions, taking action and measuring the impact of our work.”

Key Statistics:

• Approximately 1 in 2 Ontarians will develop cancer in their lifetime and approximately 1 in 4 Ontarians will die from it. • Approximately 85,648 new cases of cancer are expected to be diagnosed in Ontario in 2016, which is almost triple the number of cases that were diagnosed in 1981 (29,649 cases) • There are now more people living in Ontario with a diagnosis of cancer than there were 20 years ago – an estimated 362,557 people as of January 1, 2013 (or about 2.7 H per cent of the population). n

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Combating the overmedication of seniors By Alan Cassels

he case of ‘too much medication’ in Canadian seniors is finally starting to be recognized for the serious problem it has become. Seniors are particularly vulnerable to the adverse effects of too many prescription drugs because aging affects their ability to process medications. Working aggressively to reduce their daily medication burden may be the single best thing we can do to improve the quality of life of our aging parents and grandparents. The statistics behind polypharmacy in the elderly – the term that describes the simultaneous use of multiple medications – are surprising. In Canada, nearly 70 per cent of all seniors take five or more drugs and almost 10 per cent take 15 or more medications. Many hospitalizations in the elderly are caused by adverse medication reactions. And one of the biggest health hazards for seniors is falling – often a result of multiple medications which can cause cognitive difficulties and affect balance. The good news is awareness of the scale of the problem is growing. More and more physicians are initiating “deprescribing” discussions with their older patients. “Deprescribing” is exactly how it sounds – the deliberate and conscientious stopping or tapering of prescriptions to help improve health outcomes. Some long-term care facilities are now required to do periodic medication reviews and weed out unnecessary, ineffective or hazardous pills. A recent massive Canadian Foundation for Healthcare Improvement demonstration project has shown how to reduce the inappropriate prescribing of antipsychotic medications to seniors with dementia. Programs, research initiatives and physician education activities on deprescribing are being carried out in most provinc-

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ADVISORY BOARD Cindy Woods,

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es. Canada’s new Deprescribing Network is developing tools and information to help make deprescribing commonplace and part of the prescribing culture. This is all a step in the right direction. Unfortunately, there’s still reluctance in some quarters to cut back on medications. Some health care providers have shown themselves to be nervous when initiating deprescribing activities, worried that they are reducing medications that specialists or other doctors have ordered.

In Canada, nearly 70 per cent of all seniors take five or more drugs and almost 10 per cent take 15 or more medications. Publicly funded “medication reviews” conducted by pharmacists can be flawed too, a CBC Marketplace investigation has found. Some reviews may be motivated by potential business reasons, resulting in more, not fewer pills for patients. The same report noted that even when done properly, medication reviews often miss the very patients who would benefit most from a review, such as the elderly or people on a high number of medications. More than 90 per cent of seniors say they want to reduce their medications if a doctor suggests it. And who can blame them? No one wants to be on a potentially expensive medication with possible side-effects and possible risks if they don’t absolutely require it. So what should be done?

Helen Reilly,

Publicist Health-Care Communications

Jane Adams,

President Brainstorm Communications & Creations

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Health care communications

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ANGEL EVANGELISTA CAROLINE PAPINEAU NICK MCGRAW RENATA VALZ JEFF CHARD ARUN PRASHAD ALICESA LAROCQUE KATHLEEN WALKER STEPHANIE GIAMMARCO BILLING AND RECEIVABLES

MATTHEW PICCOTTI PHIL GIAMMARCO

Alan Cassels is an advisor with the Evidence Network and a pharmaceutical policy researcher. He’s the author of The Cochrane Collaboration: Medicine’s Best Kept Secret.

Dr. Cory Ross,

B.A., MS.C., DC, CSM (OXON), MBA, CHE Dean, Health Sciences and Community Services, George Brown College, Toronto, ON

Akilah Dressekie,

Ontario Hospital Association

David Brazeau

Director, Public Affairs, Community Relations and Telecommunications Rouge Valley Health System

Consumer-oriented literature on medicine tends to focus on ‘adherence’ and ‘compliance’ to medications and not necessarily more appropriate drug treatment. And we can’t forget that pharmaceutical manufacturers have a business incentive for volume and are not rewarded for appropriateness of prescribing. Thankfully, the folks from the Canadian Deprescribing Network have identified a few areas where they see the harms of drugs often exceeding the benefits. These include, but are not limited to, benzodiazepines and other sedative medications (commonly prescribed for sleeping), proton pump inhibitors (to treat ulcers and heartburn) and sulphonylureas (to treat type-II diabetes). Drugs that can be problematic in combination with other medications include those that treat blood pressure and glucose, where high doses of multiple medications can lead to problems. They also flag the over-use of blood thinners – which require appropriate monitoring. According to the Network, these are good places to start a consultation with your doctor. As people get older they should constantly ask if a new medication is going to affect the things that are important to them: their mobility, cognitive abilities and capacity to enjoy life. Caregivers and seniors, most importantly, have to be ready to assert their wishes when it comes to taking too many medications and always be alert to the possibility that more medication might H mean more problems. n

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Testing new ways to screen for loss of sensation in

diabetic patients By Corinne Ton That

team of clinicians at St. Michael’s Hospital is testing a new way to assess patients for diabetic peripheral neuropathy, a loss of sensation in the feet that can result in an inability to feel pain. Between 60 and 70 per cent of individuals with diabetes lose sensation in their feet, increasing their risk of foot ulcers, which can lead to infection and leg amputation. The most common test for neuropathy is the monofilament test, which involves

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How it works: the Ipswich Touch Test •P  atients are asked to close their eyes •E  xaminers lightly touch three toes on both feet • T oes are touched in a particular sequence using the index finger •P  atients are asked to indicate if they feel the examiner’s finger on their toes

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placing an instrument similar to a fishing line on areas of the foot, and asking if the patient feels sensation. But a much simpler test, called the Ipswich Touch Test, could be carried out at no cost, without the use of a special tool. “This test could be used anywhere by anyone, meaning there would be no reason not to check patients with diabetes for neuropathy,” says Ann-Marie McLaren, a chiropodist in the Wound Care Department, who proposed and developed the study. “We’re looking for a tool that can easily identify people with loss of sensation who are at risk for developing a foot ulcer.” The Ipswich Touch Test, developed by Dr. Gerry Rayman in the U.K., involves examiners using their index finger to touch the tips of the patients’ first, third and fifth toes on both feet in a particular order. Patients are asked to close their eyes and identify when the toe is touched. “About 85 per cent of people who get their legs amputated had a diabetic ulcer, which they developed because they couldn’t feel their feet,” says Suzanne Lu, a chiropodist in the Mobility Program. “If we can put into practice a simple as-

hospitals.

Photo courtesy of Yuri Markarov, Medical Media

Suzanne Lu, a chiropodist in the Mobility Program , and Ann-Marie McLaren, a chiropodist in the Wound Care Department, perform the Ipswich Touch Test, which involves examiners using their index finger to touch the tips of the patients’ first, third and fifth toes on both feet in a particular order. sessment tool, that means we could start catching people who have neuropathy earlier on, and prevent these kinds of things from happening.” The study team trained 16 clinicians to use both the Ipswich Touch Test and the monofilament test on eight diabetic patients at St. Michael’s. The team is trying to validate the Ipswich Touch Test to determine whether it could be used in various clinical settings among different healthcare professionals including nurses, chiropodists, occupational therapists, physiotherapists, dieticians and physicians.

12,000

professionals.

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“We want to see if we can get agreement between the monofilament and Ipswich Touch tests, and see if the touch test works between different healthcare practitioners, across different clinical areas,” says McLaren. “With simple screening methods, early recognition of loss of sensation, education and appropriate referrals, we can prevent patients from developing foot complications and save limbs – that’s the ultimate H goal.” n Corinne Ton That works in communications at St. Michael’s Hospital in Toronto.

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Ethics

Participation, facilitation and objection

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19 th Annual

Professional Conference and Annual Meetings October 26 – 29, 2016 Shaw Convention Centre Ottawa, Ontario

Matters of conscience and end-of-life care By Kevin Reel e’re here now in the land of assisted dying as one option for those eligible for and in need of quality end-of-life care. An evolving practice context that must respond to those distressing requests to end someone’s intolerable suffering (and other criteria as any new law stipulates). In response to this new situation, the Ministry of Health and Long Term Care has helpfully begun a voluntary registration process for physicians to log their position on involvement in elements of assessing for and providing assisted dying. This will hopefully help connect willing clinicians with those needing their assistance while allowing those not willing to either register as such or remain quiet, as their consciences direct them.

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Pondering or encountering patients whose illness leads to contemplating an assisted death is and should always be gut wrenching – the ‘yuck factor’ in extremis. In thinking about how conscience enters the realm and deliberations around assisted dying, it is evidently a key factor for all. For those who actively participate, for those who facilitate in various ways and for those who object to any involvement, conscience will lead us each to our ‘last, best judgement’, as Charles Curran described it. Conscience is multi-factorial – coming from within and outwith, to borrow a Scottish word. Sometimes what we feel most at ease doing is not what those external guideposts tell us to do. In reaching our decisions, many will rely on faith. By faith I do not mean religion, per se, but belief in some more supernatural or divine entity which can offer guidance to those seeking direction from outside the realm of the human. This is often very distinct from organized religion. For others, it is their connection with more formal religious institutions that offers additional direction and guidance. For some, religion may be the most central or even sole consideration – religious leaders and laws indicate decisively what is right and wrong. Many will look to their own secular understanding of morality to help them www.hospitalnews.com

discern what would be the most ethical action in any situation. This may be in addition to faith or religion, or it may be the primary source of one’s sense of what is the right thing to do. In any of these cases, we may not feel particularly comfortable with what we are called to do by the sum of our deliberations and discernment. In the case of assisted dying, I know of no one who feels good about the idea. For those who feel it is lamentably right, that sense of right might at times appear to have an air of enthusiasm. However, from all I know of colleagues who have been arguing in favour of access to assisted death, it is with a clear lament that they do so. Pondering or encountering patients whose illness leads to contemplating an assisted death is and should always be gut wrenching – the ‘yuck factor’ in extremis. It is invariably something of a last resort option when all else seems to be ineffective in achieving what the patient seeks from care. In this unfortunate context, death is good, counter-intuitively good. When one looks from a distance, there is broad overlap in our shared aims in achieving a patient’s goals of care, particularly remediating intolerable suffering. There are also clear differences of opinion on how best to shape this new practice as it becomes part of our reality. Our own moral and ethical guideposts will present each of us with certain preferred parameters in the broader landscape of options that are now legally open to patients. The right of providers to practice within those differing parameters is also protected by law. Together, relying on each other to step in where some of us as individuals might feel we cannot go, we can, as a broad collaborative system, offer eligible capable and informed patients all the options they may wish to pursue to achieve their own goals of care. Such decisions by patients will also be very conscientious ones – informed by their own guideposts – their own unique combination of values, faith and/or religion. Where they pursue the option of assisted death through to its provision, it will be their own last, H best judgement. n

Join your colleagues to celebrate achievements, learn, and share your commitment to supporting positive health outcomes. Conference delegates will have a unique opportunity to: • explore a variety of endocrine and metabolism related topics • hear from a wide range of inspiring speakers • find out about the latest research in Canada and around the world • share best practices and network with colleagues Enjoy complimentary lunches, wine and cheese receptions, featured lectures, and poster presentations.

REGISTER by July 29, 2016 for 15% off!* www.diabetes.ca/CDA16 Enter promo code: HCPOttawa16 *This special offer is only available to medical professionals who are not members, or have not been members in the past five years, of the Canadian Diabetes Association or Canadian Society of Endocrinology and Metabolism.

Kevin Reel is Assistant Professor, Department of Occupational Science and Occupational Therapy Faculty, Global Institute for Psychosocial Palliative and End-of-Life Care Member, Joint Center for Bioethics, University of Toronto. JULY 2016 HOSPITAL NEWS

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Respiratory therapists give the breath of life By Elaine O’Connor

s a registered respiratory therapist, Burnaby Hospital’s Darwin Chan is proud to say that he’s there with patients from their first breath to their last. Some days, the professional practice leader of respiratory services in B.C.’s Fraser Health region attends births and resuscitates newborn babies. On others, he stands at the bedside of ailing patients and is the one to turn off the machine when doctors and families agree hope is gone. And then there are times when he works right in the gap between death and new life, performing tests and compressing oxygen into an organ donor’s lungs to ready them for transplant to a grateful recipient. “For a long time in CPR, we used the acronym A-B-C to stand for Airway, Breathing and Circulation. I like to say respiratory therapists are involved in the ABCs of life. And that’s precious,” explains Chan. Chan has been a respiratory therapist for 11 years, and says the diversity of the work has meant he’s constantly growing in his field. Over the course of his career, he’s worked across the BC Lower Mainland in hospital acute care, in diagnostics at pulmonary function labs, and in home care as an educator in the community. Chan joined Fraser Health in 2005, working at Eagle Ridge, Royal Columbian and Peace Arch hospitals, before taking over as professional practice leader at Burnaby Hospital in 2015. “Because of my experience,” Chan says, “I understand a patient’s journey from home to diagnostic services to hospital so I know how help them cope at home to avoid readmission to hospital.”

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Putting hearts in rhythm By Jane Kitchen

Darwin Chan is a respiratory therapist at Burnaby Hospital in British Columbia. In a typical day, Chan spends his time doing rounds with patients, reviewing their care, medications and conditions, performing procedures that range from intubations to tracheotomies, supporting surgical and trauma patients, and responding to Code Blue emergencies. “A lot of what we do involves working closely with doctors and nurses,” Chan said. “There is no hero in healthcare. It’s not like TV where one doctor saves the day. In real life, it’s about teams. You’re always trying to support each other.” “In this job, you really need to work well with others,” he explains. “Good time management skills are important so you can prioritize patients and juggle emer-

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hanks to an innovative new technology at Rouge Valley Health System (RVHS), commercial pilot Stephen Wilcox is flying high – literally. Previously grounded by a heart arrhythmia, or irregular heartbeat, he is clear to fly once again. “At night, I would lie on the pillow, and hear my odd heartbeat missing beats,” says the 54-year-old Durham resident. “After I would have an episode like this, my heart would pause for several seconds before finally going back to beating normally.” Wilcox was suffering from a type of arrhythmia called atrial fibrillation, or AF, which occurs when there is disorganized electrical activity in the top chambers of the heart, causing an irregular heart rhythm. This can lead to a feeling of racing heart rate, irregular or skipped heartbeats, fatigue/tiredness, shortness of breath, chest discomfort, dizziness, and even fainting. Thanks to the new cryoballoon ablation therapy procedure offered through the Central East Regional Cardiac Care Program, patients like Wilcox can now get care closer to home. This procedure is specifically designed to treat AF, using freezing to treat the specific heart cells that are causing the abnormal beating. A balloon catheter is inserted into the affected heart chamber, and is inflated and filled with liquid nitrous oxide. This freezes the balloon, which is in contact with the targeted heart tissue. Often 3D-mapping technology will also be used to visualize the inside of the heart and precisely guide the balloon and ablation. The procedure is fast and effective, and can minimize radiation and anaesthesia. This specialized service is performed at the regional cardiac care centre located at Rouge Valley Centenary (RVC) hospital campus in Scarborough, Ontario, which features three catheterization labs and a designated procedure room for arrhythmia treatments. This is where Stephen Wilcox was referred to and treated by RVHS cardiologist Dr. Derek Yung, who along with cardiologist Dr. Bhavanesh Makanjee, are amongst the most experienced operators with the cryoballoon in the province. Dr. Makanjee and Dr. Yung work in collaboration at the cardiac centre with Dr. Amir Janmohamed, cardiologist and manager of arrhythmia services at RVHS, and Dr. Ted Davies, cardiologist with The Scarborough Hospital.

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gencies. With an aging population and seasonal respiratory illnesses, it can get very busy. It’s never boring.” Aside from the clinical component of respiratory therapy, Chan enjoys being involved in patient education, teaching patients about quitting smoking, how to correctly use medications, and how to manage chronic lung diseases such as asthma and chronic obstructive pulmonary disease (COPD). It’s this variety in respiratory practice that first attracted him to the field. When he graduated with a Bachelor of Science degree from UBC in the early 2000s, Chan wasn’t sure what he wanted to do. Then a friend told him about respiratory therapy and he was struck by the fact that he could be “involved in the whole spectrum of healthcare.” He earned his RT degree in a two-year fast-track diploma program at Thompson Rivers University in Kamloops, B.C. and found a job right after graduation in 2005: respiratory therapists are in high demand. They should continue to be. Service Canada’s latest April 2015 job outlook for respiratory therapists is bright. According to the federal agency, the rise in the incidence of respiratory diseases coupled with an aging population and increase in outpatient care means the number of graduates with a diploma in respiratory technology is currently “insufficient to meet the demand for respiratory therapists, especially outside the urban areas.” But for Chan, job security comes second to the daily rewards of his job. “It’s a good field because you really get to see we make a difference,” Chan says. “Many times when we first see a patient they’re very sick on a breathing tube. The next thing you know you’re visiting them at home and they’re up and walking and you think wow, we really do help people H get back to their normal life.” n Elaine O’Connor is a senior communications consultant at Fraser Health.

Continued on page 9 www.hospitalnews.com

2016-07-05 2:17 PM


Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES/COMPLEMENTARY HEALTH

9

Helping Canadians to breathe easier By Sebastian Dobosz

Photo courtesy of Jon Evans

Dr. Paul O’Byrne’s research helps to improve the quality of life of patients diagnosed with asthma. he world-renowned Firestone Clinic at St. Joseph’s Healthcare Hamilton is finding new ways to help nearly three million Canadians diagnosed with asthma. Ground-breaking new treatment options through research at St. Joseph’s Healthcare Hamilton are now being approved by Health Canada and the FDA. The prevalence of asthma has been increasing over the past 20 years. While the causes of asthma aren’t known, the disease affects almost 15 per cent of children between the ages of four and 11. In Canada, asthma accounts for approximately 80 per cent of chronic disease cases and is a major cause of hospitalization in children. Approximately 90 per cent of children diagnosed with asthma also have allergies. A series of clinical trials led by researchers at St. Joseph’s Healthcare Hamilton have validated new medications that improve upon traditional treatments for asthma.

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Testing new treatments for severe asthma

A new, antibody-based medication named mepolizumab can replace traditional, steroid-based treatments for a subset of patients with severe asthma, improving control of asthma symptoms without side effects. Previous research at St. Joseph’s Healthcare Hamilton has identified that a sub-set of patients with severe asthma have an overabundance of particular type of white

blood cells (eosinophils) present in their sputum. These patients often suffer from the most severe asthma symptoms and can only be treated through steroid-based treatments such as high dose prednisone, causing side effects such as mood swings, diabetes, bone loss, skin bruising, cataracts and hypertension. Subsequent research has successfully evaluated mepolizumab as a new treatment for severe asthma. St. Joseph’s Healthcare Hamilton served as one of the recruiting sites for this global trial, recruiting the maximum number of patients for a single site. “This is an exciting example of personalized medicine for asthma,” says Dr. Parameswaran Nair, respirologist at St. Joseph’s Healthcare Hamilton, professor at McMaster University and study author. “Our research suggests that by using a simple blood or sputum eosinophil count, we can identify which asthma patients can benefit from this new treatment. Rather than risking severe side effects through high doses of prednisone, we can precisely target the protein that brings these white blood cells into the lungs.” In late 2015, mepolizumab was approved for administration in Canada and the United States – providing physicians and respirologists with a new way to treat severe eosinophilic asthma. The technique of quantifying inflammation in sputum, a test pioneered by the late Professor Freddy Hargreave, contributed as much if not more than novel therapies to managing severe airway diseases. St Joseph’s Health-

Putting hearts in rhythm

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Relieving allergic asthma with antibodies

Another antibody-based treatment developed and successfully tested at the Firestone Clinic at St. Joseph’s Healthcare Hamilton improves quality of life for individuals with mild allergic asthma. Today, individuals with allergic asthma are typically treated with inhaled corticosteroids or bronchodilators that help to control their asthma when taken regularly. This new medication provides a new treatment option for those with allergic asthma that have issues with inhalers or steroidbased medications. Named AMG 157, the new medication reduces lung constriction and inflammation by suppressing a protein called thymic stromal lymphopoeitin (TSLP). By blocking this protein, the antibody both alleviates baseline inflammation and provides resistance to allergens. “It was known that the epithelial cells which line the airways in the lungs produce

a protein called TSLP that causes inflammation,” says Dr. Paul O’Byrne, respirologist at St. Joseph’s Healthcare Hamilton, Chair of Medicine at McMaster University and study author. “Our work, for the first time, proved that these cells continually produce this protein in humans with asthma.” Multicentre trials led by researchers at St. Joseph’s Healthcare Hamilton evaluated the effectiveness of this antibody-based treatment – establishing proof-of-concept and moving this medication into phase two clinical trials. Successfully evaluating new antibodybased treatments for asthma enables physicians and respirologists to provide effective treatment to patients without negative side effects of conventional treatment. This has the potential to transform care across Canada and around the world. Dr. Nair and Dr. O’Byrne continue to work alongside fellow researchers at the Firestone Clinic to improve care for asthH ma and other pulmonary diseases. n Sebastian Dobosz is a Research Communications Officer at St. Joseph`s Healthcare Hamilton

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“We want to get the message out – if you have symptoms like palpitations or fainting, talk to your doctor for a referral,” says Dr. Makanjee. “The cryoballoon ablation procedure is quick, safe, and effective.” For Wilcox, the procedure was a perfect success, giving him relief when other therapies and treatments could not. “The procedure was a very positive experience for me. Within six months of the diagnosis, after having what felt like every test known to man, thanks to cryoballoon ablation the problem was solved. How does it get better than that?” Patients with AF or who are experiencing issues of irregular heartbeat should discuss their condition with their family doctor, and can contact the arrhythmia www.hospitalnews.com

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http://hlln.info.yorku.ca/health-coach-institute/certificate-in-health-coaching/ Commercial pilot Stephen Wilcox in the hangar at Oshawa Airport. Previously grounded by a heart arrhythmia, he can fly again thanks to cryoballoon ablation therapy. management clinic at RVHS at 416-2848131 ext. 5327 to learn more about arrhythmia services or if cryoballoon ablaH tion therapy is right for them. n Jane Kitchen is the communications specialist at Rouge Valley Health System.

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JULY 2016 HOSPITAL NEWS

2016-07-05 2:17 PM


10 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES/COMPLEMENTARY HEALTH

High-tech heart-valve

heals seniors too weak for open-heart surgery By Gregory Kennedy

aving his golden years turn into gasping years was getting hard for retired RCMP officer Bruce Davis, once an exceptionally fit man who also protected Alberta premiers during his years of service. “I used to have a treadmill at home and work out all the time,” says the 80-yearold Edmontonian. “But in recent years, my quality of life wasn’t good. I tired easily. I puffed on the stairs. I wasn’t interested in anything. Life had become a drag. All I could do was sit in a chair and read the paper.”

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While surgical MR patients can expect to spend five to seven days in hospital, followed by three to six months of healing at home, valveclip patients fully recover and go home within a day. Davis was one of many seniors living with shortness of breath, fatigue and heart failure due to a leaky mitral valve – but who are too frail or high risk for openheart surgery. In a heartbeat, his life changed for the better this past March when he underwent a new leading-edge repair procedure that has seen him regain his health and vitality. “It was painless. I didn’t feel a thing,” he says. “I had good success with that. I’m doing much better.” His wife Kathy, a retired RN, recalls: “Before his surgery, gradually he became weaker and weaker, and less likely to get

out of his chair. But right after his surgery, when he woke up, I could see colour in his cheeks for the first time in years.” Dr. Kevin Bainey, an interventional cardiologist at the Mazankowski Alberta Heart Institute (Maz), says: “These people can’t even walk a block without being short of breath. With our new valve-clip procedure, we can improve upon that. Before this procedure, there were no other options for patients who could not have openheart surgery.” Their condition, known as mitral regurgitation (MR), is one of the more common types of heart valve disease, affecting nearly one in 10 people aged 75 years and older. It occurs when the flaps of the heart’s mitral valve – situated between the main pumping chamber, the left ventricle, and the left atrium, which receives all the blood from the lungs – fail to close completely, causing blood to flow backward into the left atrium and into the lungs. To compensate and keep up blood flow through the body, the left ventricle pumps harder, straining the heart. Symptoms of MR include: shortness of breath, fatigue, coughing, lightheadedness and swollen feet or ankles. MR also raises the risk of irregular heartbeats, stroke and congestive heart failure, which can be life-threatening. “Instead of having to open the chest, we can now repair the valve in a minimally-invasive way, using catheters inserted in the groin to guide the valve clip in place on the failing valve,” says Dr. Bainey. “This device grasps the valve flaps to close the centre of the valve, leading to relief of symptoms. Patients usually go home the next day, feeling much better.” “Historically, these patients have been treated with surgery,” adds Dr. Ben Tyrrell, an interventional cardiologist with the CK

Interventional cardiologist Dr. Kevin Bainey poses with patient Bruce Davis, 80, and his wife Kathy. Davis recently underwent a new mitral-clip procedure to repair his leaky heart valve. Hui Heart Centre at the Royal Alexandra Hospital. “But often their heart muscle is just so weak that they’re not able to tolerate open-heart surgery, which also means they’re not candidates for a heart transplant or a mechanical heart, either.” Teamwork between the Maz and the CK Hui has helped to bring the new procedure to Edmonton. To date, the pilot program has seen six patients undergo the procedure, which isn’t for everyone. “It’s still a niche procedure right now,” says Dr. Tyrrell. “There are lots of anatomi-

cal considerations in picking the right patients for this catheter approach. There are tried-and-true surgeries that are still great therapy for a lot of patients.” While surgical MR patients can expect to spend five to seven days in hospital, followed by three to six months of healing at home, valve-clip patients fully recover and go home within a day. Meanwhile, on the research front, Edmonton will soon help to pioneer the replacement, via catheter, of the entire mitral valve with a newly-developed synthetic valve. The procedure is likely to be performed in the near future once a suitable patient has been identified. “We’re part of an early feasibility study that was recently approved by Health Canada,” says Maz cardiac surgeon Dr. Steve Meyer. “We’re one of only three sites in North America doing this.” Maz cardiologist Dr. Robert Welsh, Edmonton Zone Clinical Department Head for Cardiac Sciences, says: “Minimally invasive approaches to valve therapy are revolutionary therapy. These technological advances are allowing us to improve quality of life for this important and growing patient population.” Kathy Davis, married to Bruce for 55 years, says she’s thrilled with her husband’s new energy. “He now likes to get up and do things around the house. Last week we went for a kilometre walk. The other day he went outside and decided to sweep the deck. It’s been an enormous change.” For his part, Davis adds: “While a valve repair may seem like a little thing, Dr. Bainey and his team have literally given me years more to enjoy with my grandchildren, my wife and my family. My ticker’s strong H and I’m breathing easy now.” n Gregory Kennedy works in communications at Alberta Health Services.

HOSPITAL NEWS JULY 2016

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www.hospitalnews.com

2016-07-05 2:17 PM


Focus 11

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES/COMPLEMENTARY HEALTH

MRI conditional pacemakers improving patient access to diagnostics By Melicent Lavers-Sailly

very year in Canada over 25,000 pacemakers and internal defibrillators are implanted in Canada and according to the Canadian Journal of Cardiology over 200,000 Canadians have permanent pacemakers or implantable defibrillators. Demand for these devices is only expected to grow given the link between aging and the indications necessitating these devices, such as bradycardia, combined with our shifting demographics in Canada. Until 2012, pacemaker and MRI manufacturers instructed physicians not to scan patients with pacemakers, as this exposure could disrupt a pacemaker’s electronic system and burn surrounding tissue. As a result, an MRI was not usually considered for patients with a pacemaker. However, a study published in The Japanese Heart Journal showed that an MRI procedure is requested by a physician for 17 per cent of pacemaker patients within 12 months of device implant. Four years ago, the landscape changed when Medtronic introduced Advisa, the first MRI conditional pacemaker that had been designed, tested, and licensed by Health Canada for use as labeled with MRI machines. Patients with the Advisa pacing system have access to full body scans, without positioning limitations in the MRI scanner. Since then, physicians such as Dr. Vikas Kuriachan, cardiologist and cardiac electrophysiologist at the Libin Cardiovascular Institute of Alberta, and University of Calgary are faced with deciding which patients are the more likely candidates for an MRI conditional pacemaker or implantable defibrillator.

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If you specifically look at patients with cardiac implantable devices, the estimate is 50 to 75 per cent of them will need an MRI in their lifetime. The statistics provide a strong argument for MRI conditional devices. Dr. Kuriachan reports that up to 10 per cent of the population in Canada might get an MRI every year. “If you specifically look at patients with cardiac implantable devices, the estimate is 50 to 75 per cent of them will need an MRI in their lifetime. And the reasons can be quite variable. MRIs are a crucial test for diagnosing problems in the neurological, muscular skeletal and even cardiac systems. These include things like stroke, brain tumours and sometimes more common problems such as investigating back or joint pain. So we want to be prepared for that.” In addition, MRIs are the preferred option for soft tissue imaging as they provide more detail than modalities such as CT or ultrasound. “An MRI can give images that cannot be found with other imaging, www.hospitalnews.com

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Alan’s pacemaker is MRI compatible, a relief when he learned he would require an MRI to diagnose abonomalies on his liver. especially for certain brain tumours, certain strokes that you couldn’t see, as well as certain spine, joint and cardiac muscle problems,” Dr. Kuriachan says. The historic concern of scanning a patient with a pacemaker was indeed a legitimate safety concern, he adds “I think the first thing to keep in mind is these devices are designed to be MRI conditional. And we have lots of studies now including clinical studies that show that they’re safe to use in the appropriate MRI environment and condition.” He also stresses that the Canadian Heart Rhythm Society and the Canadian Association of Radiologists have a joint consensus statement published in

2014 that specifies the appropriate procedures to be followed when scanning a patient with a MRI conditional pacemaker. Ultimately Dr. Kuriachan believes that beyond the diagnostic benefits, MRI conditional devices improve efficiency and patient care. “The MRI scan can offer advantages that other testing cannot so there are certain conditions where the diagnosis can be reached with an MRI scan but not necessarily by some of the other tests. So if you have a patient with an MRI conditional device, they can get the MRI scan and have the answer with the one test. Otherwise they may need multiple tests and still not have the answer.”

Alan, a patient from Calgary is a case in point. A recently retired government employee, he suffered a mini-stroke. When sent for an echocardiogram and carotid artery ultrasound, it was discovered he had atrial fibrillation. Further checking revealed that his pulse had been dropping into the 30s, a problem that could be resolved with a pacemaker. He notes that when the decision was made, “I had no idea at that point that there was anything that was even compatible with an MRI. It never occurred to me that there were different kinds of pacemakers. I just trusted my cardiologist to pick the right one for me.” The decision was a fortuitous one. A stress test and CT scan picked up anomalies on his liver. A subsequent ultrasound also indicated something was wrong in his pancreas which could only be diagnosed with an MRI. “I’d never thought my pacemaker could prevent me from getting an MRI,” Alan says. “But my family doctor knew I had a pacemaker that was compatible with the MRI. With a different pacemaker that wasn’t MRI conditional I would probably have felt cheated because I know that the MRI is so important in diagnosing some conditions.” Given the advances in pacemaker technology and the diagnostic capabilities of MRIs, the hope for patients like Alan is that more physicians, cardiologists, and MRI technicians will become more knowledgeable about MRI conditional devices so that their patients can also access the benefits of both pacemakers, and H MRI scans. n Melicent Lavers-Sailly leads PR and Communications at Medtronic Canada.

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JULY 2016 HOSPITAL NEWS

2016-07-05 2:17 PM


12 From the CEO's Desk

Ensuring senior friendly care in a rural community By Brad Hilker

It started with a fall. That’s how 80-year-old ‘Sandy Pine’ found herself in the Emergency Room at Campbellford Memorial Hospital. Sandy is one of a growing number of seniors treated at the Emergency Room of Campbellford Memorial Hospital (CMH), a 34 bed hospital that serves Northumberland, Peterborough and Hastings County residents, largely a rural community with a population of approximately 30,000 people plus seasonal visitors who come to stay at their cottage.

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In Northumberland County, between 2006 and 2012, the agegroup with the greatest percentage increase in population was the 85+ age-group (a 27.9% increase). Patients like Sandy present a particular challenge for the team at CMH. Sandy, who lives in a remote area, fell on the ice and was admitted to CMH with a fractured hip. Unable to move for four weeks, she was intent on returning to her home once she was mobile again. Hospital staff however were faced with a dilemma around her discharge and return home. Sandy lived alone in poor housing conditions with no family or community support in a very remote area. She did not have a family phy-

sician and she had previously refused the services of Community Care. CMH is increasingly supporting patients like Sandy. This kind of situation presents a real challenge both ethically and in terms of resources for CMH. It is a challenge anticipated to grow into the future especially with the growing number of seniors moving into the area. In Northumberland County, between 2006 and 2012, the age-group with the greatest percentage increase in population was the 85+ age-group (a 27.9% increase). By 2034, the population aged 65 and up is projected to increase by 94 per cent, including a more than doubling of the number of resident’s aged 85 years and up, compared to 2012 estimates. Canadians are living longer and in good health but the risk of developing a chronic condition increases with age, especially for individuals aged 80+. For CMH this means we are treating more patients with higher acuity living with multiple chronic diseases and requiring acute services as part of their overall healthcare plan. Many lack family and community support and the impetus to access healthcare before a health problem becomes a life-threatening issue. Our vision is to be a recognized leader in rural healthcare, creating a healthy community through service excellence, effective partnerships and the development of innovative hospital partnerships. CMH’s receipt of a 2013 Platinum Quality Healthcare Workplace Award from the Ontario Hospital Association shows the level of commitment we share in bringing this vision to life.

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Brad Hilker We are demonstrating this leadership and our award-winning team is making a difference with our concerted effort to provide senior friendly care. Our aim is to enable seniors to maintain optimal health while they are hospitalized so they can return home or transition to the next level of care that best meets their needs. For example, we use a senior friendly approach to assess and care for seniors while fostering excellence. Treatment includes helping patients like Sandy optimize physical function. This includes: • Restorative Care where a multidisciplinary team works closely with patients, assisting them to reach their highest level of ability to support their return home; • Use of a Frailty Assessment for CarePlanning Tool daily on each patient at interdisciplinary rounds as a change indicator. • Senior friendly walkabouts with patient experience advisors to review and change processes and our environment from an elderly patient point of view. • Use of assessment tools like the Barthel Tool for functional decline to ensure elderly patients at risk of falling get the most appropriate care. • A falls prevention program for people who are interested in getting information to help prevent a fall at home or in the community. • Palliative and Therapeutic Harmonization (PATH) approach to care for assessing frail, older adults who visit the ER and are admitted for treatment. This gives patients and their family’s time and space to make complex healthcare decisions that project their best interests and quality of life. Delirium in an elderly patient can add complication for the care team. A delirium, dementia, depression screening tool is completed in the ER. We’ve also educated our staff to recognize signs of delirium and responsive behaviours. Our focus on senior friendly care extends beyond the walls of the hospital and out into the community with a variety of

health service providers. Our patients now have access to a local Geriatric Assessment and Intervention Network (GAIN) team. GAIN teams provide specialized care to support frail older adults living at home, including retirement residences with multiple complex medical problems including cognitive impairment, decreased function, falls or risk of falls, impaired mobility, incontinence and/or multiple medications. Frail older adults experiencing changes in support needs, safety concerns, psychological and mental health concerns or frequent health service usage benefit from the use of these services. Ultimately, Campbellford Memorial Hospital is well-positioned to serve as a rural hub that brings together a variety of health service providers to support the needs of the aging population that defines our community. While much of our effort is focused on patients receiving acute care, we are working collaboratively with a growing network of health service and community service providers to create a wrap-around web of support for our growing senior community. Most recently, our Board of Directors hosted a day of discussion around senior friendly care that brought together members from across our Region with a shared interest in achieving the best possible patient outcomes for our older community members. This is important because it brings a variety of organizations together to find new and innovative approaches to providing care for our community. I was pleased with the outcome of the day because it supported our collaborative approach to care for our seniors. I’m proud of our team because they truly make our hospital a great place to receive care. It’s this level of commitment that enables CMH to ensure that patients like Sandy get the care they need to return home with the supports in place to continue to live independently in H the community. n Brad Hilker is President & CEO, Campbellford Memorial Hospital. www.hospitalnews.com

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CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES/COMPLEMENTARY HEALTH

Focus 13

Do you know how your clients with diabetes feel? By Krista Lamb

iven how much healthcare professionals have to do during diabetes-focused appointments, from checking A1C levels and eye health, to searching for potential foot ulcers, it’s not surprising that some aspects of their patients’ lives are rarely discussed. But if you ask people with the disease, one of the most important challenges is how diabetes affects them – an experience confirmed by findings in the 2013 Diabetes Attitudes Wishes and Needs (DAWN2) second study. What’s more, 33 per cent of people with diabetes feel anxious about their diabetes, 28 per cent feel diabetes distress (the emotional impact specifically related to diabetes and its management), and 26 per cent feel overwhelmed, according to the Canadian Diabetes Association’s (CDA’s) 2015 Report on Diabetes: Driving Change. With research showing that people with the disease are more likely to suffer from anxiety or depression, it may be time for healthcare providers to spend time addressing the issue. Twenty-five-year-old Kylie Peacock is from Halifax, and has lived with type 1 diabetes since she was eight years old. She says that while she now has a good team, many of the providers she worked with in the past just focused on the numbers, such as her blood glucose (sugar) targets, “without taking into account the daily stressors that can make attaining these goals difficult.” Peacock wishes more healthcare professionals better understood the constant

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Diabetes and mental health should not be seen as two separate issues. While it is true that living with diabetes can increase the risk of major depression, the most important observation is that living with diabetes is stressful. Dr. Michael Vallis pressure of dealing with blood sugar levels and the fear of going too high or low. “Effort doesn’t equal success in every case with type 1 diabetes,” she says. “I try my best every day to keep things managed and sometimes wish healthcare professionals knew the amount of effort I undergo to stay healthy.” Edmonton-based Donna Graham lives with type 2 diabetes, which can involve similar emotional challenges. She feels lucky to have a supportive medical team, which has been essential in helping her manage the disease. “Living with type 2 diabetes is mentally and emotionally exhausting,” says the 60-year-old, adding that she

has had difficulties with her weight, misunderstandings about her diabetes at work, and problems getting adequate coverage for the diabetes medications she needs. “The everyday life of a person living with type 2 diabetes [can] require sacrifices and choices to maintain an acceptable blood sugar level,” she says. So why are so many healthcare providers overlooking their clients’ mental health? “Healthcare providers are busy, and they have a strong focus on non-mental health issues,” says Dr. Michael Vallis, a psychologist and one of the co-authors of the DAWN2 study, who speaks regularly about this topic for the CDA. But there is

a bigger barrier: discomfort. “Healthcare providers often talk about not wanting to ‘open Pandora’s box’ or ‘opening a can of worms’ ” Another concern? “They fear that the patient will never stop talking, and [that] this will interfere with their ability to manage their clinical time.” Overcoming these barriers may seem difficult, but Dr. Vallis sees the connection between well-managed diabetes and good mental health as critical. “Diabetes and mental health should not be seen as two separate issues. While it is true that living with diabetes can increase the risk of major depression, the most important observation is that living with diabetes is stressful,” he says. Finding time to talk about emotional and mental well-being may be a challenge, but doing so can have a major impact on overall patient health. For more information or to read the entire Driving Change report, visit diabetes.ca. “Almost half of those living with diabetes experience what we call diabetes distress, and over 80 per cent of people living with diabetes report that it has a negative impact on some aspect of life. Managing the emotional experience in living with diabetes is of great importance both with respect to diabetes control as well as qualH ity of life.” says Dr. Michael Vallis. n Krista Lamb is a communications manager at the Canadian Diabetes Association.

JULY 2016 HOSPITAL NEWS

2016-07-05 2:17 PM


14 Cover Story

More isn’t always better: When less is more in medicine By Wendy Levinson and Karen Born veruse is pervasive in healthcare. Some healthcare providers say they see it every day. For example, with every daily blood draw that is routinely ordered for in-patients that does not offer any clinical value to the patient or change their course of care.

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Over 30% of long-term care residents in Canada are taking antipsychotic drugs without a diagnosis of psychosis. Others reflect on that one patient who was harmed, either physically or emotionally, by overuse. Like the patient who underwent a CT scan to rule out a pulmonary embolism, when a blood test would have sufficed. Or the patient who has a routine chest x-ray that finds an incidental small lesion in the lung, leading to a CT scan, then a needle biopsy, then complications of the biopsy, only to discover in the end that the lesion is benign.

Estimates are that up to one third of medical care adds no value to patients. Over testing and treating our patients leads to unnecessary harm and wastes valuable healthcare resources. Overuse is an epidemic in healthcare. From primary to acute care there are examples of how we order tests and treatments, in spite of strong evidence that they do not help, and may even harm our patients. Modern medical care is all about making choices. Weighing the potential harms and risks against the potential benefits to our patients and their wellbeing. Doctors do this every day, but generally, we err on the side of doing more, rather than doing less. We are often seeking a quick fix to difficult problems. For example, for that older patient who is having trouble sleeping, it seems like an easy solution to scribble off a prescription note for sedative medications. But, that small pill comes with big harms and dependency problems. We know that far too many elderly Canadians are taking these drugs. The risks of these drugs include cognitive problems, falls and hospitalizations.

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It is estimated that about 80 per cent of health care costs can be traced back to a doctor’s decision. However, the problem of overuse doesn’t just have to do with doctors’ choices. Patients and their family members often request tests or treatments that offer no clinical value. These are generally wellintentioned. Patients are often fearful from hearing stories of healthcare problems of family and friends, or media coverage. They want to be reassured by a healthcare professional that they are well. We live in a society where ‘more is better’ and so we think that more healthcare means better health. Plus, healthcare providers are often under enormous time pressure in the clinic or at the bedside and often order tests or treatments that may not be necessary just to ‘cover all bases’. The problem of unnecessary use of antibiotics is a symptom of this approach, and overuse is the cause. In Canada, of the over 23 million antibiotic prescriptions each year, about half are inappropriate and unnecessary. Overuse and misuse of antibiotics comes with serious consequences for healthcare. The emergence of antibiotic resistant superbugs and patient complications, like C.diff infections, has been seen with increased frequency in our hospitals.

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Superbugs are on the rise because of antibiotic overuse. Half of all antibiotic prescriptions are unnecessary.

Turning the tide on the epidemic of overuse requires a conversation from both sides of the exam table or bedside. While clinical practices need to change to stop using treatments or ordering tests that aren’t evidence based, so too do patient and public expectations. There is a need for more public awareness about the potential risks and side effects of over testing, overtreatment and too much medicine. That is why the Choosing Wisely Canada campaign was launched in April 2014. Modeled after the United States’ Choosing Wisely campaign, Choosing Wisely Canada works with Canadian national specialty societies to develop lists of ‘Five Things Clinicians and Patients Should Question.’

These lists identify tests and treatments which are commonly used in each specialty, but are not supported by evidence and may expose patients to harm. To date, more than 175 recommendations have been released by over 30 medical specialty societies, with more to come, including lists created by and for nurses. There is also a list for medical education that was developed by Canadian medical student organizations. While national specialty society representatives have worked on developing the recommendations, putting them into practice has been led by frontline clinicians and provider organizations from coast to coast. We want to share some examples of how recommendations are improving patient care and sparking innovation at the bedside.

Lose the tube

Sunnybrook Health Sciences in Toronto, Ontario

The Hospital Medicine and Internal Medicine lists both include recommendations related to the inappropriate or unnecessary placement of urinary catheters. Dr. Jerome Leis, an infectious disease specialist, conducted an audit and found that 18 per cent of admitted inpatients on the medicine unit had a urinary catheter even though 69 per cent lacked an evidence-based reason. Leis worked with nurses on the medicine unit to develop a medical directive to standardize removal of catheters when patients were transferred to the medicine ward. The team halved the rate of catheter use on the unit and significantly reduced the rate of urinary tract infections since the medical directive was put in place.

Don’t give two when one will do Halifax, Nova Scotia

The Transfusion Medicine list includes a recommendation “Don’t transfuse more than one red cell unit at a time when transfusion is required in stable, nonbleeding patients.” In Halifax, a team from Capital Health modified red cell guidelines developed for elective non-bleeding general hematology and bone marrow transplant patients. This modest initiative had a major impact – it decreased the number of patients transfused by 10 per cent, and was estimated to have saved $1.8 million dollars’ worth of precious blood over two years from 2012-2014. Continued on page 15 www.hospitalnews.com

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Cover Story 15 Continued from page 14

Drop the pre-op Manitoba

A number of national specialty society lists include recommendations against unnecessary pre-operative testing prior to low risk surgery. These tests, such as chest x-rays or ECGs prior to low risk surgery like a cataract replacement have been shown to provide no benefit to patients. Choosing Wisely Manitoba has focused on large-scale projects in the province that can improve patient care and reduce waste. They zeroed in on pre-operative testing. They set the goal of reducing preoperative tests by one quarter by working directly with primary care as well as surgical teams to improve information given to patients before surgery. Further, pre-operative order sets and packages shared between physicians have been updated so that it is much more difficult to tick off a box for an unnecessary test. The next steps for this project include updated history physical exam forms from the provincial health authority as well as revised pre-operative guidelines.

Reducing unnecessary urine tests in the emergency department Alberta Health Services

The Canadian Psychiatry Association list includes a recommendation “Do not routinely order urine drug screen testing on all psychiatric patients presenting to emergency rooms.” This blanket approach to drug testing has not been shown to improve the care of psychiatric patients in

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70% of diagnoses can be determined from a medical history alone, without needing any tests. emergency departments. In fact, it can cause delays in assessment and management. In Alberta, there is a Strategic Clinical Network dedicated to addiction and mental Health. They chose to tackle stat drug toxicology tests in emergency departments, and did so by providing education to providers and showing data around the pitfalls of stat toxicology tests. The implementation resulted in a 96 per cent decrease in testing over six months.

Less sedatives for your older relatives

McGill University, Montreal, Quebec

A number of medical specialty societies have a recommendation related to inappropriate use of powerful sedative medications, such as benzodiazepines, which are particularly harmful for older adults. These drugs are also very difficult to stop once started. For example, the Canadian Psychiatry Association recommends “Don’t use benzodiazepines or other sedative-hypnotics in older adults as a first choice for insomnia.” In Montreal, a community-based program to educate patients about the harms of sedative hypnotic drugs like benzodiazepines was launched

in pharmacies to provide information to elderly patients, and their family members, about how to slowly taper off this drug. The intervention was successful in helping patients talk to their doctors and ask about how to decrease their use of these powerful drugs.

Asking the four questions to reduce overuse

The campaign is also engaging the public and patients, and has developed patient friendly information to go along with recommendations, including over 30 patient pamphlets. In addition to that, we wanted to give patients tools to talk to their healthcare providers. Four questions were developed as a way for patients to start the conversation. You may have seen these in your hospital, doctor’s office or community lab. They spread the message that sometimes in medicine, as in life, more is not always better. 1. Do I really need this test, treatment or procedure? 2. What are the downsides? 3. Are there simpler, safer options? 4. What happens if I do nothing?

What you can do to help

The task of reducing unnecessary care and encouraging appropriateness is up to patients and clinicians. Patients can ask questions, and engage in conversations about unnecessary care. Clinicians can drive improvement using the Choosing Wisely Canada recommendations to

inspire innovation and changes to work flows and processes leading to unnecessary tests and treatment. Local context, practice and cultures vary widely across healthcare settings. We have seen tremendous impact when implementation is focused on local priorities, and there is a growing body of research and data detailing this.

The amount of radiation from one full-body CT scan is equivalent to 200,000 airport scans. Choosing Wisely Canada encourages and supports local ingenuity in the implementation of recommendations. Our hope is that the stories of individuals and organizationswho are doing so inspire you to look at where you can influence change locally. Reducing unnecessary care is in all of our hands, and together we can work to avoid harm and ensure high quality care for our patients, and our healthcare system. To learn more, please visit www.choosH ingwiselycanada.org n Dr. Wendy Levinson is Chair of Choosing Wisely Canada and a professor of Medicine at the University of Toronto. Karen Born is Knowledge Translation Lead of Choosing Wisely Canada and an assistant professor at the University of Toronto.

JULY 2016 HOSPITAL NEWS

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16 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES/COMPLEMENTARY HEALTH The Ted Rogers Heart Failure Patient Education website (www. tedrogersheartfunction.ca) is a brand new resource.

Online educational tool launches for heart failure patients By Amber Daugherty

hen Elaine Fantham was diagnosed with heart failure in 2013, she had questions: what could she eat? How could she prevent further deterioration of her heart? To find answers, she relied on printed brochures that explained the basics of heart failure and its effects. Fast forward three years, while Elaine is waiting for her appointment in St. Joseph’s Health Centre’s Heart Function Clinic, she now just scrolls through a new online resource that has the latest information she needs to answer her questions and help inform the conversation she is about to have with her cardiologist. The Ted Rogers Heart Failure Patient Education website (www.tedrogersheartfunction.ca) is a brand new resource developed by a St. Joe’s physician in partnership with the Peter Munk Cardiac Centre, University Health Network and the Ted Rogers Centre for Heart Research that is changing the way people get their health information. “It makes me more comfortable knowing this resource is available,” says Elaine.

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“I would use it after speaking with my cardiologist if I had any questions. The videos are helpful – it’s very good if you can actually see what’s being explained.” Every year, more than 50,000 people are diagnosed with heart failure in Canada. The news can be unexpected and information that is shared during the first few conversations between patients and their doctors can be difficult and overwhelming to absorb. “We wanted a resource that patients could access on their own, when they were ready to learn more about their diagnosis,” says Dr. Peter Mitoff, a cardiologist at St. Joe’s who was the lead physician on the website. “We spoke with patients and the feedback we got was that they didn’t want to read about heart failure – they wanted to be able to visualize what’s happening in their body.” The bright, bold website shares information through text, diagrams and videos. It provides a comprehensive look at what heart failure is, how it’s caused, what the treatments are and how someone with heart failure can live a healthy life.

Elaine Fantham said she appreciates having the Ted Rogers Heart Failure Patient Education website available to her as a resource. “This is amazing for us as educators,” says Jennifer Comello, Registered Nurse in the Heart Function Clinic. “We’re working to make this available on all patient monitors at bedsides so when we’re meeting with patients in the clinic or in their rooms, we can actually show them what we’re talking about; this will be so beneficial in terms of helping them understand their health condition and how to manage their diagnosis. Patients can also use the videos to talk about heart failure with their family when they go home.” This website is an exciting patient edu-

cation resource that is helping to innovate and redesign our patient experience by giving people the tools they need, where they need them, to help manage their health conditions. This is just one of the many patient education resources being developed by our teams. Teaching and education is deeply ingrained in everything we do at St. Joe’s – learn more about our other initiatives by H visiting www.stjoestoronto.ca. n Amber Daugherty is a Communications Coordinator at St. Joseph’s Health Centre.

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CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES/COMPLEMENTARY HEALTH

Focus 17

New program making a world of difference for COPD patients By Priscilla Hsu

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hen Gordon Ying was admitted to North York General Hospital for a chronic obstructive pulmonary disease (COPD) flareup, he said it changed his life. Through the hospital, he enrolled in a new program that connects acute care (hospital care), community care and primary care (e.g. family physicians), which taught him the techniques to take control of his condition. Launched in March 2016, the North York Central Integrated Care Collaborative program for COPD focuses on coordinated care and communication between hospital, community and primary care providers during and after hospital discharge. With this program, patients with COPD will receive a coordinated approach to care that starts at North York General with a Clinical Care Consultant, and continues for up to eight weeks after discharge. During the eight weeks, the Clinical Care Consultant, family doctor and community partners from Circle of Care, North York ProResp, Saint Elizabeth and West Park Healthcare Centre, work together with the patient and their family to ensure the right interventions are in place. This includes home assessments from a registered nurse within 24 hours, a respiratory therapist within 48 hours and a physiotherapist within the seven days. Patients are then enrolled

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Gordon Ying at his last Outpatient Pulmonary Rehabilitation class with Leigh Guertin, Clinical Care Consultant for North York Central Integrated Care Collaborative program for COPD. in either the Outpatient Pulmonary Reha- through the night, I’m able to walk for lonbilitation Program at North York General or ger, and I don’t cough as much anymore. home rehabilitation provided through the This amazing team of people helped me uncommunity partners. derstand COPD, taught me how to manage Gordon was the first patient to be en- it, and the exercises through rehab helped rolled in the program and on May 20, he me regain my strength to take control of completed the last Outpatient Pulmonary my life again. I have already enrolled myself Rehabilitation class. in another exercise class so I can maintain “Before I started this program, I couldn’t my health.” do what I am able to do today,” says GorLeigh Guertin is a registered respiratory don. “My appetite is better, I’m sleeping therapist and the Clinical Care Consultant

for the North York Central Integrated Care Collaborative for COPD. She explains that patients with COPD or a chronic disease often need more care and attention. By ensuring patients receive the right education and supports, at the right time it can make a big difference in their quality of life. “We see a lot of patients who say they know they have COPD but are unsure about what it is or what to do,” says Leigh. “When patients are diagnosed or in hospital, they are getting a lot of information, usually during a difficult time. This often means understanding the diagnosis and following through on appointments and treatments are less likely. We are trying to reverse that process by delivering education and strategies to manage their COPD over an eight week period, during their recovery.” Leigh says the collaborative approach between acute, community and primary care is the strength of the program. Through developing the program, these organizations were able to come together and breakdown some of the siloes and barriers between providers at different points of care for COPD. The results are a seamless transition of care for patients as they recover, and for patients like Gordon, to see COPD as being a manageable part of his life rather than defining H it, and staying out of hospital. n Priscilla Hsu is a Communications Officer at North York General Hospital.

JULY 2016 HOSPITAL NEWS

2016-07-05 2:17 PM


18 Evidence Matters

Preventing another stroke with outpatient cardiac monitoring By Dr. Janice Mann

stroke can be devastating for patients and their families. Seeking immediate treatment as soon as you recognize the symptoms of a stroke can go a long way in preventing long-term consequences or death. However once you have experienced a stroke, the risk of having another is very real. But what if there was a test that could help determine if you have a condition putting you at increased risk of another stroke? Atrial fibrillation – or AF – is an abnormal heart rhythm. Because the heart does not beat regularly, blood in the heart can pool and clots can form. These clots can travel from the heart through the bloodstream and get lodged in an artery in the brain, causing a stroke or transient ischemic attack (TIA). A TIA is like a stroke except that the symptoms are short-lived and there is no permanent damage. People with AF have a stroke risk of 4.5 per cent per year, but medication that helps to prevent clots, called anticoagulation therapy, can reduce this risk to 1.4 per cent. However, you can take anticoagulation therapy to help prevent a stroke only if you know you have AF. And diagnosing AF is trickier than you might

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think. This is because AF often has no symptoms and many people alternate between a normal heart rhythm and the abnormal heart rhythm of AF. Roughly 30 to 40 per cent of first-time strokes are due to an unknown cause, and many of these

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may have been caused by undiagnosed, or occult, AF. Once you have experienced a stroke or TIA, determining whether you have AF can be important to help prevent future strokes – but as we know, diagnosing AF isn’t always easy. Long-term continuous electrocardiography (ECG) monitoring using devices after you are discharged from hospital can help to identify occult AF that is undetectable by other means. There are a number of devices that can be used for outpatient monitoring, including ambulatory Holter monitors, external loop recorders (ELRs), implantable loop recorders (ILRs), and mobile cardiac outpatient telemetry (MCOT) devices. Ambulatory Holter monitors typically have three to eight leads connected to your chest, and a small monitor that is carried in a pouch around your neck or waist. Data from the monitor’s continuous recordings are stored, then transmitted over the Internet. ELRs use chest electrodes or a wristband to continuously monitor your cardiac activity.

Long-term continuous electrocardiography (ECG) monitoring using devices after you are discharged from hospital can help to identify occult AF that is undetectable by other means. The information is transmitted to a physician or data centre via telephone. ILRs operate similarly to ELRs but are implanted beneath the skin through a small incision and can remain there for up to three years. MCOT devices use three or four electrodes to monitor cardiac activity. The information is sent to your cellphone, then sent in real time to a data centre. Currently the use of these outpatient cardiac monitoring devices varies across

Canada. The healthcare community is uncertain how well these devices work to identify occult AF in people who have experienced a stroke or TIA and whether their use offers good value for the costs to the healthcare system. To try and answer these questions and to determine how best to use these outpatient cardiac monitoring devices, the healthcare community turned to CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – to find out what the evidence says. CADTH gathered the evidence from medical research and compared the different monitoring devices to determine their clinical and costeffectiveness for diagnosing AF in outpatients who have experienced a stroke or TIA. CADTH also identified patient perspectives on the value and impact of the AF monitoring devices on their health, healthcare, and quality of life. In general, the results show that there is a substantial increase in the number of AF diagnoses when monitoring for longer than 24 hours. In other words – the longer you monitor, the more likely you are to detect AF. The results also show that cardiac monitoring after stroke or TIA for the investigation of AF can be cost-effective. Most patients, according to research, perceive outpatient cardiac monitoring devices to be comfortable and easy to use, and satisfaction with outpatient cardiac monitoring is high. Based on the evidence found by CADTH, an expert panel made recommendations on how best to use the outpatient cardiac monitoring devices. The panel recommends monitoring patients who have been discharged from hospital after a stroke or TIA continuously for seven days with either a Holter monitor or ELR. However, if patients have already been monitored while in hospital, outpatient monitoring may not be costeffective. The panel does not recommend ILRs because they are not cost-effective and from a practical point of view would not make a lot of sense for only seven days of monitoring. A recommendation on MCOT devices isn’t possible because there is very little evidence available for this device. Knowing the evidence on the use of outpatient cardiac monitoring devices in patients who have experienced a stroke or TIA will help to guide important decisions by patients and their healthcare teams – helping to reduce the risk of future strokes and making the best use of our health care dollars. If you’d like to learn more about CADTH and our project on monitoring for atrial fibrillation after stroke visit www.cadth.ca, follow us on Twitter: @ CADTH_ACMTS, or talk to our Liaison Officer in your region: www.cadth.ca/conH tact-us/liaison-officers. n Dr. Janice Mann, Bsc, MD is a Knowledge Mobilization Officer at CADTH. www.hospitalnews.com

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Nursing Pulse 19

Treatment of pressure injuries made clearer with recommendations

By Grace Suva

lizabeth is a 74-year-old patient on the orthopaedic ward. She was admitted to the hospital for a fractured hip. She is quite uncomfortable and doesn’t want to get out of bed. As a healthcare professional, you are anxious to prevent wounds from forming on pressure points on Elizabeth’s body, but every time you try to reposition her, she cries out in pain and doesn’t want to be moved. She says you don’t understand her pain. She eats some of her meals, but has lost her appetite and prefers tea and toast. In the week since her surgery, Elizabeth has only been out of bed twice, and you notice that her buttock is red.

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es, registered nurses, a nursing student, a registered practical nurse, nurse practitioners, a physical therapist, a dietitian, an occupational therapist, a physician, educators and researchers. A patient representative was also invited to sit on the panel to provide a lay person’s experience. This patient perspective was important in ensuring that a person-centred approach to the recommendations was applied during the guideline development process. The guideline recommends best prac-

tices for identifying and treating the causes of pressure injuries, determining the healability of a wound, and wound care treatments such as debridement (removal of dead tissue from the wound), controlling inflammation/infection, moisture balance, and the use of alternative approaches for injuries that are not responding to standard wound care. To learn more about the BPG, contact Grace Suva, RNAO BPG program manager (gsuva@RNAO.ca), or Erica D’Souza,

project co-ordinator (edsouza@RNAO. ca). You can also access an electronic copy of the BPG for free at RNAO.ca/bpg/ H guidelines/pressure-injuries n Grace Suva is a program manager for the International Affairs and Best Practice Guidelines Program at RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario.

According to the Canadian Institute for Health Information (CIHI), pressure injury rates range from 0.4 per cent to 14.1 per cent, which means many people are affected by these injuries in Canada. You determine it is likely a pressure injury (formally known as a pressure ulcer), and begin to think about next steps. What is the extent of the injury? What can you do to reposition Elizabeth and prevent additional pressure injuries? What dressings are best for her buttock? How can you encourage her to eat more nutritious foods to help improve the healing process? Pressure injuries are a complex phenomenon. In general terms, they refer to damage to the skin or underlying tissue as a result of sustained pressure. And they have a profoundly negative impact on a person’s physical, social, psychological and financial quality of life. According to the Canadian Institute for Health Information (CIHI), pressure injury rates range from 0.4 to 14.1 per cent, which means many people are affected by these injuries in Canada. In ideal circumstances, wound care is best informed by evidence-based best practices and managed by an interprofessional wound care team. In Elizabeth’s case, it is important to collaborate with Elizabeth, her family, her nurses, physician or nurse practitioner, a physical therapist, occupational therapist, and dietitian to manage her injury. The Registered Nurses’ Association of Ontario (RNAO) first published its clinical best practice guideline (BPG) Assessment and Management of Stage I to IV Pressure Ulcers in 2007. This spring, a third edition was released under a new name: Assessment and Management of Pressure Injuries for the Interprofessional Team. It contains best practice recommendations for pressure injury care, with three new features. In addition to replacing the word “ulcer” with “injury,” it now recognizes: the role of various healthcare professionals on a team in the assessment and management of pressure injuries; and the importance of collaborating with the person and their circle of care to better manage the injury. The panel behind this updated RNAO BPG includes enterostomal therapy nurswww.hospitalnews.com

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2016-07-05 2:17 PM


20 Long Term Care

Product Feature: IC+™ Upholstery Solution

If you can’t clean it, don’t buy it. Improving infection prevention and control in Long Term Care facilities urnishings covered with woven upholstery or vinyl with unsealed seams are an infection control hazard. IC+™ Upholstery Solution is a patent-pending breakthrough technology developed by healtHcentric™ (a division of ergoCentric®) for the healthcare industry. It provides the most durable, cleanable and impermeable medicalgrade surface available. Pathogens, fluids, and bed-bugs stay out because IC+ is non-porous, seamless and forms a completely sealed moisture-free barrier that makes microbial growth virtually non-existent. Creating a home-like environment in Long Term Care (LTC) facilities is important in order to make residents feel comfortable, because whether it’s for a long or short time, it is their home. Home-like environments often include carpeting and plush upholstered couches and chairs. On one hand these provide a sense of comfort, warmth and acoustic value. On the other hand, they can enable the spread of infectious diseases. Often used in common areas throughout LTCs for residents, guests and staff to sit on, upholstered couches and chairs can be exposed to various spills and bodily fluids on a daily basis. Woven fabrics naturally lend themselves to create opportunities for microbial growth as well as odour issues. Instead of creating a nice place to relax, these furnishings have the potential to harbour microorganisms and even bedbugs. They are also difficult to clean and when, for example, a cloth chair becomes soaked in feces from a patient infected with CDifficile, the item needs to be discarded.

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Striking a balance

Keith Sopha, President of the Canadian Association of Environmental Management and the Founder of CleanLearning says, “I believe, that the LTC sector needs to find a balance between a comfortable home environment and an environment that promotes infection prevention and patient safety.” This can only be achieved by introducing furnishings that are cleanable and stand up to hospital grade disinfectants. The Provincial Infectious Advisory Committee (PIDAC) in the Best Practices for Environmental Cleaning for the Prevention and Control of Infection in all Health Care Settings states “If you can’t clean it don’t buy it.” LTC facilities are considered healthcare settings and have a high risk of infectious diseases spreading as residents often share rooms and communal areas. Plus LTC residents generally have a higher risk of acquiring an infection because elderly are more vulnerable to illness.

Pikac Checklist

To reduce microbial contamination, when selecting furnishings for use in clinical and communal areas choose surfaces with the following characteristics: • Cleanable with hospital grade cleaners • Easy to maintain and repair • Resistant to microbial growth HOSPITAL NEWS JULY 2016

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• Non-porous (smooth) and seamless Sopha adds “Furnishings using IC+ have all the characteristics Environmental Managers look for. It allows staff to effectively clean and disinfect furniture, thus assisting in infection prevention and control.”

Proven results

An independent study to test the efficacy of IC+ was conducted at Antimicrobial Test Laboratories. The lab tested the effectiveness of a common isopropanol disinfecting wipe, Cavi Wipes, on a piece of seamed hospital grade vinyl and a piece

of seamless IC+ to compare the reduction of microorganisms on the upholstery samples. The microorganism selected for this test was Staphylococcus aureus, known to be difficult to disinfect but vulnerable to low level disinfectants. Continued on page 23

Advance directives in long-term care

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recent Supreme Court decision allowing physician-assisted death in Canada has ignited a broader national debate on end-of-life care, including the rights of individuals to determine what kinds of interventions they want or don’t want at the end of their lives. Many Canadian jurisdictions now encourage advance care planning to ensure a more person-centred approach to end-of-life care. In long-term care, advance directives allow individuals and their families/legal guardians to communicate preferences for interventions and treatments in the event that these individuals are no longer able to make decisions for them. CIHI’s recent study, A Snapshot of Advance Directives in Long-Term Care: How Often Is “Do Not” Done?, examines how often do-not-hospitalize (DNH) and donot-resuscitate (DNR) directives were recorded for residents in 982 reporting Canadian long-term care facilities between 2009–2010 and 2011–2012 and, to the extent possible, whether these directives were followed in acute care settings.

The findings of this study will shed light on how end-of-life preferences of long-term care residents are upheld and communicated across the continuum of care.

How often is a DNR directive followed?

More than three-quarters of longterm care residents in the study had a directive to not resuscitate. A DNR directive states that no cardiopulmonary resuscitation (CPR) or other lifesaving methods are to be used in the event of cardiac arrest or respiratory failure. Over the study period, less than 0.05 per cent of residents with a DNR directive received resuscitation in an acute care hospital after being transferred there for treatment. This number represents about one in 2,500 long-term care residents with a DNR directive. This suggests that do-not-resuscitate orders are well communicated between care facilities and well understood by care providers.

How often is a DNH directive followed?

About one in five long-term care residents (21 per cent) had a documented DNH directive. This type of directive states that the resident is not to be hospitalized even if he or she acquires a medical condition requiring hospital care. It is important to note that a DNH directive comes into effect only if the resident is unable to provide informed consent at the time of a decision to hospitalize or if a family member or legal guardian is unavailable to consult about treatment options. Almost 6,000 hospitalizations occurred among residents with a recorded DNH directive over the three-year study period. This represents almost seven per cent of long-term care residents with a DNH directive. More than half of these cases involved residents who were moderately to severely cognitively impaired (or who likely could not make decisions for themselves). Continued on page 23 www.hospitalnews.com

2016-07-05 2:17 PM


Focus 21

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES/COMPLEMENTARY HEALTH

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at 905-532-2600 x2237 or denise@hospitalnews.com www.hospitalnews.com

062516_HN_EDIT.indd 21

JULY 2016 HOSPITAL NEWS

2016-07-05 2:17 PM


22 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES/COMPLEMENTARY HEALTH

Medically-assisted dying:

What does the passage of Educational Bill C-14 mean for hospitals? & Industry Events By Patricia North, LL.B., LL.M.

To list your event, send information to “events@hospitalnews.com”. We try to list all events and information but due to space constraints and demand, we cannot guarantee it. To promote your event in a larger, customized format please send enquiries to “advertising@hospitalnews.com”

n July 7 -8, 2016 eLearning Alliance of Canadian Hospitals Toronto, Ontario Website: www.eachconference.ca n July 7-8, 2016 World Conference on Disaster Management International Centre, Toronto Website: www.wcdm.org n July 25-27, 2016 Institute for Patient and Family Centered care Conference New York, NY United States Website: www.ipfcc.org n September 20, 2016 2016 iHT2 Health IT Summit Toronto, Ontario Website: www.ihealthtran.com n September 20-21, 2016 Patient Experience Summit Toronto, Ontario Website: www.patientexperiencesummit.com n September 28, 29 & 30, 2016 Mental Health For All Conference Hilton, Toronto Website: www.conference.cmha.ca n October 16, 2016 Sustainable Compassion Training Workshop Emmanuel College, University of Toronto Website: https://bit.ly/ECABSI n October 17-18, 2016 Saskatchewan Health Care Quality Summit Saskatoon, Saskatchewan Website: www.qualitysummit.ca n October 30-November2, 2016 Critical Care Canada Forum Toronto, Ontario Website: www.criticalcarecanada.com n November 7-9, 2016 HealthAchieve Toronto, Ontario Website: www.healthachieve.com n November 27–December 2, 2016 RSNA 2016 McCormick Place, Chicago, United States Website: www.rsna.org n December 8, 2016 Data Analytics for Healthcare Toronto, Ontario Website: www.strategyinstitute.com n January 24, 2017 Mobile Healthcare Toronto, Ontario Website: www.strategyinstitute.com To see even more healthcare industry events, please visit our website www.hospitalnews.com/events HOSPITAL NEWS JULY 2016

062516_HN_EDIT.indd 22

A

bhorrence of the vacuum left following the Supreme Court of Canada’s (SCC) 2015 decision in Carter v. Canada on medical assistance in dying finally prompted the federal government to introduce Bill C-14 to fill the legislative void. The bill received royal assent Friday, June 17th after passing a final vote in the Senate earlier in the day, despite the Senate’s desire to see a broader scope for medical assistance in dying. However, the timid approach of the Bill to the most contentious aspects of the issue – advance directives, mental health conditions and minors – disappoints in comparison to well-reasoned recommendations that the Special Joint House of Commons-Senate Committee (Committee) tabled in its report released in February of this year. The Bill deviates substantially from the Committee’s recommendations, adopting a far narrower and more conservative approach. While the Bill provides a national framework for assisted dying, individual provinces may, as Quebec has, pass provincial legislation which flesh out some of the salient details around the delivery of these services. What follows is a brief synopsis of Bill C-14 with respect to eligibility and process. Note that the Bill permits assisted dying services to be provided by both medical practitioners and nurse practitioners, so the language has shifted from ‘physicianassisted’ to ‘medically-assisted’ dying. 1) Bill C-14 Eligibility Criteria for Medical Assistance in Dying (“MAID”) a)  Conditions and Suffering: As expected, the Bill’s amendments to the Criminal Code do not attempt to statutorily define specific medical conditions which would be eligible for MAID. Rather, a person is eligible for MAID if s/he has a “grievous and irremediable” medical condition which must be: (a) serious and incurable, (b) in an advanced state of irreversible decline in capability, (c) causing enduring physical or psychological suffering, and (d) natural death has become reasonably foreseeable. This language is substantially more restrictive than Carter; the requirement that the individual’s natural death has become reasonably foreseeable would arguably preclude obtaining MAID where a mental health issue is the sole underlying medical condition. However, notably the Bill does not require that the individual has been given a specific survival window, which allows patients and practitioners more latitude around the timing of the assistance. b) Age: Individuals under 18 years of age are not eligible for MAID. This approach deviates from the Committee’s recommendation that a two-stage legislative process dealing first with competent adults and then applying to ‘competent mature minors’ to be in force within the following three years. c) Express Consent and Residency Requirements: in addition to meeting the medical condition threshold, an individual must both be given an opportunity to withdraw the request and must provide express consent at the time the assistance is delivered. A request can be made, and witnessed, in writing after the person’s medical or nurse practitio-

ner has informed the person that his or her “natural death has become reasonably foreseeable”. However, once competency is lost MAID may not be provided due to the individual’s inability to provide express consent. For many individuals, the loss of competency might be the trigger for wanting to avail themselves of MAID, but the above express consent requirement would seemingly preclude this option. In terms of residency, MAID would only be available to persons eligible for publically funded health care services in Canada. 2) The Process involved in requesting MAID The Bill requires a written request documenting a person’s application for MAID, signed and dated by the individual or, if the individual is unable to sign, singed by someone on behalf of the individual and witnessed by two independent people having no conflict of interest. a)  Participating in MAID: Hospitals, medical and nurse practitioners are not required to provide MAID under Bill C-14, and no provisions are included in the Bill requiring that health care professionals who conscientiously object to MAID make an effective referral to another medical or nurse practitioner as was recommended by the Committee. However, the Bill prohibits the destruction of a document requesting MAID if the intent is to interfere with access to, or the assessment of a request for, MAID. Medical and nurse practitioners must provide the request to the Minister of Health or his or her designate. b) Assessments: Two independent medical practitioners or nurse practitioners are required to determine that an individual meets the eligibility criteria for MAID to be carried out. The second practitioner’s opinion, which confirms that all of the criteria are met, is required to be in writing. c) Waiting or reflection period: A 15-day waiting period between the request and the delivery of assistance is required, unless both opining medical or nurse practitioners agree that death or loss of capacity to provide informed consent is imminent.

What does this mean for hospitals?

Hospitals providing MAID services should establish internal policies and protocols, including forms and educational documents for patients, to support the medical and nurse practitioners, pharmacists and other staff who deliver, or assist in delivering, these services to eligible patients. This approach should include an oversight function to address organizational accountability for the assessment and administration of MAID. The Quebec legislation (Bill 52 - An Act respecting end of Life Care) provides an interesting and instructive approach to an institutional framework for assisted dying. For example, Quebec’s legislation requires that hospitals include a clinical program for end of life care in its organizational plan, which must include in-home care for end-of-life patients. Continued on page 23 www.hospitalnews.com

2016-07-05 2:17 PM


Long Term Care 23

Infection prevention and control Continued from page 20 The samples were infected with the bacterial culture spread over one square inch and into the seams, where applicable. After a drying time of 45 minutes, test samples were cleaned using the wipes according to the manufacturer’s instructions, allowed to dry for three minutes, and were then ready for a bacterial count. The lab established that the cleaning and disinfecting wipe had a 0.4 log reduction from the healthcare grade vinyl and a 3 log reduction from IC+ Upholstery Solution. These findings reinforce the recommendation put forth by PIDAC and other reputable organizations that seams in healthcare furniture can harbor pathogens even after being cleaned and disinfected.

Additional applications

The use of IC+ Upholstery Solution is limitless and healtHcentric is expand-

ing its application to other high-touch products that require extraordinary durability and cleanability. One such product is a commode with an IC+ seat cushion that is much softer than plastic seats and much more durable and cleanable than vinyl seat cushions. And because of the anti-slip nature of the product, healtHcentric is also developing IC+ for transport wheelchairs.

IC+ is used in hospitals across Canada and the United States. Ontario hospitals and LTC facilities receiving funding from the Ontario Government are able to take advantage of the Ontario Public Services Vendor of Record Contract with ergoCentric (healtHcentric’s parent company). Product and sales representation information can be found at www.healthH centric.com. n

Continued from page 20 Table 1 Top 10 causes of hospital stays among long-term care residents with a DNH directive Number of cases

Most responsible diagnosis*

Total DNH hospital stays Pelvic/hip/femur trauma/repair Viral/bacterial/unspecified pneumonia Palliative care Urinary tract infections Gastrointestinal hemorrage/obstruction Chronic obstructive pulmonary disease Other trauma/injury/complication Sepsis Aspiration pneumonia Heart failure without intervention

5,783 909 460 350 300 270 288 225 219 218 216

Percentage of total cases

15,7% 8.0% 6.1% 5.2% 4.7% 3.9% 3.9% 3.8% 3.8% 3.7%

Note: *BAsed on modified CIHI Case Mix Groups. Source: Discharge Abstract Database, 2009-2010 to 2011-2012, Canadian Institute for Health Information

Why are residents with a DNH directive hospitalized?

The top 10 causes of hospital stays listed below were responsible for nearly 60 per cent of all hospital admissions, including: • Trauma or injury, such as a broken hip sustained in a fall • End-of-life or palliative care • Infections such as pneumonia, urinary tract infections and sepsis (infection of the blood stream) • Exacerbation of chronic conditions such

as heart failure and chronic obstructive pulmonary disease (COPD).

Conclusions

Advance care planning or advance directives are associated with better patient experience and lower costs for the health system. While long-term care facilities in Canada typically discuss care goals with residents, little information is currently available to understand what kind of directives are in place, and whether documented patient preferences are being followed in clinical practice and across the continuum of care. CIHI’s analysis helps shed light on the use of do-not-hospitalize and do-notresuscitate directives in long-term care, based on the largest sample of any CanaH dian study on the topic. n This article was submitted by the Canadian Institute for Health Information.

Medically-assisted dying Continued from page 22 Quebec hospitals must adopt a policy with respect to end-of-life care and make the policy known to personnel and patients, and must also establish measures to promote multidisciplinary cooperation among the different health or social services professionals. Hospital leadership must report annually to the board of directors on the implementation of the policy, and the report must contain the number of end-of-life patients who received palliative care, the number of terminal palliative sedations administrated, the number of rewww.hospitalnews.com

062516_HN_EDIT.indd 23

DEADLINE FOR AUGUST 2016 ISSUE: JULY 26, 2016 VIEW CAREER ADS AT:

www.hospitalnews.com

To advertise please contact

Denise Hodgson

denise@hospitalnews.com 905-532-2600 ext. 2237

Where to find IC & Upholstery Solution

Advanced directives in long-term care

Residents with a DNH directive were about half as likely to be hospitalized as those without one. The hospitalization rate of residents without a DNH directive was 15 per cent. However, hospitalization for both groups of residents declined by about half between 2009–2010 and 2011–2012. This coincides with a push in Ontario’s long-term care sector to reduce avoidable hospitalizations.

Careers

quests for medical aid in dying the number of times this aid was administered, the number of times refused and the reasons for the refusals. Preparing for the passage of Bill C-14 has been an iterative process for most hospitals, and as new issues or challenges arise, flexibility and support for the patients and staff involved will continue to H be paramount. n Patricia North, LL.B., LL.M. is Legal Counsel, University Health Network.

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WWW.SAINTELIZABETH.COM/CAREERS JULY 2016 HOSPITAL NEWS

2016-07-05 2:17 PM


24 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES/COMPLEMENTARY HEALTH

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Hospital News 2016 July Edition  

Focus: Cardiovascular Care, Respirology, Diabetes & Complementary Health

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