Hospital News September 2018

Inside: From the CEO’s Desk | Evidence Matters | Ethics | Nursing Pulse | Careers

September 2018 Edition

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The need for

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Contents September 2018 Edition

IN THIS ISSUE:

Online learning – made for physicians

28 ▲ Cover story: The need for Lyme literacy

14

▲ Simulated car crash

5

COLUMNS

▲ PTSD in health professionals

▲ Trauma at a tiny hospital

8

34

Editorial .............................4 In brief .............................6 From the CEO’s desk .....22 Evidence matters ...........10 Infection C ontrol .............11

▲ Experience a shift in the emergency Online E ducation ............24 department Ethics .............................20

Long-term care ...............38 Nursing pulse ................46 www.hospitalnews.com

26

Air response: Anatomy of a mass casualty incident

44

Where we live, work and play

influence our health Why doctors and urban planners need to work together to improve public health and prevent chronic disease

S

www.hospitalnews.com

Editor

Kristie Jones

editor@hospitalnews.com Advertising Representatives

Denise Hodgson

By Jean Wang and Kevin Lam ince John Snow mapped out the large cholera outbreak in 1854 to where people lived in London, it has been known that where we live, work and play strongly influences people’s health. The way that our cities and towns have been built plays a large role in many of the health conditions that Canadians develop. Cities like Montreal and Vancouver have been working in recent years to better cycling infrastructure and public transit, with the goals of improving the quality of life and health of their citizens.

It’s a good start, but is it enough? We need systemic collaboration between physicians, public health departments, developers and urban planners to help Canada design the cities we want – ones that can keep us healthy.

Let’s take obesity as an example.

Among OECD countries, Canada has one of the highest prevalence rates of obesity, with an alarming one in five Canadian adults affected. Yet despite all that Canada is doing to address the lifestyle factors that contribute to obesity, many public health goals are stubbornly hard to reach and nowhere near close to targets.

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Ninety per cent of Canadian children do not reach the current physical activity recommendations despite physical inactivity and sedentary lifestyles being flagged as a priority focus for the Public Health Agency of Canada.

It can be difficult to make healthy choices in certain contexts. If our daily lives are surrounded by cities without green spaces to play or where public transit is difficult to access, it can be hard to make healthy choices in spite of all the health promoting.

So what can be done?

Current solutions are heavily focused on targeting individual behaviour change. A great deal of funding is spent on promoting exercise, the food guide, community weight loss programs – all with a focus on individual behaviour. But evidence demonstrates that social marketing campaigns surrounding healthy eating and exercise are not sufficient to address the problem.

Instead of simply telling people to spend more time exercising, we can incorporate it into their everyday lives. We could encourage stair use instead of elevators by making stairs easier to access. We could integrate walking and biking to work – forms of active transport – or make cities more walkable in general.

Continued on page 7

Jean Wang is a second year medical student at the University of Ottawa. She completed her Bachelor of Health Sciences at McMaster University and has previously been involved in chronic disease management and prevention research. Kevin Lam is a second year medical student at McMaster University. He has an interest in public health and its intersection with emergency medicine, with a special focus on improving health through urban design. He studied epidemiology and biostatistics in his undergraduate studies at Western University. They are both Contributors to EvidenceNetwork.ca based at the University of Winnipeg.

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Publicist Health-Care Communications

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President Brainstorm Communications & Creations

Bobbi Greenberg, Health care communications

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Dr. Cory Ross, B.A., MS.C., DC, CSM (OXON), MBA, CHE Vice President, Academic George Brown College, Toronto, ON

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NEWS

This simulated car crash uses clinical-reality education to raise awareness with youth of the traumas of impaired driving.

Photo credit: Vanessa Gomez

Simulated car crash steers students away from the trauma of impaired driving

By Vanessa Gomez s the fallout of a simulated car crash unfolded before them under rainy skies, Grade 9 students at J.H. Picard School got an eyeful they won’t soon forget when members of Alberta Health Services Emergency Medical Services (EMS), Edmonton Police Service (EPS), Edmonton Fire Rescue Services (EFRS) and healthcare re-enacted the serious, and often fatal, consequences of impaired driving.

The P.A.R.T.Y. Program (Prevent Alcohol and Risk-related Trauma in Youth) is an initiative that uses clinical-reality education to raise awareness with youth of the preventable traumas associated with drugs, alcohol and impaired and distracted driving.

“At that age students need to understand the decisions they make have a ripple effect that goes beyond themselves,” says Alex Campbell, EMS Public Education Officer.

“Being able to see and hear the sounds of someone being cut out of a car – and seeing the number of people involved in responding to just one incident – has an impact on these students.”

A

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In addition to the simulated collision, EMS, EPS, EFRS, healthcare frontline staff and a spinal cord injury survivor shared stories of their experiences.

The P.A.R.T.Y. Program, now in its 25th year, offers 60 full-day sessions annually, mostly at Covenant Health’s Misericordia Community Hospital, and simulates the car collision once a year.

With injury being the leading cause of death in youth aged 15-19 in an environment of peer pressures and easy access to dangerous drugs, the P.A.R.T.Y Program plays a valuable role in their well-being.

“The primary messaging is about making smart choices. That message becomes even more important as students are increasingly faced with these new pressures,” says Marcia Lee, R.N., P.A.R.T.Y. Program Coordinator and former Emergency Department nurse.

“We need to get them present to the reality of trauma.”

Currently, the program reaches about a third of Edmonton’s Grade 9 students. With the generous support of community partners – including

Covenant Foundation, Edmonton Oilers Community Foundation, Edmonton Community Foundation and the Insurance Bureau of Canada – the program is in the process of expanding.

“No parent should ever face the loss of a child, particularly to something that is preventable,” says Lee. “This program moves young people and inspires them to H make conscious, informed decisions.” ■

Vanessa Gomez works in communications at Alberta Health Services.

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IN BRIEF

Future of health care system dependent on innovation and innovative approaches

ore than 750 physicians, health stakeholders and patients came together at the inaugural CMA Health Summit to strategize on the potential of innovation and new technologies to improve healthcare. Whether through the integration of augmented intelligence in clinical care or through increased patient empowerment through access to data and EMRs, the underlying message was clear: now is the time for change.

The outcome of these discussions will form the basis of a policy paper on innovation in healthcare to be released in early 2019.

These conversations build on the CMA’s recent work on the impact of technological changes on healthcare.

Last week, the CMA released the findings of an Ipsos survey that narrowed in on Canadians’ perception and acceptance of technology in health care. The

THREE OUT OF FOUR CANADIANS (75%) BELIEVE THAT NEW TECHNOLOGIES COULD SOLVE EXISTING ISSUES IN OUR HEALTH CARE SYSTEM.

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report, Shaping the Future of Health and Medicine, found that 3 out of 4 Canadians (75%) believe that new technologies could solve existing issues in our health care system.

“A national voice is needed to prepare the medical profession for the massive changes coming to health care, and the CMA will be at the centre of this discussion”, says Dr. Laurent Marcoux, CMA president.

The CMA and its subsidiary Joule intend to play a significant role supporting Canadian physicians in adopting

and integrating new technologies and innovative solutions. Foundational to these changes is a vibrant profession and addressing issues affecting physician wellness. To drive these conversations, the CMA will be hosting the upcoming International Conference on Physician Health in Toronto this October and will lead a series of member forums in early 2019.

As well, the CMA is launching a community engagement platform that will be a virtual space where physicians and other stakeholders, including pa-

tients, can come together to address health issues they’re passionate about.

The platform will allow groups of people with a shared passion to come together to explore ideas and experiences, solve problems, and take action. To support this initiative, the CMA recently announced five grants supporting communities of interest on Indigenous health, creating an inclusive and equitable medical community, medical aid in dying, health of marginalized populations and substance abuse.

The Canadian Medical Association unites 85,000 physicians and physicians-in-training on national health and medical matters. Formed in Quebec City in 1867, the CMA’s rich history of advocacy led to some of Canada’s most important health policy changes. As we look to the future, the CMA will focus on advocating for a healthy population H and a vibrant profession. ■

Protecting public health care.

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IN BRIEF

Care coordination improves health of older patients

with multiple chronic diseases

or older adults with multiple chronic diseases, such as diabetes, depression, heart disease and others, care coordination appears to have the biggest impact on better health, according to a study published in CMAJ (Canadian Medical Association Journal).

By 2050, there will be two billion people worldwide older than 60 years. Seniors are the fastest-growing demographic in Canada, and almost half have multiple chronic conditions and consume a substantial portion of healthcare spending. There will be a greater number of people with chronic diseases, yet there is a lack of understanding about the impact of effective approaches to managing multiple chronic diseases in patients.

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CARE COORDINATION STRATEGIES HAVE THE GREATEST POTENTIAL OF IMPROVING HEALTH IN SENIORS WITH MULTIPLE CHRONIC DISEASES.

To fill this gap, researchers conducted a systematic review of all studies on the topic published in any language between 1990 and 2017. In the final analysis, they included 25 studies, many of which were randomized controlled trials, with 12 579 older adults (average age 67 years). The authors found that care coordination strategies (i.e., organizing different providers and services to ensure timewww.hospitalnews.com

ly and efficient health care delivery) have the greatest potential of improving health in seniors with multiple chronic diseases. For example, care coordination involving case management, patient self-management and education of patients and providers significantly reduced symptoms of depression in adults with combined depression and chronic obstructive pulmonary disease or in those with combined diabetes and heart disease.

“Our study highlights the lack of interventions specifically focused on managing co-existing chronic illnesses in older adults, especially those that appear in clusters, such as diabetes, depression, heart disease and chronic obstructive pulmonary disease. Depression is common in patients with diabetes and, because each can be a risk factor for the other, self-care and taking medications correctly can be challenging for improved health,” says lead author Dr. Monika Kastner, North York General Hospital and the University of Toronto, Toronto, Ontario.

The authors point out that clinical guidelines usually focus on a single disease, so management of multimorbidity can be overwhelming for patients and difficult for health care providers because of the complexity of overlapping or conflicting treatments with potential adverse interactions. They suggest that interventions to manage multiple chronic diseases should not only focus on clinical aspects of care, but also consider patients’ health priorities and goals and their social and emotional well-being.

“Effectiveness of interventions for managing multiple high-burden chronic diseases in older adults: a systematic review and meta-analysis” H was published August 27, 2018. ■

Live, work and play Continued from page 4 This is an area where physicians and public health departments can collaborate with built environment experts to influence health.

Urban planners are the experts at improving the livability of towns, cities and regions. Meanwhile, physicians see the downstream effects of a poorly built environment in their clinics, operating theatres and emergency rooms every day – from chronic diseases to motor vehicle collisions.

The future of chronic disease and obesity prevention involves professions working together across silos to generate collaborative solutions. We need to work together for better places to live, play and work.

Many studies have demonstrated that active transport is associated with a decreased risk of developing chronic illness. Physical activity reduces the risk of cardiovascular disease, including a reduction in heart attacks, strokes and heart failure by up to 11 per cent. Systematic reviews, which pool together the results of multiple studies, also demonstrate that active transport is associated with a reduced risk of obesity, type 2 diabetes and high blood pressure.

With the large health benefits that can be realized from encouraging more active transport, health workers have an important role in advocating for and working with their urban planning

colleagues to implement these ideas.

How can we take action?

It’s time for health workers to speak up and get involved to help improve neighbourhoods for everyone. Urban planners can also help with determining the health impact of land-use and transport decisions by working with public health departments.

The good news? This collaboration is already starting to happen in some places.

And various areas across Canada, including in Toronto, Vancouver and the Region of Peel, are employing urban planners to examine the impact of different developments on the health of a community. This means new developments and existing ones are being built to encourage more active transportation.

Furthermore, the Canadian Association of Physicians for the Environment has started a campaign advocating governments to adopt a national active transport strategy, which was one of the main recommendations in a reported released by the CPHA-Lancet Countdown Briefing for Canadian Policymakers.

The future of chronic disease and obesity prevention involves working together across silos to generate collaborative solutions. We need to fight together for better places in which to H live, play and work. ■

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SEPTEMBER 2018 HOSPITAL NEWS 7

NEWS

PTSD

in health professionals

By Olena Chapovalov ealthcare is a dynamic, demanding and often unpredictable environment to work in. Depending on the specific job, healthcare workers can become exposed to psychosocial and physical hazards, including traumatic events. Traumatic experiences on the job, often seen in the healthcare sector, may lead to post-traumatic stress disorder (PTSD). PTSD is a mental health condition caused by witnessing or experiencing actual or threatened death, serious injury or violence. Being affected by these types of events and having some post-event reactions can be normal. However, if the thoughts or memories of these events start to persistently affect the life of the person long after the event, that person could be experiencing PTSD.

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IMPACT ON WORKPLACE HEALTH AND SAFETY In 2017, there was a heightened focus on mental health in health and community care workplaces as a result of Workplace Safety and Insurance

Board (WSIB) policy changes, allowing for coverage of Chronic Mental Stress claims, which took effect on January 1, 2018. Additionally, in late December 2017, the Government of Ontario announced that it would propose to include nurses in the Supporting Ontario’s First Responders Act, presumptive legislation for coverage related to PTSD. On May 8, 2018 the Ontario government passed an amendment to the Workplace Safety and Insurance Act (WSIA), 1997, making it easier for nurses and front-line healthcare workers to access WSIB benefits for PTSD specific to work-related trauma events.

Like first responders, front-line nurses are likely to suffer from PTSD because they have a greater potential to be exposed to traumatic events.

With the new proposed presumption, once a front-line nurse is diagnosed with PTSD by a psychiatrist or a psychologist, the claims process for WSIB benefits will be expedited, and nurses will not be required to prove a causal link between PTSD and a specific event.

Canadian research on PTSD among nurses estimates prevalence rates as high as 40 per cent . This number can potentially be higher as the system continues to evolve and make PTSD more recognizable and reportable for workers.

Nurses spend their entire careers helping others recover and live healthier, happier lives. There are a number of tools employers can implement to help support the nurses. These can include appropriate training, screening and assessment protocols, policies, on-

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8 HOSPITAL NEWS SEPTEMBER 2018

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NEWS

CANADIAN RESEARCH ON PTSD AMONG NURSES ESTIMATES PREVALENCE RATES AS HIGH AS 40 PER CENT

going refreshers, open communication channels between frontline staff and supervisors to leadership of the organization, and in-house support programs.

WHAT ARE SOME OF THE MEASURES EMPLOYERS CAN IMPLEMENT NOW TO PREVENT AND RESPOND TO PTSD IN THEIR WORKERS? Although the vital discussion about PTSD in workers has begun and a number of efforts are underway to develop tools and resources, there is still much work that needs to be done in this area. From what is known to-date, here are some of the steps that employers should consider to protect their workers’ psychological health:

1. PRIMARY PREVENTION Employers have a legal duty under the Occupational Health and Safety www.hospitalnews.com

Act to assess the risks specific to this hazard and notify the worker of its existence. Hence, employers need to recognize the hazard and assess the risk of being exposed to trauma in their workers. As a next step, employers need to put controls in place to protect workers based on the results of the risk assessment. In general, organizations who engage in proactive primary prevention should develop a prevention program specific to psychological health and safety that will include an element of PTSD (primary) prevention as well as appropriate post-incident response.

One example of primary prevention is resiliency training. Resiliency training should include an overview of what resiliency is and why it matters, how resiliency is related to prevention of PTSD, information for reducing arousal symptoms, techniques for managing distressing emotions, and preparing for a crisis. Additionally, understanding the risk factors, such as severity of exposure, should be included in training.

2. PEER-SUPPORT PROGRAMS TO PREVENT PTSD IN NURSES Peer-support programs are becoming particularly common in organizations with high-risk of exposure to traumatic events. Although the evidence to show its efficacy is still limited, organizations and workers who have this active inhouse resource report very positive feedback. Overall, there seems to be a benefit to having access to an individual within the organization who is skilled and knowledgeable in trauma counselling.

Resources such as the in-house peer-support program, should be part of a larger, organization-wide strategy and prevention plan with a specific focus on addressing post-traumatic stress injuries. The recent change in legislation is a step in the right direction that not only acknowledges the importance of helping workers who have been diagnosed with PTSD, but also the need to develop and implement prevention plans to protect the health and safety of workers who may be at risk. Psychologically healthy and safe workers are essential for quality patient care, successful functioning of an organization and a strong health care system.

The prevention system partners are working together to better under-

stand work-related trauma injuries and identify some effective tools to help workers. One example is a current research project that is looking at trauma experiences in psychiatric workers.

Any questions can be directed to the project team contact, Kayla Sherborn ksherborn@waypointcentre.ca

RESOURCES: PSHSA has been working on supporting front-line workers, with the following tools and resources: PTSD Fact Sheet PTSD Awareness for Nurses First Responders First Provides information about PTSD and the development of PTSD Prevention Plans including prevention, intervention and recovery and return to work. The site includes organizational assessments, sample policies and links to resources. It also includes research and news related to PTSD. View submitted PTSD Prevention Plans on the MOL Website.

PSHSA PTSD Website Provides information about PTSD and links to resource and tools including prevention, intervention and recovery and return to work sample

policies and procedures, news and research: www.firstrespondersfirst.ca Think Mental Health Is a joint effort from Ontario’s Health and Safety System Partners to provide business owners with resources needed to support positive mental health prevention efforts.

Stress Assess An evidence based tool to assess psychosocial factors in your workplace.

Mental Injury Toolkit This guide and resource kit will provide workers with a basic understanding and a place to start to learn about workplace stress and what to do about it. The guide gives definitions, common causes of mental distress, legal frameworks (focusing on Ontario), possible actions to take, and resources available. It is an introduction and action guide created by workers for workers.

Although the current available resources focus on first responders, there has been ongoing discussion and a plan to build a resource dedicated to PTSD in nurses. This will be in development over the next few months and will be disseminated through PSHSA H to all stakeholders. ■

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EVIDENCE MATTERS

Rapid tests for the diagnosis of Streptococcal infections:

Viable alternative or sorely overrated?

By Sarah Garland and Effie Helis robably one of the most relatable illnesses is the sore throat, also known as pharyngitis. Many of us have experienced the sensation of a burning throat – when eating, drinking, and even talking becomes painful due to the inflamed, red tissue at the back of our mouths. Most of the time, a sore throat is the result of a viral infection; but in some cases, it’s caused by a bacterial infection.

Group A Streptococcus, also called GA Strep, are bacteria that can cause a variety of conditions, notably pharyngitis and skin infections, and it can sometimes lead to serious complications. It’s estimated that 20 to 40 per cent of sore throats in children, and five to 15 per cent of sore throats in adults, are caused by GA Strep.

If pharyngitis is caused by GA Strep, treatment with antibiotics is often effective; but antibiotics will not be effective if it’s caused by a viral infection. Additionally, it’s important to prescribe antibiotics only when the infection is bacterial, as the inappropriate use of antibiotics contributes to the problem of antimicrobial resistance. To avoid the overuse of antibiotics and avoid possible complications from untreated infections, GA strep should be diagnosed correctly.

However, based on clinical presentation alone, it can be difficult to determine whether a sore throat is caused

by GA Strep or a viral infection. The gold standard for diagnosing GA Strep is a diagnostic test based on a throat culture. The main limitation of traditional, laboratory, culture-based tests is the time it takes between obtaining the culture (i.e., throat swab) and receiving the test results. This process may take several days, and patients

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may not always be able to return to the clinic for treatment.

In response to the need for more timely diagnostic tests for GA Strep, several non-culture based tests have been developed; these are often referred to as rapid tests. The two main categories of rapid tests are those based on immunoassays and those based on molecular assays. These tests may still require a throat swab, but due to different diagnostic techniques, the results are obtained much sooner than traditional culture-based tests – some can provide results in a matter of minutes! However, it’s uncertain how accurate of a diagnosis they provide compared with culture-based methods and whether they improve health outcomes for patients.

When questions like these arise, the health care community turns to CADTH – an independent agency that finds, assesses, and summarizes the research on drugs and medical devices. CADTH undertook a Rapid Response report to look for evidence on the diagnostic accuracy and clinical utility (i.e., changes in the duration of symptoms, severity of condition, and antibiotic prescribing practices) related to rapid diagnostic tests for GA Strep. Learn more about the methods and scope of CADTH’s Rapid Response Service at: https://www.cadth. ca/about-cadth/what-we-do/products-services/rapid-response-service.

In terms of diagnostic accuracy, the CADTH review found that the sensitivity, or ability of the tests to correctly identify people with GA Strep, varied between 93 and 99 per cent for molecular tests and between 55 and 94 per cent for immunoassays. The specificity, or ability of the tests to correctly identify people without GA Strep, varied between 91 and 99 per cent for

molecular tests and between 81 and 100 per cent for immunoassays. This suggests that for rapid tests, molecular-based techniques may be better able to identify GA Strep. Additionally, it appears that there is no test that distinguishes between GA Strep carriers and an active GA Strep infection.

Often, the decision to prescribe an antibiotic is made during the patient’s initial visit to the doctor and is based on a clinical score – an assessment of a patient’s symptoms and medical history. The CADTH review looked for evidence regarding the clinical utility of rapid tests compared with clinical scores, but the evidence that was found was limited and conflicting.

There was, however, limited evidence to suggest that the use of a rapid test might decrease the number of antibiotic prescriptions written for patients with sore throats.

So what’s the bottom line? Overall, rapid tests for diagnosing Group A

Streptococcus offer good diagnostic accuracy, and molecular-based tests are likely to be more sensitive than immunoassay-based tests; however, the evidence regarding clinical utility of rapid tests is limited. While rapid detection tests could be used for obtaining a clinical diagnosis for Group A Streptococcus faster, the use of these tests will depend on patient and practitioner factors – such as familiarity and skill with the tests, feasibility of each approach, type of test used, and severity of patient symptoms.

If you’d like to read CADTH’s full report on rapid tests for GA Strep, it’s freely available at https://www.cadth. ca/rapid-tests-diagnosis-group-streptococcal-infection-review-diagnostic-test-accuracy-clinical-utility. To learn more about CADTH, visit www. cadth.ca, follow us on Twitter: @ CADTH_ACMTS, or talk to our Liaison Officer in your region: www.cadth.

H ca/contact-us/liaison-officers. ■

Sarah Garland and Effie Helis are Knowledge Mobilization Officers at CADTH. 10 HOSPITAL NEWS SEPTEMBER 2018

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INFECTION CONTROL 2018

Pre-hospital care and infection control

By Molly Blake and Greg Bruce aramedics are relatively new to the healthcare profession: The late 1800s had horse drawn ambulances. It was not until the early 1970s when the modern Paramedic emerged in areas across North

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America. Their primary focus was rapid response and transport, with very little attention to infection control, except as it related to protecting the provider.

Since then the profession has evolved considerably. Scope of prac-

tice has evolved as the complexity of care offered in prehospital settings has increased. Invasive procedures previously reserved for the emergency room are now common in the prehospital setting. Intubations, chest needles and surgical airways are being performed in the street. Full cardiac arrests are worked on in homes. Transport ventilators and blood products are common during critical care transport.

ters, starting with Point of Care Risk Assessments prior to patient contact and hand hygiene according to the Four Moments for Hand Hygiene.

Cleaning and disinfection so the vehicle and equipment are safe for the next patient is vital as everyone deserves safe care.

To achieve this, educational institutions must include Routine Practices within the curriculum. Prehospital

INFECTION CONTROL IN PREHOSPITAL MAY LOOK DIFFERENT THAN IN FACILITY; HOWEVER THE PRINCIPLES REMAIN THE SAME. And with changes in healthcare delivery, more people than ever are accessing the healthcare system through prehospital care.

This all leads to even more need for appropriate infection prevention and control practices in prehospital care. The stakes are much higher and patient safety must be the motivating factor. The good news is infection prevention and control is achievable. All providers need to know how to correctly apply Routine Practices in all patient encoun-

organizations must build on and regularly review this education. In this response driven environment, Managers must support timely application of Routine Practices.

Infection control in prehospital may look different than in facility; however the principles remain the same. Effective use of Routine Practice leads to decreases in infections.

For more information on IPAC Canada and Routine Practices E-Learning Modules, see www.ipac-canada.org or H call 1-866-999-7111. â–

Molly Blake RN BN MHS CIC is President of Infection Prevention and Control Canada (IPAC Canada). She is Director, Infection Prevention and Control for the Winnipeg Regional Health Authority. Greg Bruce EMCA is Chair of the IPAC Canada PreHospital Care Interest Group. He is Platoon Supervisor and Infection Control Officer for the County of Simcoe Paramedic Services.

12 HOSPITAL NEWS SEPTEMBER 2018

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INFECTION CONTROL 2018

The need for improved lyme literacy

As Lyme disease makes inroads across Canada, activists say the medical community needs to better informed

By Diana Swift t may be September, but that doesn’t mean you can’t still contract a summer infection that’s quickly gaining ground in Canada: Lyme disease. As more Canadians and their pets take to campgrounds and hiking trails, invading the habitats of blacklegged ticks spreading north and west with the warming climate, cases of this potentially serious disease are rising incrementally.

Lyme disease is caused by the spirochete bacterium Borrelia burgdorferi typically carried by about 20 per cent of blacklegged ticks (Ixodes scapularis), that feed off the blood of animal and human hosts and hide in leaf debris and long grass. “The nymphs are particularly active feeders,” says medical entomologist Dr. Robbin Lindsay, a research scientist at the Public Health Agency of Canada’s National Microbiology Laboratory in Winnipeg.

Lindsay warns that the geographic distribution of blacklegged ticks in Canada has rapidly expanded and is not likely to decline any time soon. More ticks are likely entering Canada on migratory birds, and a warmer climate likely plays a role.

“Studies suggest that temperature is one of the critical factors that determines where and how quickly tick populations can establish.” says Dr. Lindsay. “Tick populations take hold more rapidly in warmer areas.”

The tick explosion is driving Lyme incidence – and Lyme phobia. Back in 1994, 144 Lyme cases were reported in Canada, according to federal government surveillance figures.

Thanks partly to greater awareness and Lyme’s designation as a nationally notifiable disease in 2009, by the year 2016 Canadian cases had increased to 994, almost 90 per cent from Ontario, Quebec and Nova Scotia, for an incidence of 2.7 cases per 100,000 population. A year later,

I

cases jumped by almost 50 per cent to 1479, and last year, a troubling 2025 cases made the books.

“In 2018 the incidence of Lyme is projected to double and rise to about 10 cases per 100,000 of population,” says microbiologist/biochemist Dr. Tara Moriarty, an associate professor in the University of Toronto’s Faculty of Dentistry and

14 HOSPITAL NEWS SEPTEMBER 2018

Medicine. “But globally, only about 10 per cent of infected people will get serious, hard-to-treat forms of the disease.” She adds that some cases are missed because primary care physicians may not have encountered many cases.

Although Canada’s annual incidence of Lyme is small compared with, say, influenza (55,000+ as of

June for the 2017-18 season), it is much larger than that of mosquito-borne West Nile virus, of which 200 cases were reported in 2017.

As cases increase, so does polarization around the issue. “Lyme has become highly politicized,” says Dr. Isaac Bogoch, an infectious diseases specialist at Toronto General Hospital. “The rapid expansion of cases reported in the media is driving concern,” says Moriarty, adding that 90 per cent of cases are readily treated.

Lyme pressure groups, however, stress the lack of awareness among clinicians, delays in treatment, a paucity of diagnostic tools and general confusion over the interpretation of Lyme blood tests, putting growing numbers at risk of delayed treatment and serious chronic symptoms. Although the Internet abounds with troubling examples of patients who did not receive timely treatment and suffered long-term consequences, there is still some controversy as to whether a true chronic form of the illness exists.

No one would argue that early diagnosis and therapy aren’t important since without appropriate antibiotic treatment the infection can in some cases lead to long-term problems, including facial paralysis, chronic fatigue, cardiac disturbances and neurological deficits. These can set in long after the initial symptoms of fever, rash, headaches, arthralgias, nausea and general flu-like chills and aches. A case in point is that of Emily Simon (see sidebar: “A Worst-Case Scenario’), who was sick for months before her rashes, severe joint pain and flu-like symptoms were treated belatedly as Lyme disease. And studies reveal that only 40-80 per cent of patients will exhibit the telltale bull’s-eye rash, the spreading, ringlike lesion caused by the tick’s bite and known as erythema migrans and often mistaken for a spider bite.

Continued on page 16 www.hospitalnews.com

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INFECTION CONTROL 2018 Continued from page 14

Improved lyme literacy According to Bogoch, Canadian healthcare providers are increasingly aware of the Lyme issue and are committed to providing better care.

“Some doctors choose to treat Lyme empirically right away based on a patient’s symptoms and the context – where they were before the symptoms started – and others will wait a few days for the blood tests to come back positive.” Either way, he says, there are well-documented guidelines for treating all phases of the disease, which is not difficult to diagnose or treat. “It’s actually a rather wimpy bacterium, although residual symptoms can be challenging to manage,” he adds.

Lyme activists note, however, that cats and dogs are better protected than people, having access to vaccination that is no longer an option for humans. “There was an early vaccine that was 80 per cent effective, but it required multiple doses and was discontinued after unsubstantiated reports that it caused Lyme disease,” says Moriarty. A newer version, VLA15, developed by the French biotech company Valneva, has just finished phase II trials in Europe, and may be on the market in the not too distant future.

Other experts caution that the hyperbole around Lyme disease poses a risk of unnecessary long-term exposure to antibiotics and their inherent side effects as well as the spectre of antibiotic resistance exacerbation and the emergence of intractable superbugs.

“If they don’t have Lyme disease, but they have symptoms for which they are receiving ‘Chronic Lyme’ antibiotics, they’re at risk of side effects from unnecessary antibiotics,” says Dr Lynora Saxinger, an associate professor of infectious diseases at the University of Alberta in Edmonton.

“And they’re also at risk of whatever they actually have becoming more of a problem while they’re distracted by this question of Lyme treatment.”

While Dr Saxinger acknowledges that Lyme is becoming more common and can have serious consequences if not treated, she cautions that “there’s unfounded distrust of validated tests

and unfounded trust in terrible tests, and strange beliefs about chronic infection.” And, she continues, “Even when patients with well-established

true Lyme disease have long-term symptoms after infection, long-term and repeated antibiotic treatment have not been shown to improve these

Photo of Rob, Samantha and Emily Simon courtesy of Samantha Simon Photography.

A worst-case scenario Samantha Simon, a photographer who resides on a rural property in Durham, Ont., near Owen Sound, is one of a growing number of Canadians who believes much more needs to be done to address the Lyme disease threat. In 2017, her then 20-month-old daughter, Emily, was bitten by ticks during a family hike on wooded trails. The toddler eventually developed three characteristic bull’s-eye lesions – first on her arm and then on her leg and foot. She also had fever, vomiting, and joint pain. “Emily became completely lethargic and would cry and grab at her knees and try to bite them,” recalls Simon.

Suspecting Lyme, Simon took her daughter to the local emergency room, where the initial lesion was dismissed as an allergic reaction to a mosquito bite. Simon’s belief that Lyme disease was causing Emily’s symptoms was equally waved off by her family doctor and even by a children’s hospital.

Although a local nurse practitioner prescribed a brief course of antibiotics, it took an appeal to the advocacy group Lyme Ontario to put Simon in touch with a naturopath, who definitely diagnosed Emily with the tick-borne infection. But in order to receive further antibiotics, the family had to seek care in British Columbia, where naturopaths are able to prescribe antimicrobial drugs.

Emily’s symptoms improved with treatment, but she remained on antibiotics for five months and now, more than a year later, she has lingering neurological symptoms related to Lyme. “The infection caused a brain inflammation and today she’s very volatile and flies into rages,” says Simon.

Now on the board of the advocacy group Lyme Ontario, Simon is fighting for better recognition of and prompt treatment for all tick bites, since, she notes, these vectors can transmit several other infections as well. “Ticks H are filthy creatures,” she says. ■

troublesome post-infection symptoms and are not recommended.”

Moriarty agrees that some activists downplay scientific evidence and promote unproven experimental diagnostics and treatments. And, increasingly, profit-driven companies are exploiting the fear around Lyme.

“There’s a lot of inaccurate information and heavy marketing around methods for prevention and diagnosis that have not been validated,” says Moriarty. “Some sick people are told they have Lyme when they don’t.” She refers, for example, to a recent study that had asymptomatic people without Lyme disease tested with an unvalidated alternative assay. “More than 50 per cent tested positive!” she says.

All the more reason, say activists, for mainstream medicine and public health to step up their game. And citizen advocacy for more awareness and prompter diagnosis and treatment is on the rise with the formation of vocal groups such as the Canadian Lyme Disease Foundation and LymeHope.

For its part, the federal government is taking the encroachment of Lyme disease into Canada very seriously and is committed to raising public and professional awareness and improving prevention, diagnosis and treatment. The Public Health Agency of Canada’s website urges all healthcare providers to update their knowledge of this infection and its potential consequences and provides links to the guidelines of the Infectious Diseases Society of America and the International Lyme and Associated Diseases Society.

But according to international Lyme disease expert Dr Raphael Stricker of San Francisco, pockets of the medical community are still far from Lyme-literate and there’s lingering resistance to taking the infection seriously. “The medical community is not open-minded about accepting newer, more sophisticated tests and some members feel there’s no need for treatment a lot of the time. This is blocking progress in H Lyme disease.” ■

Diana Swift is a freelance writer in Toronto.

16 HOSPITAL NEWS SEPTEMBER 2018

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NEWS

Death and dying in PICU: Bringing academic focus and wisdom to frontline care

By Karen Dryden-Palmer and Christopher Parshuram alking about death can be uncomfortable in children’s hospitals. Clinicians, parents and families think about it, worry about it, and work tirelessly to resist/oppose it. Fortunately, most never have to experience it. In the case of critical childhood illness, new and enhanced curative treatments have provided realistic hope for survival and improved outcomes. However, the reality is that five per cent of paediatric intensive care unit (PICU) patients die in the PICU at SickKids each year.

Providing high quality care to dying children and their families is an honour, a privilege and a responsibility that we embrace in critical care. We know it’s important to provide quality care to children and their families in all phases of illness. The death of each child is profound, with implications that extend beyond the events of the death and can impact the family and the healthcare team for years.

Providing high-quality end-of-life care is a fundamental skill for all clinicians working in critical care settings. Having found limited practical guidance in critical illness end-of-life

EXPERTS FROM AROUND THE WORLD CRAFTED THE 17 ARTICLES OF THE DEATH & DYING IN PAEDIATRIC ICU SUPPLEMENT OF PAEDIATRIC CRITICAL CARE MEDICINE

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care for frontline providers, we set out to address this important gap. However, we couldn’t do this alone. We needed to bring together decades of experience, the expertise of leading scholars and the focus of those passionate about bridging the gap between knowledge and practice. An international collaboration was born and experts from around the world began crafting the 17 articles of the Death & Dying in Paediatric ICU supplement of Pediatric Critical Care Medicine.

As the supplement editors, our role was to bring together the 39 leading clinicians and scientists who contributed to the supplement. Our primary objective was to ensure each individual article contributed evidence-informed guidance for frontline providers – and that the guidance was

articulated in an accessible and practical manner.

As we moved deeper into the work and reflected on our collective experiences in caring for dying children, the things that we knew were most important became clear. We identified how the experience of death is unique in different circumstances; where therapy is withdrawn, when active therapies are continued, where organ donation is pursued and where death outside the PICU environment is desired. Each of these end-of-life situations is addressed in the supplement. Each article’s goal is to enable frontline practitioners to better understand and appreciate nuances, and to catalyze reflection about how they can best provide compassionate, evidence-informed care at the end of life.

The 17 articles also provide a framework for understanding the ethical tensions of death as part of childhood critical illness, plus approaches to communication and building relationships with families and clinical teams to realize best end-of-life care. The international experience of paediatric end-of-life care is explored in a series of contributions by senior clinicians from five continents. Finally, the supplement offers information to support the health and wellbeing of providers, and presents a forward-looking view of the training and cross-training of future practitioners in the PICU. The Pediatric Critical Care Medicine supplement is an important beginning that builds on the SickKids Critical Care Program’s tradition of advancing careful, compassionate evidence-informed care of critically ill children and families. It has been – and continues to be – a privilege for us to lead the creation of this resource for providers in continuing the tradition of leadership and innovation of our program.

This work is supported by the Robin DeVerteuil Foundation. Supplement articles are available as a free downH load from PCCM.org. ■

Karen Dryden-Palmer and Christopher Parshuram are clinicians and academics in the SickKids Critical Care Program.

18 HOSPITAL NEWS SEPTEMBER 2018

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ETHICS

Brain Death: An area fraught with more questions than answers

By Andria Bianchi he topic of neurologically determined death (“brain death”) is fraught with ethical and philosophical questions. A 2014 policy by the Canadian Medical Association characterizes neurological death as “catastrophic brain injuries that lead to the irreversible cessation of all clinical brain functions (“whole brain” death).” Some of the primary ethical questions that often arise in relation to this topic consider whether “brain death” is actually a type of death (versus cardiovascular death), whether someone deemed “brain dead” is a person, and whether/ how much conflicting cultural and religious conceptions of death ought to be taken into account when it comes to maintaining life-support.

The reason for discussing this topic in this edition of Hospital News is because of an evolving and precedent-setting case in Brampton, Ontario. The case involves a 27-year-old woman named Taquisha McKitty, who was declared brain dead in September 2017. According to the Ontario hierarchy of substitute decision-makers, Taquisha’s parents were responsible for making decisions on their daughter’s behalf. After Taquisha was pronounced dead, her parents requested that she be kept on a mechanical ventilator and received a legal order so that the hospital could not withdraw life-support. According to available news reports, their justification for deciding to keep their daughter on life-support was twofold: (1) Taquisha continues to show signs of life and (2) Taquisha’s Christian beliefs suggest that she is alive insofar as her heart is beating.

A court battle between the McKitty family and the hospital occurred last fall, and in June 2018, Ontario Superior Court Justice Lucille Shaw ruled in a precedent-setting decision that Taquisha should be taken off life-support. Justice Shaw gave the family 30 days to appeal, which they did on July

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BECAUSE A PERSON’S CARDIAC FUNCTION CAN BE MAINTAINED EVEN AFTER THEY ARE DECLARED DEAD BY NEUROLOGICAL CRITERIA, QUESTIONS OF WHETHER AND WHEN LIFE-SUPPORT OUGHT TO BE DISCONTINUED ARISE. 26th. The family argued that withdrawing Taquisha’s life-support would infringe her rights under the Canadian Charter of Rights and Freedoms.

Similar cases to Taquisha’s continue to occur in Canadian society, such as the case of Shalom Ouanounou who was pronounced brain dead shortly after Taquisha. And similar to Taquisha’s parents, Shalom’s family received an injunction to keep him on a mechanical ventilator. He died shortly thereafter while on life-support.

There are a few reasons that cases similar to Taquisha’s continue to transpire. First, death is a process, and determinations of what classifies a per-

son’s death and when a person should be pronounced dead vary across the globe. According to the World Health Organization, death is typically pronounced when a person’s cardiorespiratory function ceases , however, technological advances have made it such that a person with irreversible brain function loss (which would typically result in the body dying) can have their cardiac function maintained.

Because a person’s cardiac function can be maintained even after they are declared dead by neurological criteria, questions of whether and when life-support ought to be discontinued arise. Some cultural and religious con-

ceptions of death may make it such that only cardiovascular death is recognized as legitimate, and so substitute decision-makers may challenge a declaration of death based on neurological criteria if they/their loved one holds a conflicting view.

The above situation prompts us to consider the uncomfortable question of whether, and if so, where, a line ought to be drawn when it comes to providing culturally sensitive care.

Some theorists suggest that scientific evidence ought to be the primary guide of determining death and the cessation of life-support. Other theorists, however, say that different conceptions of death ought to be heavily weighted, taking into account varying cultural and religious perspectives.

This, of course, leads to the complex topic of how scarce resources (e.g. publically funded hospital beds) ought to be utilized, and whether a person who is declared clinically dead should be offered medical resources in certain contexts.

In addition to different religious and cultural conceptions of death, a family may find it difficult to believe that their loved one is dead when their body maintains some physical functions because of its dependence on technology; ensuring that a family is provided with clear and comprehensible information about brain death may help to mitigate this challenge. In fact, and as discussed with some of my colleagues, offering education to members of our society about the meaning of neurological death and what happens to one’s body when one’s brain no longer functions may be a helpful first step.

Ultimately, a consensus on these complex ethical, philosophical, clinical, and legal questions about brain death has not been achieved. And while I anticipate the debate to continue, it seems that Taquisha’s case and the upcoming legal ruling may at least help to inform future H discussions ■

Andria Bianchi, PhD, is a Bioethicist at the University Health Network and a board member of the Canadian Bioethics Society.

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FROM THE CEO’S DESK

Searching for the sustainable

health-care unicorn

By Dr. Jack Kitts bout a decade ago, many hospitals were having a tough time controlling a nasty form of bacteria known as MRSA. At the time, the standard practice was to screen only high-risk patients who were transferred into hospital.

At The Ottawa Hospital, our infection control experts said that, based on best practices and data, we should screen all admitted patients. Every single one. The decision wasn’t taken lightly. It meant that all patients had to have their nose, throat and rectum swabbed, no matter what they were being admitted for. This was unpopular with patients and nurses alike.

We hired more staff, which increased our costs. But, with expert opinion on my side, I was confident in my decision.

I turned out to be wrong.

This situation illustrates how complex and, yes, maddening, the subject of sustainable healthcare can be. It’s not merely an academic or ecological concept. There’s a lived aspect to sustainability, as our experience showed.

Two years into the universal MRSA screening program, our data surprised us. The screening program had added about $1 million to our annual costs, but we discovered it didn’t significantly reduce MRSA transmission rates.

Clearly, it was unsustainable. So instead, we targeted areas with a known high risk of infection.

That was the first time in my career as a health-care leader that I had the data to revisit a decision, to see if it was the right call. And that experience left an impression. It showed me how important it is to test expert opinion with reliable data harvested from well-designed research. I realized we will never achieve a sustainable system until we get a handle on the value of our health-care interventions. It’s value that helps us navigate the many factors that drive our decisions.

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Dr. Jack Kitts.

SHIFTING FOCUS FROM VOLUME TO VALUE WOULD LIKELY BE THE MOST REVOLUTIONARY AND DISRUPTIVE MOVE EVER MADE TO A PUBLICLY-FUNDED HEALTH-CARE SYSTEM. Health-care leaders and government officials have been searching for the sustainability unicorn for quite some time. So far, it has been a fruitless quest.

In his final Royal Commission report on healthcare sustainability in 2002, Roy Romanow stripped sustainability down to its essence: “Will Medicare be there for me, when I need it?” His answer: The health-care system was “as sustainable as we want it to be” and that it had “more to do with ‘who pays’ than ‘how much we pay.’”

After years of investments and reform, most Canadians remain significantly concerned about our health system’s sustainability and resilience.

In the 2003-2004 Health Accord, the First Ministers were right when they stated that money alone cannot ensure sustainability.

So, what does a sustainable healthcare system look like? It should:

• give optimal health outcomes to individuals and populations • be affordable for patients, employers and governments • be responsive to new diseases, changing demographics, or scientific and technological discoveries In searching for sustainability, decision-makers get bogged down by non-tangible factors that are impossible to test or measure. Or they go granular by reducing the cost of inputs while ignoring outcomes. It’s a land of false savings and unacceptable risk.

A far better option would be to anchor sustainability on value. Michael Porter of Harvard University defines value as the health outcomes achieved per dollar spent, which maps neatly onto efficiency. Since value depends on results, not inputs, Porter says, value in healthcare must be measured by the outcomes achieved (e.g. a patient recovers well from hip replace-

ment surgery, without infection), not the volume of services delivered (e.g. number of patients who receive hip replacements).

Value can be measured. It’s right there in the Triple Aim, a framework developed by the U.S.-based Institute for Healthcare Improvement and adopted by many Canadian hospitals.

The Triple Aim calls for a balanced focus on achieving better health of populations, better individual experience of care, and better value by finding lower costs for better-quality care.

Shifting focus from volume to value would likely be the most revolutionary and disruptive move ever made to a publicly-funded health-care system. The value equation – benefits over costs – allows for rational evidence-based decision-making and also for engaging professionals with fact, rather than emotion. But today, planners don’t have the required data to fill in the numerator or the denominator, or the solid cause-and-effect data to determine whether an increased investment actually improved the health of Canadians. What we have is data that is easily collected or tied to billings for services performed.

Yet measuring and reporting outcomes of individual patients as well as patient populations are essential if we are to make smart investment decisions. So is the willingness to act on what the data tell us.

Framing health-system reform in sustainability terms is a way to have honest conversations about what our society wants to build together, what is worth trading off, and what must be held onto, for dear life.

Our experience years ago with MRSA screening was a telling example of how health-care sustainability can be achieved, albeit on a small scale. The innovation we can harness by applying data-driven solutions more broadly will be key to sustainability on H a larger scale. ■

Dr. Jack Kitts is the President and CEO of The Ottawa Hospital.

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Rob is a seasoned litigator.

As an experienced advocate for seriously injured clients and their families, Rob Durante has successfully represented clients at all levels of court in Ontario. He is also an in-demand speaker and authority on issues concerning personal injury law. To relax at the end of the day, Rob enjoys spending time in the kitchen, cooking and creating traditional Italian dishes passed down from his parents.

Rob understands that in litigation, a recipe for success includes prep work. Like a chef, a lawyer always needs to be in prep mode, getting ready for the next step. Adding creativity to the mix helps Rob blend all the ingredients he needs to build a di cult case into one that wins the day.

Rob gets great satisfaction when he’s able to help provide a sense of justice and closure for family members who can then begin the healing process. at level of commitment means that when the pressure is on, Rob can really take the heat.

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ONLINE EDUCATION

Fifteen minutes of online education for a lifetime of compassion

By Helen Reilly umber River Hospital (HRH) believes in continuous learning and education for its employees.

Why? Nowhere is the expectation of constant learning more relevant than in health care, where lives are at stake.

As North America’s first fully digital hospital, Humber has always embraced high tech and high touch. To them, innovation means evolving and adopting new approaches, while using

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technology and training to deliver highly safe, reliable and exceptional patient care.

Today, continuous education and skills development for all staff are available through individualized education plans, based on each employee’s specific role and expertise.

Rolled out via online learning, also referred to as e-learning, is an efficient vehicle for imparting education and new information to improve knowledge in a variety of areas. “It’s

Through continuing education, patients at Humber River Hospital benefit from innovation and leading edge equipment.

NOWHERE IS THE EXPECTATION OF CONSTANT LEARNING MORE RELEVANT THAN IN HEALTH CARE, WHERE LIVES ARE AT STAKE. important to ensure employees are educated and up to date with the equipment, technology and interconnectivity of systems, to support patients medically and to treat them respectfully,” says John Ellis, Education Coordinator.

Humber’s e-learning tool of choice is LiME (Learning Information Management Environment), an online learning management system that is accessible to Humber employees both on and off site, 24-hours-a-day. At HRH, employees learn at their own pace and are supported to complete their learning during work hours.

Naziim, a new nurse at Humber, was familiar with mandatory and annual courses to be completed in health care, such as emergency codes, confidentiality, and hand hygiene, but when ‘bariatric sensitivity training’ was offered as a core course, she was interested in learning more. “The more I learn, the more I want to learn,” says Naziim. “I appreciate the value of a 15-minute online education session that provides me with facts and infor-

mation I can use every day – not just professionally, but also in my personal life,” she says. “I see obesity differently. There’s less judgement and I can also educate my children, my family and friends, about being sensitive and compassionate to those suffering with the disease.”

As a result of her online learning and ongoing training, Naziim learned that Humber not only encourages staff and visitors to be sensitive to patients receiving treatment, but better understands how patients suffering with obesity may feel while navigating their health journey and how to be supportive.

“The hospital’s bariatric care clinic delivers outstanding care and service to our community and beyond. Offering our staff online bariatric sensitivity training is just on example of our commitment to offer cost-effective development opportunities that reflect the hospital’s values of compassion, professionalism and respect for all of our patients,’’ says Scott Jarrett, Humber River Hospital’s Vice President of H Patient Services. ■

Helen Reilly is the Senior Writer & Communications Specialist at Humber River Hospital.

24 HOSPITAL NEWS SEPTEMBER 2018

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ONLINE EDUCATION

CNA introduces accreditation services With 110 years’ experience in providing credible continuing professional development (CPD) programs to nurses, the Canadian Nurses Association (CNA) is excited to now also offer accreditation services.

This endeavour is part of CNA’s new direction to grow its programs, services and networks. Its aim is to support nurses so they can continue to make a real impact on the lives of Canadians.

The CNA Accreditation Program helps nurses identify top-quality group-learning and self-assessment opportunities. It also gives external and partner organizations the opportunity to earn national recognition through CNA for their CPD programs, courses, conferences and activities.

Eligible applications to the CNA Accreditation Program are carefully reviewed to ensure their learning and development objectives meet CNA’s accreditation standards. Applications that satisfy all the requirements will be assigned credit values based on the activity’s length, complexity and thoroughness. For a CPD activity to be eligible for accreditation, a nursing organization must have played a lead role in its development.

To date, CNA has accredited e-learning modules on medical assistance in dying, suicide prevention and the Code of Ethics for Registered Nurses.

For information about the application process and fees, please contact accreditation@cna-aiic.ca

26 HOSPITAL NEWS SEPTEMBER 2018

Experience a shift in the

emergency department

By James Scarfone ove over, Catan and Monopoly. There’s a new player in the board game world that is fun for the whole (medical) family.

GridlockED is a serious game (i.e. simulation-based game) that helps doctors prepare for work in the hospital’s emergency department (ED).

A group of Hamilton Health Sciences (HHS) emergency physicians and McMaster University students created it as part of their academic research.

The game is intended to be a safe way for doctors to learn how to manage multiple patients in a busy, simulated ED before they experience those

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challenging real-life scenarios. Players plan strategies as a group to admit, treat and release patients while minimizing threats to patient safety.

Dr. Teresa Chan and her colleagues developed GridlockED as a way to teach medical students and residents how to manage multiple patients with various degrees of illness or trauma in a low-risk environment.

“GridlockED started as a conversation over coffee between friends one afternoon,” says Dr. Chan, co-creator of the board game and an emergency physician at HHS. “I became so obsessed with the idea that I went home that day to doodle some designs. One www.hospitalnews.com

ONLINE EDUCATION

Accreditation Program GridlockED is a serious game (i.e. simulation-based game) that helps doctors prepare for work in the hospital’s emergency department (ED).

thing led to another and we started development just a few months later.”

THE OBJECT OF THE GAME Like many strategy board games, the game takes a few minutes to set up using multiple players. To win the game you must treat as many patients as possible within an eight-hour shift. Players work together to use their action points to fulfill care for every patient they look after.

Players review patient cards with different ailments and conditions listed on them, and actions are distributed between the various types of medical and nursing providers. It reveals the complexities of collaborative, inter-professional care.

Prioritizing each patient based on availability of doctors, nurses and specialists is key to the game.

EXISTING ED DATA PAVED THE WAY TO DEVELOPMENT Dr. Alim Pardhan, a co-creator of GridlockED, provided some statistics early in the development stage that helped kick-start the execution of the idea.

“I thought this was a great idea to help our learner physicians navigate the challenging world of the ED,” says Dr. Pardhan, ED site lead at HHS. “I offered some data based on the different levels of acuity and presenting problems we experience in our hospitals.”

Dr. Pardhan hopes the game will improve the learner experience for

those wishing to work in emergency medicine.

The creators previewed the game at various sites across North America.

Many members of the medical community praise the game for its realistic portrayal of life in the ED.

GLOBAL INTEREST FOR GRIDLOCKED Since they announced the availability of the board game earlier this month, the creators garnered interest from around the world with many requests to own a copy.

“In just under a month, we’ve had inquiries from Australia, Africa, Europe, Asia, South America and North America.” says Dr. Chan, who is also an assistant professor of medicine at McMaster.

“Basically, there has been interest everywhere except Antarctica. We couldn’t be more thrilled with the response.”

Interest was so high during the early release stages, the GridlockED team decided to move up their launch date by several months. It is on sale now for US$89.99 (plus shipping). All proceeds have been generously donated by the developers to help fund future emergency medicine research.

Beyond learner physicians, the team wants to promote the game in the broader healthcare community as a way to increase knowledge on how hospital EDs work. Soon, they also plan to develop a version for the general public.

You can visit gridlockedgame.com to learn more or to purchase the game H online. ■

James Scarfone is a Public Relations Specialist at Hamilton Health Sciences. www.hospitalnews.com

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cna-aiic.ca cn a-aiic.ca SEPTEMBER 2018 HOSPITAL NEWS 27

ONLINE EDUCATION

Online learning – made for physicians f you are a physician, you are also quite likely used to making sacrifices. It starts with an immense amount of education. Then, the job is tough – one of the toughest. Your social calendar? It could not be scarcer. To top it all off, despite everything you’ve learned in medical school, there is a lot of on-the-job learning you are expected to undertake. Confidence isn’t one of the things you should have to sacrifice.

That’s where online learning can help. It’s almost as though it was created for physicians.

Life-long education is a must for physicians. The benefits of in-person courses are obvious – you’re immersed in it, you’re with your colleagues, you

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have face-to-face discussions with facilitators and instructors. The value of online learning is high but not always quite as clear. It lies within the fluidity of it all, the flexibility, the opportunity for physicians to pick and choose their education as they see fit so they finally feel like they can take their time, as opposed to cramming things in.

The biggest advantage though, is that it teaches physicians to be self-directed, and in a career that demands leadership, that is one crucial skill.

“These courses are designed for the self-motivated,” says Jennifer Wickenden, Associate Director of Physician Leadership and Development at Joule.

“They are often more convenient but a learner still has to push themselves.”

Jennifer is responsible for development and delivery of online courses at Joule, the Canadian Medical Association’s newest company, and she says that it is only normal for physicians who not have taken an online course to fully understand what it will be like. When you’re used to the traditional education cycle, online learning is an adjustment, but she says physicians are always pleasantly surprised. Primarily, they are impressed with the insidious benefits that arise from such in-depth courses.

“It’s a very different type of learning,” she says. “You take a course over a six-week period, so you have the chance to apply knowledge gradually, test concepts out in the real world, reflect and give critical thought to what you’ve learned before coming back.”

Another benefit, Jennifer says, is the unique kind of camaraderie that occurs with online courses. “Physicians have said this is a great way to network,” she says. “They meet once a week in live webinars where they can discuss what they learned, bring their own challenges to the table, but the conversation keeps going afterwards.”

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IN A CAREER FILLED WITH SET SCHEDULES, ONLINE LEARNING LETS PHYSICIANS PRIORITIZE THEIR TIME THEY WANT THEY WANT TO.

Providing an online sphere for Canada’s brightest medical minds to discuss such challenges is monumental, Jennifer says, to the future of health-

care. “Every province has its different perspectives on healthcare,” she says, “It’s so interesting to hear people come together and form best practices. Hav-

ing these online courses is a great way to continue building those contacts across the country.”

The most noticeable advantage however, not surprisingly, is the flexibility of online courses. With demanding work schedules, patient loads and family lives, physicians can’t always carve out two-three days to travel for face-to-face courses. In a career filled with set schedules, online learning lets physicians prioritize their time they want they want to.

“I had one doctor tell me she was taking an online course while on vacation in France,” she says. “They can manage their learning with everything else they have going on.”

The plethora of online material is expansive, but Jennifer says she enjoys developing courses catered specifically to making physicians better leaders.

With courses in self-awareness, leading change, engaging with others, and financial acumen, Joule highlights the everyday lessons you can’t get in medical school.

“Physicians take these courses and have so many light bulb moments about themselves,” she says. “They are so focused on that clinical piece in medical school; they miss out on all these other aspects of their education, specifically who they are as a leader. In this career, bettering yourself as a leader is one of the H most important things you can do.” ■

Joule, a subsidiary of the Canadian Medical Association, is home to the Physician Leadership Institute, a platform for physician leadership development.

With a wide range of online courses, Joule is becoming a major player in the online learning game. With courses on self-awareness, leading change, and financial management, Joule provides physicians and residents with the tools they need to improve their practice. Click here to shop through Joule’s online catalogue.

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www.CHA Learning.ca SEPTEMBER 2018 HOSPITAL NEWS 29

ONLINE EDUCATION

How a simulation dramatically

improved blood delivery times for trauma patients

By Amber Daugherty hen a critically injured and bleeding patient is rushed into a trauma bay, every second counts – the faster they can receive blood, the higher their odds are of survival. So when St. Michael’s trauma team discovered unnecessary delays in getting blood from the blood bank to the trauma bay, they eliminated them. As a result, blood is being delivered on average 2.5 minutes faster – improving patients’ survival odds by 12.5 per cent.

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“Two and a half minutes might not seem like a long time but it can feel like an eternity when you’re waiting for this critical treatment for a bleeding trauma patient,” says Dr. Andrew Petrosoniak, emergency physician and trauma team leader who was the senior author of the study working alongside lead author Dr. Alice Gray and collaborator Dr. Katerina Pavenski. “That’s why we started running simulations to look at our massive transfusion protocol (how we get blood to a trauma pa-

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30 HOSPITAL NEWS SEPTEMBER 2018

USING SIMULATION IN HEALTH CARE IS ONE WAY TEAMS CAN IDENTIFY ISSUES AND TEST CHANGES BEFORE ANY PATIENT IS IMPACTED. tient) – we wanted to identify areas for improvement.”

Using simulation in health care is one way teams can identify issues and test changes before any patient is impacted. They can be done in situ – meaning in the actual clinical environment – to make them feel more real. In this case, they were done right in the trauma bay; the team was activated as though there was a real trauma patient and they went through their normal processes – the only difference was that there was a manikin (simulation version of a mannequin) in the bed instead of a patient. After each simulation, they would debrief to talk about what happened and what they could do better.

Within the first few simulations, the team found three issues that meant blood wasn’t being delivered to the trauma patient as quickly as it could be.

“When there’s a trauma, our nurses have to let the blood bank know and they also have to request a porter to deliver the blood to the trauma bay,” says Dr. Petrosoniak. “That’s two phone calls – we identified that as a potential risk because with everything else going on, they could forget to make one of those calls.”

The interprofessional team, including Lee Barratt, ED nurse educator, and Yvonne Davis-Read, transfusion safety nurse, changed the process to require just one phone call – a nurse would call locating to request a porter, who would then forward them

to blood bank to prepare and release blood products. In the process, they discovered an IT issue – the trauma phone, because of its emergency purpose, couldn’t be forwarded, so it would drop the call.

“If we weren’t running through this scenario, we could have waited a long time until somebody identified this dropped call issue, ultimately affecting patient care,” says Dr. Petrosoniak. “But because of the simulation, we were able to fix this in 24 hours and it didn’t negatively impact a single trauma patient.”

The team also identified that porters weren’t following a consistent route from the blood bank to the trauma bay so even though the two units are just a floor away from each other, delivery times would vary. And once they arrived, porters didn’t know where to go or who to give the blood to. As a result, there’s now a standard route for porters to take and a designated dropoff spot once they arrive.

“This was so significant because it shows we can do testing and quality improvement without impacting any patients,” says Dr. Petrosoniak, who presented the study’s findings at the annual congress of the International Society of Blood Transfusion in June.

“It’s a way to crash test the system just like you would crash test a car to make sure it’s as safe and effective as possible. This allowed us to iron out the kinks so that by the time real trauma patients were involved, the only impact they were more likely to see was H better outcomes.”■ www.hospitalnews.com

ONLINE EDUCATION

A simulation that was run to identify areas of improvement in massive transfusion protocol at St. Michael’s Hospital.

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SEPTEMBER 2018 HOSPITAL NEWS 31

ONLINE EDUCATION

Technology-enhanced collaboration in

Safety Improvement Projects

By Christopher Thrall anadian Patient Safety Institute (CPSI) is the only national organization solely dedicated to reducing preventable harm, improving the safety of the healthcare system, and engaging patients and families as partners in safer care.

Over the next 30 years in Canada, 12.1 million Canadians will be harmed by the healthcare system, and 1.2 million Canadians will lose their lives to a patient safety incident. Within acute and home care settings, patient safety incidents will cost the healthcare system $82 billion.

CPSI has a new direction called Patient Safety Right Now. You can hear the urgency in our call to action to focus on demonstrating what works and strengthening commitment to pa-

C

tient safety in Canada… right now!

As part of this new strategy, CPSI will work with committed partners to implement and evaluate measurable and sustainable Safety Improvement Projects that align with pan-Canadian priorities.

CPSI has new Safety Improvement Projects being offered that provide a complementary element to quality improvement learning collaboratives.

The design includes the integration of Quality Improvement and Knowledge Translation disciplines. Unique in their philosophical backgrounds, methodology and body of knowledge, the goal of engaging healthcare teams to achieve greater sustainable improvement is common. CPSI has created its learning design with synergies from each field to demonstrate what works.

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I really enjoyed the legal perspective and the ability to interact with people working with the same patients that I do.

Ross Johnson, Medical Director and Attending Physician, LTC

An example of this alignment can be seen where measurement of processes or change ideas take place together with an understanding of the organizational context – including readiness for change – contributing to sustainable change. In an article about harnessing the synergy between improvement science and implementation science, Koczwara argues that “it is time for these two approaches to become more closely aligned so that health care providers and researchers can harness the full power of a synergistic approach that is greater than its parts.”

CPSI’S NEW SAFETY IMPROVEMENT PROJECTS: Each Safety Improvement Project will use principles from the Institute for Healthcare Improvement Breakthrough Series and the Knowledge to Action Framework. The learning design for the Safety Improvement Projects is unique in that it is guided by the Quality Improvement/Knowledge Translation integrated approach. Topics align with current patient safety priorities in Canada.

• Measurement and Monitoring of Safety will create a culture of safety and reduce harm.

• Teamwork and Communication will lead to improved patient safety culture and positive patient outcomes.

• Medication Safety at Care Transitions will improve medication safety at discharge for frail elderly patients with poly-morbidity.

• Enhanced Recovery Canada will lead to improved outcomes and system efficiencies for colorectal surgery patients.

BENEFITS TO PARTICIPATION: • Teams will benefit from expert faculty and coaches who are knowledgeable about the best-known evidence

as well as practical ideas, tips and tools for application.

• Participating organizations will have the opportunity to demonstrate, showcase and share the practices that have worked to reach their established AIM at a congress event.

• Improvement results have the potential to positively impact participating organizations’ quality improvement plans, demonstrate their achievements and thus support meeting their organization strategic and operational objectives.

A blended model for learning design (Face to Face and Technology Enhanced Learning) Changes in the workplace as well as advancements in technology are impacting how people work and learn.

To be responsive to the needs of learners and allow collaboration with experts with specialized knowledge, the way we have designed our new learning programs is transforming. Virtual access to coaches will allow for timely feedback with continuous learning to support skill acquisition. Learning in a social environment or team collaborative space will also allow for the opportunity for professional problem solving and a link to build knowledge (Littlejohn & Margaryan, 2014).

The CPSI Safety Improvement Projects have been designed to use a learning design that includes face to face learning opportunities as well as technology enhanced learning. Teams will benefit from a collaborative virtual space for networking with other participating teams and faculty, and continual and ongoing support provided through in-person and virtual contact opportunities with coaches.

Given CPSI’s mission to inspire and advance a culture committed to sustained improvements for safer healthcare, finding synergies in KT and QI will leverage the strengths of each field H for greater impact. ■

Christopher Thrall is a Communications Officer at The Canadian Patient Safety Institute. www.hospitalnews.com

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NEWS

Trauma at a tiny hospital

By Tracey Richardson t was early evening in May this year – a weeknight – at the tiny Lion’s Head Hospital on the Bruce Peninsula. The day had been warm, 20 degrees, with a heat wave right around the corner, but still too early in the season for the waves of tourists gliding up and down Highway 6, heading to the national park or Tobermory and the Chi-cheemaun ferry.

There was nothing to suggest it would be an atypical shift in the emergency department for the one nurse and the RPN on duty, while the doctor, Dr. Jonathan Thomas, slipped home to eat dinner with his family.

Nothing except for the unending sirens suddenly piercing the air.

RN Dana Fries wondered if something was up, but it wasn’t until an ambulance roared up to the back doors that she sprang into action. And quickly realized that what she had on her hands was no broken ankle or chest pain complaint.

On the stretcher was an adult male patient in critical condition after an ATV crash. Fries knew immediately she’d need all the resources at her disposal – her RPN, Margaret Thompson, the doctor, and the on-call X-Ray technician. ORNGE too, and whatever help she could get from the paramedics and even the police. All would be pressed into action.

Without the ability to intubate, without a CT scan or MRI, with no other doctors to call upon and the regional hospital – Grey Bruce Health Services Owen Sound Hospital – more than 65 kilometres away, Fries and Thomas were limited. What wasn’t limited was their determination that night to save a life.

With the patient hemorrhaging blood and his breathing compromised, Thomas and Fries got to work on the basics – circulation, airway, breathing.

A laryngeal mask airway, two separate chest tubes, blood transfusions. Even then, the patient was barely hanging on as ORNGE rushed to the scene

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RN Dana Fries (right) and Dr. Jon Thomas in the Lion’s Head Hospital ER. and police officers tag teamed to Grey Bruce Health Services Wiarton Hospital to retrieve blood for the patient.

“A lot of mistakes happen when you try to do more than that early on,” Thomas says of their treatment plan that night. “You’ve really got to stick to the fundamentals.”

Following that standardized approach helped them to “stay organized, to compartmentalize,” he said, “especially when we don’t have a giant team or different parts of the team attending to different parts of the case.”

And if they’d had a large team at their disposal? Thomas insists the same protocols would have been followed for stabilizing the patient. “If this had been at a Level 1 Trauma Centre like

Sunnybrook, the treatment would have been no different. Again, you stick to the basics.”

They knew the patient had catastrophic injuries, even though at the time it wasn’t known how bad. “Basically, any one of his injuries could have and should have killed him,” says Thomas. The patient, who is still recovering, had suffered a ruptured spleen, a ruptured diaphragm, lacerated liver, lacerated aorta, a perforated bowel, and his stomach was in his chest wall.

When Thomas and his team later discovered the extent of the man’s injuries, and better yet, his positive prognosis, “to be honest, it was pride at that point.”

For Fries, a nurse for 18 years, “it’s one of those things where all your education paid off, the training and everything. Makes you proud of your career choice. And proud of our little facility, proud of our physicians, our team.”

Thomas likes to call it “frontier medicine. We’re just used to not having the same resources as elsewhere, so we just take care of it. It may not be a perfect solution, but we’ll come up with a solution that’s workable.”

Both health care professionals credit teamwork as the key to success in such a small emergency department.

The Lion’s Head Hospital is a fourbed facility with a 24-hour ED, one of the six hospitals under the Grey Bruce Continued on page 35

RN Dana Fries (right) and Dr. Jon Thomas in the Lion’s Head Hospital ER. 34 HOSPITAL NEWS SEPTEMBER 2018

www.hospitalnews.com

NEWS

THE CARE COURSE (COMPREHENSIVE APPROACHES TO RURAL EMERGENCIES) IS DESIGNED FOR SMALL RURAL HOSPITALS Continued from page 34 Health Services umbrella, and one of the smallest in Ontario.

“In a situation like (the one in May), we need the team,” Thomas says. “If I was on the hook as the sole leader who’s making (all) the choices, that (patient) would have died, for sure.”

It’s the isolation of the hospital that promotes that much needed teamwork, Thomas says, because “it promotes self-reliance, and that drives the necessary teamwork.”

A timely two-day rural emergency medicine course on the Bruce Peninsula just two months before May’s incident also played a critical role in the successful outcome, Fries and Thomas said. The CARE Course (Comprehensive Approaches To Rural Emergencies) is designed for small rural hospitals where generalists (family physicians), nurses and paramedics tend to medical emergencies without the support of a large, specially trained team. “It was excellent and it certainly did help us in this scenario,” Fries says.

The course originated in British Columbia and offers healthcare providers working in isolated areas opportunities to hone their emergency response skills in simulated emergency situations. It was the first time the course had been offered in Ontario, and dozens of nurses, doctors, and EMS on the Bruce Peninsula participated. The course is being piloted as part of a rural medicine initiative of the Ontario College of Family Physicians’ Collaborative Mentoring Networks.

Thomas called May’s incident “a once-in-10-years case for us.” But it’s one he and the team were better prepared for than at any other time, he said. “I feel to a certain extent that we’ve been preparing for that case for years. We’ve been slowly, slowly learning little bits and pieces here…We’re more prepared now than we were five H years ago.” ■ www.hospitalnews.com

Sport-related brain injuries

continue to impact thousands of Canadians

By Angela Baker rom the playground to the pro ranks, the topic of brain injuries related to sports is a concerning trend that will likely continue. It is an area that requires more attention and data to identify its prevalence in Canada.

From concerned parents of a child who has taken a nasty fall off a bike, to the fans of an NHL team whose star player suffers a concussion, the chance of a brain injury is ever-present.

Updated data from the Canadian Institute for Health Information (CIHI) showed that the number of emergency department (ED) visits for sport-related brain injuries in Ontario and Alberta has gone up 28% in the last 5 years. In 2016-2017 alone, there were more than 17,000 ED visits for sport-related brain injuries.

The vast majority of those visits (94%) resulted in a concussion diagnosis.

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CANADA’S SPORT AMONG WORST OFFENDER Hockey is the sport most associated with brain injuries, in Canada – which is perhaps unsurprising considering the sport’s popularity and prominence in Canadian culture. The physical component to the game, coupled with the large volumes of Canadians who play the game every winter, resulted in more than 3,000 ED visits in Alberta and Ontario for brain injuries last year.

Hockey Canada, the governing body for hockey in Canada from the grassroots to the Olympic Games, has created safety tips and The Hockey Canada Concussion app to help you and your family enjoy the game and stay safe.

KIDS AT RISK Sport-related brain injuries are also commonly associated with other sports like cycling, football, rugby, skiing and snowboarding.

We have seen increases in sport-related brain injury emergency department visits among the youngest patients, growing 50% over the past 5 years.

This increase does not necessarily mean they are injured more often.

One other possible explanation could be that injury awareness has increased and parents are taking their injured kids to the emergency department as a precaution.

Brain injuries were part of the more than 2 million reported emergency department visits due to injury in Canada last year.

No matter how much of an emphasis we put on safety, accidents do happen. There is still more work to be done to make sure sport in Canada is H as safe as possible. ■

More about sportrelated brain injuries • 26% of all emergency visits for brain injuries were sportrelated • 60% of emergency visits for sport-related brain injuries were made by men • 29% of emergency visits for sport-related brain injuries were for kids 10 to 14 years

Angela Baker is a Communications Team Lead at the Canadian Institute for Health Information.

SEPTEMBER 2018 HOSPITAL NEWS 35

NEWS

Enhanced training for healthcare teams who treat critically ill pediatric patients

By Steven Gallagher oon after becoming Niagara Health’s Chief of Pediatrics more than three years ago, Dr. Madan Roy saw an opportunity to enhance training for healthcare teams who treat critically ill pediatric patients.

On average, approximately 20 per cent of cases seen in Niagara Health’s three Emergency Departments and two Urgent Care Centres are children under the age of 18. Among these, only a small number of patients present with life- or limb-threatening emergencies. But when they do, they need immediate, highly skilled care.

Niagara Health Emergency Department physicians and other members of the healthcare team participate in Pediatric Advanced Life Support (PALS) courses every two years. But given how infrequently they see pediatric emergencies, need for continuous training and upgrading of skills to care for these patients was identified.

In April 2017, Dr. Roy, who is also Deputy Chief at McMaster Children’s Hospital in Hamilton, in collaboration with Dr. Christopher Sulowski, Deputy Chief in the Division of Emergency Medicine at McMaster Children’s Hospital, Niagara Health’s Chief of Emergency Medicine Dr. Rafi Setrak, and South Niagara Deputy Chief of Emergency Medicine Dr. Shira Brown, along with others, started the Niagara-McMaster Pediatric Regional Skills Rounds.

The program sees healthcare providers from McMaster’s Pediatric Emergency Department, as part of the McMaster Pediatric Outreach Program (McPOP), coming on a rotating basis to Niagara Health’s Emergency Departments and Urgent Care Centres to provide hands-on simulation-based training to physicians, nurses, respiratory therapists and paramedics from Niagara Emergency Medical Services.

The training involves real-life scenarios such as resuscitation of children presenting with sepsis, seizures, hypothermia and bronchiolitis. A manne-

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A simulation-based training exercise to prepare health professionals for pediatric emergencies.

THE TRAINING INVOLVES REAL-LIFE SCENARIOS SUCH AS RESUSCITATION OF CHILDREN PRESENTING WITH SEPSIS, SEIZURES, HYPOTHERMIA AND BRONCHIOLITIS. quin is used as the patient during the training. The Niagara Health team performs all steps of resuscitation in each of the scenarios under the watchful eyes of the McMaster team. Afterward, the group discusses the process and possible improvements to care.

“We give them a real-life case, then they work their way through it,” says Dr. Roy. “They feel it’s real life, their skills have improved and they’re more able to problem-solve on the spot.

They’re much more confident if a similar situation comes in next time, with the whole team performing together better.”

Dr. Sulowski is the leader of the newly formed McPOP program. The collaboration with Niagara Health is McPOP’s pilot project.

Dr. Sulowski says the first half hour or hour of treatment is essential in caring for critically ill pediatric patients.

“The goal of these training sessions is to remind the healthcare teams of those goals in that first half-hour of treatment.”

The hands-on training is vital, says Dr. Sulowski. “We want to make sure the teams are comfortable and that they have the skills to do it and responding to what they’re seeing,” he

says. “We’re trying to give them everything in real time. We didn’t want to do a lecture with slides. We wanted them to be in the moment.”

The training focuses on the importance of teamwork and communication amongst the healthcare providers.

Feedback from training participants has been positive.

“It’s a tremendous help,” says Dr. Charlene Wayda, a physician at Niagara Health’s Urgent Care Centre in Port Colborne. “This reinforces our bi-yearly training from the PALS course. The (McMaster) training has supported my learning and created new ideas and new techniques. This is extremely beneficial. It is invaluable.”

The training will be ongoing for the Niagara Health team, adds Dr. Roy. “We felt it is really important to do continuous quality improvement, which means we keep coming back,” he says. “It will provide better outH comes.” ■

Steven Gallagher, Communications Specialist 36 HOSPITAL NEWS SEPTEMBER 2018

www.hospitalnews.com

NEWS

Global digital health

partnership The vision of the Global Digital Health Partnership is to support governments and health system reformers to improve the health and well-being of their citizens through the best use of evidence-based digital technologies. ountries around the world are looking to digital technologies as the means to improving and modernizing the ways in which health care services are delivered.

They are working to design systems and create infrastructure and harness the power of technology. They are making significant investments in innovation and public-private partnerships that can support high quality healthcare. Until recently, this work has mostly been done by individual countries and jurisdictions, all committed to solving their own problems and forging their own paths. The Global Digital Health Partnership (GDHP) was created to change that.

The GDHP is an international collaboration of governments, government agencies and multinational organizations that have come together to promote and enable the use of evidence-based digital health technologies. Canada is one of 16 countries, along with Hong Kong and the World Health Organization, participating in the GDHP. “The GDHP is exactly what the health world, and the digital health world, need right now,” says Infoway President and CEO Michael Green.

“The issues that we are facing here in Canada are very similar to the challenges that our peers in other countries are dealing with. We can accelerate our learning and accomplish more by sharing information and collaborating with partners all around the world.”

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Continued on page 45 www.hospitalnews.com

Kaizen event brings new ideas to improve patient experience

By James Scarfone any patients and visitors to the hospital often have to find their way to certain departments. In high stress situations, it can be tough to find one’s bearings and know exactly where to go.

One unit at Hamilton Health Sciences (HHS) looked specifically at standardizing key parts of its operation, including patient wayfinding.

The aim? To improve a person’s experience at the hospital.

“We recognize the need to address certain parts of the patient experience,” says Dr. Shawn Mondoux, an emergency physician at HHS. “We needed to zoom in on and examine the way we operate, of course, with an eye on always improving the quality of care we give.”

Patient flow is always top of mind for doctors in emergency medicine as well as many staff.

Combine that with a steady resolve to continuously improve processes in their unit, and you have a team willing to try anything to make a patient’s hospital stay better.

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EVENT DRAWS MANY STAFF TO WORK ON UNIT IMPROVEMENTS Hamilton General Hospital’s emergency department (ED) recently underwent a week-long series of sessions called a kaizen event.

Developed from the lean management philosophy, the event was an opportunity for staff and doctors on the unit to find new ways to improve the patient experience. Over 50 HHS staff attended the sessions.

A facilitator leads the intense allday sessions with the goal to create new outcomes. Many involved creating standardized work or ensuring equipment is optimized.

As a former engineer, Dr. Mondoux brings a unique approach to HHS. “We developed a system-focused process for evaluating the way we do things and why we do them,” says Dr.

Dr. Shawn Mondoux.

Mondoux. “There are many doctors now who bring that kind of mindset to their work.”

Dr. Mondoux also took a course in lean management. One reason he was recruited to join HHS and to be a champion of the kaizen event was because of his attention to quality improvement.

create meaningful change that will be felt across the hospital,” says Dr. Mondoux.

He added that all projects are being tracked by the hospital’s CQI initiative. Dr. Mondoux’s vision is very much in line with the hospital’s vision for its staff: to empower them to make change.

CULTURE CHANGE THROUGHOUT THE HOSPITAL

EMERGENCY DEPARTMENT CONSTANTLY INNOVATING

There has been a lot of change happening at HHS the past two years, notably with the launch of the Continuous Quality Improvement management system.

The kaizen event used similar tools as what CQI units use regularly. For instance, the group needed to prioritize its improvement opportunities using a quadrant chart. This helped determine whether to continue with projects or to kibosh them altogether based on their impact and effort needed to complete them.

“This is about developing a series of overarching projects that not only affect the ED, but we want to

The ED at the General isn’t new to innovation.

In March, a pair of HHS doctors launched a new board game that simulates the ED experience by teaching students and residents how to manage patients in a busy unit.

It was also one of two pilot units that helped develop CQI. It contributed a large portion of the total number of improvements seen across the entire organization since 2016, including the introduction of naloxone kits.

The unit hopes to implement all its desired outcomes from the kaizen H event within a year. ■

James Scarfone is a Public Relations Specialist at Hamilton Health Sciences.

SEPTEMBER 2018 HOSPITAL NEWS 37

LONG-TERM CARE NEWS

Who’s caring for the carers?

Nursing home care aides burning out

By Carole A. Estabrooks and Stephanie A. Chamberlain any of us have moms and dads or older friends and relatives in nursing home facilities and care very much about their well-being and the supports they receive. But who’s caring for the care aides who do the bulk of the front-line work in nursing homes?

Their welfare is almost entirely overlooked in the health system. And it turns out, the health of the care aide affects the quality of care they deliver.

Care aides, also known as nurses aides, personal support workers or continuing care assistants, are the largest work force in nursing homes in Canada. Research suggests between 75 and 90 per cent of direct care to residents is provided by care aides, including physical care, such as helping those they care for to eat, bathe and dress, as well as emotional care and so-

M

cial interaction. Their role is central to the quality of care and quality of life of nursing home residents.

Yet up until recently, we’ve known little about them. When the health force is studied at all, typically care aides and registered nurses are lumped together, even though their job functions are distinct, and their educational, social and ethnic backgrounds, as well as their positions in the hierarchy of the health care workforce, are often significantly different.

So what happens when you focus specifically on the contributions and the health of nursing home care aides?

You discover care aide burnout in Canada is rampant.

Along with our colleagues at the Translating Research in Elder Care (TREC), we recently published a study in the International Journal of Nursing

Studies which surveyed almost 1200 care aides from 30 different nursing homes in three Western Canadian provinces. We found that care aides, despite high belief in their professional abilities and finding their work meaningful, were at high risk for emotional exhaustion and cynicism.

WHAT IS BURNOUT EXACTLY? Burnout is a psychological condition that results from work-related stress and can present itself as emotional exhaustion, such as a lack of emotional response or a lack of physical energy. It can present as a negative and detached attitude and a lack of feeling of accomplishment in your work. Research shows that those who are burnt out report providing lower quality care.

In our study we found that care aides work efficiently, sometimes under challenging conditions, and with a strong sense that what they do is meaningful – but the risk for burn out is great.

More than 60 per cent of the residents in the nursing homes where care aides work have a dementia-related condition. High stress demands on care aides is linked to this complex and demanding care. We found that, on average, care aides experienced at least three dementia-related behaviours in the last five shifts.

Combine these complex care demands with often inadequate staffing, limited or nearly non-existent continuing education and training opportunities and lack of decision-making opportunities for the residents they care for, and it’s no surprise that the threat of burn out is high.

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LONG-TERM CARE NEWS

The consequences for burn out are significant – and costly.

If care workers are not healthy, their work suffers, and so does the quality of patient care as a result.

Care aide burn out can also result in job dissatisfaction and affect workplace productivity, high staff turnover and poor staff retention, as well as high absenteeism.

SO WHAT CAN BE DONE? Based on this study and over 10 years of research in nursing homes, we have a number of recommendations aimed at improving our understanding of the care aide work force.

Firstly, we need the implementation of national training and continuing education program standards for care aides. Care aides increasingly need to know how to deal with complex res-

idents, such as those with dementia, and need opportunities to learn the latest best practices and have the skills to provide quality care.

Improving the work culture for care aides would also help with burnout, including strategies to engage them in

decision-making about the residents they care for.

Finally, we need coordinated efforts across governments to track the care aide work force including numbers and migration patterns across Canada. We also need mandatory provincial care aide registries.

The regulation of the care aide work force must be addressed, particularly given the frail, highly vulnerable population of older Canadians that are in their care. And what’s good for the carer turns out to be good for the nursH ing home resident too. ■

Dr. Carole A. Estabrooks is Professor, Faculty of Nursing, at the University of Alberta and Scientific Director of the Knowledge Utilization Studies Program (KUSP) and the pan-Canadian Translating Research in Elder Care (TREC) research program hosted at the University of Alberta. Stephanie Chamberlain is a doctoral candidate at the University of Alberta. She is an Alzheimer Society of Canada Doctoral Fellow and a Revera Scholar.

LONG-TERM CARE NEWS

Taking action to improve the lives of

seniors and people who care for them the lives of eople living and working in residential care homes throughout B.C. will benefit from $2.6 million in provincial funding, which has been allocated to purchase new equipment that will help improve safety and quality of life of residents.

“Dignity, comfort and security are what people and their loved ones expect and deserve when they are in residential care,” says Adrian Dix, Minister of Health. “Government is investing in these long-term care homes by adding new and replacement items, like beds and mattresses and ceiling lifts and sensory rooms, so people can feel comfortable in their surroundings and enjoy their homelike setting.”

The Seniors Safety and Quality Improvement Program, managed by the BC Care Providers Association, allows long-term care home operators to apply for funding for new equipment intended to improve safety and quality of life for residents. An advisory group, which includes representatives from the provincial government, BCCPA, Denominational Health Association and SafeCare BC, oversees funding allocation.

Those approved may receive up to $500 per publicly-funded bed to purchase equipment and enhance the safety and quality of life of seniors. Applications for a second round of funding opened at the end of August 2018.

The 88 successful funding applicants will receive more than 1,000 new items: beds and mattresses, shower chairs and tubs, mobility equipment – such as floor and ceiling lifts, lighting and visual aids, sensory rooms, music therapy and ergonomic furniture – such as specialized chairs and tables. Preventative and urgent response systems were funded to promote both resident and employee safety.

P

“We look forward to continue working with our partners as they continue with this important work of improving services for those in residential care homes,” says Anne Kang, Parliamentary Secretary for Seniors.

“BCCPA is extremely pleased to see these dollars invested into strengthening the delivery of seniors care,” says BCCPA CEO Daniel Fontaine. “With our partners in the Ministry of Health, we have established a simple and fair system to make sure all publicly funded long-term care providers can purchase new equipment that will improve safety and quality of life for B.C. seniors.”

“Revera is very grateful to the Ministry of Health and the BC Care Providers Association for making this important safety equipment funding available,” says JP Cadeau, VP, Operations, Transformation, Redevelopment at Revera. “We all share a commitment to the safety and quality care of all residents, and we welcome investments like this that contribute to the most supportive environment possible for the seniors we serve.”

Residential care provides 24-hour professional care and supervision in a protective, supportive environment for people with complex care needs,

who can no longer be cared for in their own homes or in an assisted-living residence.

Through Budget 2018, government is investing $548 million over three years to improve care for seniors, including investments in primary care, home and community care, residential care and assisted living. This funding comes in addition to the $250 million in federal funding for home and community care, which will assist many seniors, along with the $189 million from the Ministry of Health’s base budget that has been allocated for H seniors’ care. ■

Download the recreation therapy in long-term care report he Canadian Association for Long Term Care (CALTC) has released a tool designed to provide best practices for recreational programs in residential care and calls for further study to help ensure the best care is being provided for Canada’s seniors.

Recognizing the importance of recreational therapy for seniors, CALTC members worked collaboratively with Mitacs and Simon Fraser University to develop the report entitled “Recreation Therapy to Promote Mobility Among Older Adults in Long Term Care.”

The report highlights ten key findings or recommendations and provides an overview of the scientific evidence and current practices for recreational therapy in long-term care, focusing largely on programs for improving or maintaining the mobility of older adults. The report also identifies some best practices and outlines many of the challenges and barriers to implement-

T

40 HOSPITAL NEWS SEPTEMBER 2018

IT IS CRUCIAL THAT WE ADDRESS THE CURRENT CHALLENGES AND BARRIERS IMPACTING THE DELIVERY OF RECREATION THERAPY PROGRAMS IN LONG-TERM CARE SETTINGS ACROSS THE COUNTRY. ing recreational therapy programs in long-term care such as limited space and inadequate staffing.

“The quality of life for our diverse long-term care population can be increased by implementing recreational therapy programs,” says Daniel Fontaine, Chair of CALTC. “Identifying effective recreational therapies will help inform caregivers in long-term care settings as they choose tailored recreation programs for mobility for our seniors.”

This report was developed through extensive literature review, as well as a survey that was distributed among recreational therapists and those

who provide recreational therapy services in residential care homes across British Columbia, Alberta and Ontario.

“It is crucial that we address the current challenges and barriers impacting the delivery of recreation therapy programs in long-term care settings across the country,” says Fontaine. “We’re pleased with the introduction of this report, which provides the opportunity to further explore our commitment to ensuring Canada’s seniors are receiving the most appropriate care that best enhances their quality of life.”

To download the report visit H https://caltc.ca ■ www.hospitalnews.com

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LONG-TERM CARE NEWS

Dealing with swallowing disorders in long-term care

By Dale Mayerson and Karen Thompson ysphagia’ means a problem with swallowing and this can happen for many reasons. Any disease, treatment or surgery that weakens or damages the muscles and nerves used for swallowing may cause dysphagia.

Common conditions that may affect swallowing include stroke, dementia and Parkinson’s disease.

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tube) instead of their esophagus (eating tube). This can sometimes cause a chest infection or pneumonia which can be life threatening.

As well, people with difficulty swallowing sometimes don’t take in enough food or fluid. This can cause them to lose weight or become dehydrated, which can lead to other medical conditions, physical disabilities and mental confusion.

WHY ARE SWALLOWING PROBLEMS DANGEROUS?

HOW DO YOU KNOW IF YOU HAVE A PROBLEM WITH SWALLOWING?

In the throat there are two tubes that are side by side. When a person has a swallowing problem there is a danger that food or drink may go into their trachea or windpipe (breathing

Some people have clear signs that they are having difficulty while others show no signs.

Some common signs and symptoms may include:

• Coughing or choking while eating or drinking or soon after eating or drinking • Clearing the throat frequently • Wet, gurgly voice after eating/drinking • Swallowing many times for each bite • Drooling (saliva or food) • Trouble getting the swallow started • Trouble clearing food from the mouth or throat after swallowing • Chest congestion after eating or drinking • Pain during swallow • Unusually slow eating/ holding food in mouth • Needing extra effort to chew or swallow • Tiredness or shortness of breath while eating • Watering eyes when eating • Regurgitation • Fever or rising body temperature • Loss of weight due to not finishing meals • Pneumonia or chest infections

HOW TO MANAGE DYSPHAGIA Usually it is helpful to change the person’s food or drink consistency to make swallowing safer and easier. A swallowing assessment is useful to determine which textures can be swallowed easily and safely. It may be done in-house by a member of the healthcare team, or by a Speech Language Pathologist (SLP).

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When a person has swallowing problems, changes in diet texture can give more control, making it easier to swallow and reducing the risk of aspiration, which could lead to pneumonia.

Examples of different food textures include • Pureed – foods are pureed in a blender until completely smooth (example pureed peaches) • Minced – food is ground or finely minced and moisture is added so it is not dry (example shepherd’s pie

• Minced Meat or Soft – meat is ground or finely minced (hamburger patty) • Hard Solids (example nuts) Some people with swallowing difficulty may be better off when they avoid sticky foods such as peanut butter, bread, and cheese, or crumbly foods such as crackers, cookies and muffins. Often foods with two or more textures such as cold cereals with milk, and chunky soups are best avoided.

FLUIDS A swallow assessment will also determine drink textures that are swallowed easily and safely. Drinks or thin liquids including water, tea, coffee, juice or soup, can be difficult to swallow because they move very quickly down the throat and may enter the breathing tube.

Drinks can be thickened to make them easier and safer to swallow, or they may be avoided by substituting moist food items. For example, a person could have pudding or yogurt instead of milk, or applesauce instead of juice.

Examples of Drink Textures include • Pudding thick –(thick) – falls off spoon like pudding, must be eaten with a spoon • Honey thick – (slightly thick) – runs off spoon like honey, may be taken from a glass or eaten with a spoon • Nectar thick – Slightly thicker than water, must be taken from a glass • Regular/thin – example water, juice It is important to note that there has been an international initiative working towards standardizing the definitions of texture modified food and fluids used to address dysphagia.

See www.IDDSI.org for more information. The new terms and textures were recently introduced and it is expected that these will be in full use within the next couple of years.

OTHER STRATEGIES Other ways to improve swallowing may be recommended including spewww.hospitalnews.com

LONG-TERM CARE NEWS cific head positions when eating and drinking. Positioning at meal times can also improve safety and comfort when eating. Sitting in a chair with hips and knees at 90 degrees with chin slightly tucked down is the safest body position for safe swallowing. An Occupational Therapist (OT) can assist in planning for more challenging issues with body positioning while a Speech Language Pathologist (SLP) may be asked to participate in developing a plan for safe ingestion. Physicians and Nurses may identify other concerns affecting swallowing such as the effects of medications, physical limitations and other medical conditions.

Best practice would ensure homes have a program in place that support multi-disciplinary: • Assessment of swallowing problems • Dysphagia care conferencing • Care planning that is clear and easy for staff to follow • Quarterly reviews of resident’s acceptance and success and challenges with strategies

In addition, LTC homes need to support staff and volunteers with frequent training on safe feeding techniques and to provide residents and decision-makers with information on swallowing disorders that is user friendly and easy to understand.

TIPS FOR SAFE EATING AND SWALLOWING • Reduce distractions – example turn off the television or radio • Eat and drink only when fully awake • Sit up straight in a chair or bed • Be sure to wear dentures, hearing aids and glasses at all meals • Be sure mouth is clean and clear of food particles before and after meals • Tuck chin slightly downward towards the chest while eating and drinking • Take small bites and sips • Make sure to swallow the first bite or sip before taking the next one.

Watching for movement of the Adam’s apple/throat will help to show if the person has swallowed

• Remain sitting up straight for 20 to 30 minutes after eating • Try to have a slow and relaxed dining experience

• If coughing or choking occurs, stop eating until it has stopped • Tell the staff if you notice someone who H is having trouble eating or drinking ■

Dale Mayerson, B Sc, RD, CDE, and Karen Thompson, B A Sc, RD are Registered Dietitians with extensive experience in Long-term care. They are coauthors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide” and have participated for many years on the Ontario Long Term Care Action Group, an advocacy group of Dietitians in Canada.

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NEWS

ORNGE assets at the Collingwood airport responding to the mass casualty incident.

Air response: Anatomy of a mass casualty incident

By Courtney Kraik he textbook definition of a Mass Casualty Incident (MCI) is an event where The number of patients vastly exceeds the resources of what the local health care resources can provide over a short period of time.

Not all MCIs look the same, but this equation is constant.

For Ornge, Ontario’s provider of air ambulance and related services, such an event puts all aspects of the operation suddenly to the test.

On February 2, 2018 a coach bus carrying a group of high school students was travelling southbound on a rural highway through the small community of Stayner, Ontario just southeast of Collingwood. At around 1:30 p.m., a northbound van on the same highway occupied by six children and two adults crossed the line and collided head-on with the coach bus.

The reason was unknown – poor road conditions were often cited in media reports – but the outcome was acute.

Information about the incident

IN UNDER AN HOUR, SIX SEPARATE EMERGENCY HEALTH CARE AGENCIES WERE WORKING IN TANDEM TO PROVIDE CRITICAL PRE-HOSPITAL EMERGENCY CARE.

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was first relayed through the London Central Ambulance Communications Centre (CACC) on behalf of the Georgian CACC. The two areas share a boundary close to the incident. Two first responder units on scene initially reported as many as a dozen possible paediatric patients. Georgian CACC and the Operations Control Centre (OCC) at Ornge officially declared the crash an MCI and the CACC requested “as many helicopters as you can send.”

As it turns out, this call response involved more than just helicopters.

Two fixed wing air ambulances based in Thunder Bay and Sioux Lookout happened to be in southern Ontario

44 HOSPITAL NEWS SEPTEMBER 2018

at the time and were diverted to the Collingwood airport. Ornge also sent three land ambulance units including the Critical Care Transport Unit with Toronto Paramedic Services. Three helicopters from Ornge’s Toronto and London bases were dispatched.

In under an hour, six separate emergency health care agencies were working in tandem to provide critical pre-hospital emergency care.

Once an MCI is declared in the OCC in conjunction with a responding CACC, workloads of assets and communications officers are reassigned within the OCC itself. Triage decisions result in some non-urgent inter-facility transports being put on

hold temporarily as teams are re-routed to the scene.

Ornge’s helicopters are the most commonly used assets when responding to scene or modified scene calls because of their speed and versatility.

When the request went out for assets to be sent to Stayner, an Ornge team was in the process of transporting a non-urgent transfer patient at a tertiary hospital. The Transport Medicine Physician in the OCC spoke urgently with the sending facility’s intensive care physician to arrange a delay in the transfer so the helicopter could be re-routed to the scene.

“Once we have a patient in our care, that’s it, they’re ours. We’re responsible for their safety,” says Fabiano Medungo, the Operations Control Manager on duty that day. “The fact that we returned that patient to the sending facility to be transported at a later time really spoke to how serious the situation was in Stayner.”

Meanwhile in Stayner, patients were being triaged at Collingwood General www.hospitalnews.com

NEWS

Global digital health Continued from page 37 And indeed, the current GDHP work streams reflect concerns and priorities that are shared by Infoway and many others in the digital health community. These five streams are as follows: 1) Cyber Security, with a focus on protecting healthcare related devices, systems and networks from security risks and cyber-attacks.

2) Interoperability, with a focus on the evolving challenges of sharing patient data between care providers, organizations, caregivers and patients.

3) Evidence and Evaluation, with a focus on building digital health evaluation frameworks, and developing strategies for rapid knowledge sharing across participant countries.

4) Policy Environments, with a focus on the role of government in supporting innovation and development in digital health technology, and the privacy and consent issues that arise when sharing health data and information.

5) Clinical and Consumer Engagement, with a focus on digital health literacy and supporting patients and

and Marine Hospital and stabilized for transport to acute trauma centres.

In a stroke of good luck, if there could be such a thing on a day like that, one of Ornge’s Transport Medical Physicians, Dr. Doug Chisholm, was on duty at CGMH. Having worked with Ornge paramedics for a number of years, his presence made the transport decisions easier as the teams began arriving in the area.

“Normally the transporting teams know roughly what condition the patient is in before they get there,” says Medungo. “In this case, no one knew anything. There were so many patients it was difficult to assign a particular patient to a specific team.

Having Dr. Chisholm there to triage and delegate patients to exact teams was a special circumstance, but absolutely crucial as he has an intimate

understanding of our paramedics’ scope of practice.”

In total, seven critical patients were transported by Ornge to trauma centres in the Toronto area; two adults and five paediatric patients.

Events as extreme as this one don’t generally get rated on a scale of success or failure. Patient outcomes and excellent care management are what matter to all the teams at the end of the day. This involves extraordinary teamwork, organization and communication among emergency workers at the scene, the hospital, dispatchers and crews. For the air ambulance crews, it also involves some good fortune like favourable weather and available aircraft in the area.

Things rarely go according to plan, but the anatomy of this mass casualty H incident was as seamless as it gets. ■

2018

clinicians in their efforts to use digital health technologies to support better health and care across countries.

The GDHP was initiated in 2018 by the Australian Digital Health Agency, which is also providing secretariat services for the first 18 months of the partnership. The Agency’s CEO, Tim Kelsey, is an outspoken champion for the international collaboration and is excited about Canada’s participation given the similarities between his mandate and that of Canada Health Infoway’s. Kelsey will be in Canada in November and, among other obligations, will provide a keynote address at Infoway’s Partnership Conference.

Anyone interested in learning more about the Global Digital Health Partnership should consider attending Infoway’s Partnership Conference, which every year brings together health care leaders for two days of debate and discussion, as well as an exchange of digital health best practices. It is being held this year on November 13 and 14 in Montreal. GDHP is certain to be a H popular topic of conversation. ■

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Courtney Kraik is a Communications Intern at Ornge and a student in the Paramedic program at Georgian College. www.hospitalnews.com

SEPTEMBER 2018 HOSPITAL NEWS 45

NURSING PULSE

FAR from home

Personal experience leads RN on path to help families cope with addiction

By Victoria Alarcon

t Toronto’s Mount Sinai Hospital, RN and lactation consultant Louise Lemieux White reviews the chart for a new mom who has just had her first baby and is struggling with breastfeeding. It says she uses cannabis. “Five years ago, I would have ignored that. I was naive and feared what I did not know,” White admits.

But today, knowing what she knows about addiction, she decides to address her patient’s drug use and listen to her story.

In 2014, White’s then 14-year-old daughter was struggling with an addiction to drugs and alcohol, and needed 15 months of treatment to get to a place where she would not need to self-medicate to relieve her emotional pain. “Having that knowledge and empathy allowed me to have that conversation (with my patient),” says White, who approached the woman with a sense of understanding, not judgment.

White credits the experiences in her own personal life that have allowed her to become the nurse and person she is today. And she’s not afraid to talk about those experiences.

White’s nursing career started in 1986 after graduating from the French Nursing Diploma Program at Algonquin College in Ottawa. She began working in the surgical infant unit

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FAMILIES FOR ADDICTION RECOVERY’S GOAL IS TO SUPPORT FAMILIES AND PROTECT INDIVIDUALS, PARTICULARLY YOUTH AND YOUNG ADULTS. at the Children’s Hospital of Eastern Ontario. She treated everything from wounds and burns to tumours, learning a lot about infant care along the way. After six months, White left Ottawa for a position at the Hospital for Sick Children (SickKids) in Toronto to expand her knowledge in neonatal surgery.

“It was a higher level of illness and intensity of care,” she says, noting one aspect of the role was to develop relationships with the parents of the infants she cared for. Despite learning a lot in her position, she knew additional education would help her to provide better support to parents.

In 1989, White left SickKids to pursue her BScN at McMaster University, working part-time at Toronto General Hospital on an adult intensive care unit. Two years later, she graduated and accepted a position as case manager for a Toronto home care organization. In that role, she oversaw nurses and services for clients who required in-home care. But the position was

short-lived. She put her career on hold in 1992 to begin her family.

Shortly after this, White followed her husband, who took a job in London, England. During her break from nursing, White focused on her growing family and reassessed what she wanted to do professionally. She knew she wanted to continue working with babies and parents, but also believed she had a gift for teaching. In 2003, now back in Canada, she became a certified childbirth educator and began teaching at Mount Sinai Hospital before earning her certification as a lactation consultant in 2006.

It would be less than 10 years later when White would discover her young daughter’s drug and alcohol addiction. “In a few months, we were facing a daughter who did nothing but look for her next fix,” White explains.

“When we were seeking some help in our province and in our city, we found that there wasn’t any. There were long wait lists... over a year for a residential bed,” she says, adding she felt isolated,

judged and stigmatized because addiction is seen by many as a moral failing.

Desperate, White found a residential treatment centre in the U.S, and sent her daughter away to begin her recovery. She has been drug and alcohol free ever since.

Something needed to be done about the lack of support for parents in the same situation, she says. That’s why, in 2016, White and Angie Hamilton, a parent whose son had a similar experience, teamed up to form the grassroots Canadian registered charity, Families for Addiction Recovery (FAR). Their goal is to support families and protect individuals, particularly youth and young adults. They want to change the face of addiction by ending stigma and advocating for evidence-based treatment. “(We would like) to bring awareness and be a movement for social change,” says White.

At 53, White now balances her work as a lactation consultant with her busy schedule advocating for an open-minded approach to individuals with addiction. Supporting parents and families is a big part of what she does as the co-founder of FAR. “I’ll keep on that slow road to progress and see what happens… because I know I can make a difference,” H White says. ■

Victoria Alarcon is editorial assistant for RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. This article was originally published in the May/June 2018 issue of Registered Nurse Journal, the bi-monthly publication of the Registered Nurses’ Association of Ontario (RNAO).

46 HOSPITAL NEWS SEPTEMBER 2018

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