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New! Monthly Healthcare Technology Section FOCUS IN THIS ISSUE


Canada's Health Care Newspaper

Pain management interventions. Advancements in complementary treatment approaches to various diseases and conditions. Innovative health promotion programs that focus on disease prevention.

MARCH 2014 | VOLUME 27 ISSUE 3 | www.hospitalnews.com

nual 9th AnSING UR



INSIDE Evidence Matters ................................. 6 Ethics ..................................................13 Nursing Pulse .....................................19 From the CEO's desk.......................... 24 Travel ...................................................30 Careers ............................................... 31

The vaccine controversy By Tania Haas ixty years ago an average of 400 Canadians contracted polio per year. Those who survived were left with a paralyzed nervous system and permanently maimed limbs. Today, polio is prevalent in only a handful of countries and eradicated in Canada thanks to routine immunizations against it and 12 other potentially fatal conditions. Along with flush toilets and clean water, routine immunizations, or vaccines, are considered the world’s most important defence against preventable diseases.


Surprisingly, while vaccines are free and readily available in Canada, cases of infectious diseases, like measles and pertussis (also called whooping cough), are on the rise. The resurgence is a result of Canada’s falling child vaccination rates – resulting from parental complacency and hesitancy, widespread misinformation, socioeconomic factors, cultural miscommunication, a fragmented national strategy and passive public health efforts. Continued on page 14

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In Brief

Examining disparities in cancer control

CMA hitting the road

A new report, System Performance Special Focus Report: Examining Disparities in Cancer Control, uncovers potentially important disparities in the cancer care received by Canadians based on how much they earn, where they live, and if they are recent immigrants or Canadian-born. Led by the Canadian Partnership Against Cancer, the report shows that people from the poorest urban neighbourhoods are less likely to survive cancer compared with urban residents from the richest neighbourhoods and that this might be related to inequities in access to diagnosis and treatment services. The new report shows that the wealthiest urban residents have a 73-per-cent chance of surviving their cancers five years after a diagnosis (relative to others in the general population of their age, sex and income level) compared with 61-percent for people living in the poorest urban neighbourhoods. Earlier research has established that, with higher rates of smoking and obesity, lower income and rural Canadians have a greater risk of getting some cancers and dying from them. However, gaps in survival tend to reflect differences in diagnosis and treatment as opposed to differences in the risk of getting cancer. In this context, the report reveals for the first time at a pan-Canadian level that people living in lower income and rural and remote communities may not be accessing the best cancer care as compared to their wealthier urban neighbours. For example, although finding cancers early can often offer a better chance of surviving the disease, the report's results suggest that Canadians from lower income households are less likely to report being screened for cancer than those from higher-income households. The report provides indicators that suggest that across the diagnosis and treatment pathway from screening and early detection, to radiation therapy, surgery, and enrolment in clinical trials – at every step of the cancer-care journey, these lower income and more rural-dwelling segments of the Canadian population could H be falling behind. ■

The Canadian Medical Association (CMA) will be travelling across the country over the next three months to find out what Canadians think about end-of-life issues in a national dialogue. The first of five town hall was held in St. John's, Nfld., in February. Dr. Louis Hugo Francescutti, CMA President, says the goal is to engage and hear Canadians' thoughts on physician-assisted dying, palliative care and advance care


to sound out Canadians on end-of-life issues planning. "Most of the attention has been focused on the question of physician-assisted dying and we're concerned the end-of-life debate is being oversimplified. We need to hear more from Canadians about how their health care system can ensure not only a long, healthy life but also a good death.'' In addition to the town hall meeting in St. John's the other public town halls, in association with the Canadian Society of Pallia-

tive Care Physicians and the Canadian Hospice Palliative Care Association, will be held in: • Vancouver, March 24 • Whitehorse, April 16 • Regina, May 7 • Mississauga, May 27 Following the town halls, the CMA will release a summary report on how the public views end-of-life issues to provide H guidance in future policy decisions. ■

Antidepressant holds promise in treating Alzheimer's agitation An antidepressant medication has shown potential in treating symptoms of agitation that occur with Alzheimer's disease and in alleviating caregivers' stress, according to a multi-site U.S.-Canada study. "Up to 90 per cent of people with dementia experience symptoms of agitation such as emotional distress, restlessness, aggression or irritability, which is upsetting for patients and places a huge burden on their caregivers," says Dr. Bruce G. Pollock, Vice President of Research at the Centre for Addiction and Mental Health (CAMH), who directed research at the CAMH site. "These symptoms are a major reason why people go into long-term care prematurely." The antidepressant citalopram, sold under the brand names Celexa and Cipramil, significantly relieved agitation in a group of Alzheimer's disease (AD) patients as reported in the February 19 issue of the Journal of the American Medical Association. "When agitation occurs, it's paramount to try non-medication approaches first, such as looking for underlying physical discomfort in a patient, reducing external triggers such as noise or overstimulation, and encouraging light exercise," says Dr. Pollock, Director of CAMH's Campbell Family Mental Health Research Institute. When these approaches don't work, anti-

psychotic medications are commonly used to treat agitation. "Antipsychotics are not an ideal therapy and significantly increase the risk of strokes, heart attacks and sudden death," he adds. Based on promising early findings from Europe, Dr. Pollock began conducting studies on citalopram, which suggested it

might be a viable treatment alternative to antipsychotics. To provide stronger evidence, the Citalopram for Agitation in Alzheimer's Disease Study (CitAD) was initiated with eight leading Alzheimer's research centres across the United States and Canada, including the Geriatric ProH gram at CAMH. ■

Safety concerns with new drugs A York University study of drug safety shows that new drugs are often on the market in Canada for more than three years before they are withdrawn as unsafe, raising concerns about turning to the newest drugs available. The study by Joel Lexchin, an emergency room physician and professor of the School of Healthy Policy and Management in York’s Faculty of Health was published in Open Medicine. “As a doctor my policy is not to prescribe new drugs until they have been on the market for at least three or four years since I don’t know how safe they will be for my patients,” says Lexchin. “Based on the findings in this study, doctors should not prescribe drugs during this period and patients should not take them, unless they are substantially better than existing

medications.” Lexchin found that 4.2 per cent of the 528 new drugs approved in Canada in a 20-year period (Jan. 1, 1990 to Dec. 31, 2009) were later withdrawn. Of the 22 drugs withdrawn, 11 first had a serious safety warning and 11 did not. The median time between approval and withdrawal was almost three-and-a-half years. The study examined four 5-year periods and found no difference in the percentage of approved drugs that were eventually withdrawn from the market. This shows that the drug review system’s ability to detect serious safety issues and keep those drugs off the market did not change over the 20-year period, he says, but also raises questions about the rigour of the surveillance system once drugs are H on the market. ■

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Vaccines are safe – time to communicate it Being a parent is hard – probably the most difficult job those of us with children will ever have. Don’t get me wrong, it’s also one of the best jobs – but it doesn’t come easy. Should you formula or breast-feed? Use cloth or disposable diapers? The questions are never-ending. In the early sleep-deprived days it’s astounding that new parents are able to make decisions on the most trivial of parenting issues – let alone deciding on whether or not to vaccinate their new baby. Regardless of opinions on feeding, diapering, sleeping, schooling – one thing most parents have in common is that we want the best for our children and will do anything we can to keep them safe. Prior to becoming a mom I didn’t give vaccination a second-thought. I accepted and supported that vaccinations protect humans from terrible, highly infectious, potentially fatal diseases. I was vaccinated. Without question, my children would be too. Then I actually became a mom. And people aren’t lying when they say that changes everything. I had a new purpose and it was to protect this amazing little human from everything I possibly could. It’s a tremendous responsibility – one that comes with a lot of pressure and second-guessing. We are fortunate that we live in an information age – basically anything we want to know is just a few keystrokes away. We can educate ourselves on any topic, find a wealth of parenting advice and even join forums to discuss issues with other parents. Before bringing my baby to receive the first round of vaccinations I looked up possible side-effects and what to look for to detect adverse reactions. There is some terrifying information about vaccinations online. It’s no wonder the anti-vaccination movement has made such headway. Being

a strong supporter of vaccination, it wasn’t hard for me to research and find credible information refuting the wealth of misinformation and reasons I shouldn’t vaccinate my baby. But I can completely understand how some parents buy into it. Back in 2011 I penned a column entitled “Immunization is not a bad word.” Not surprisingly, I received a lot of feedback. One letter I received from a family physician in Ontario was quite disheartening. In the column I stressed the role health care professionals have in educating parents and dispelling the myths about the dangers of vaccination. This family physician disagreed and believed it was not his job to educate parents saying he did not have time to spend with parents – they should be able to sort through what is reliable information and what is not. If it’s not the job of our doctor to help us make decisions about our health, and the health of our children then whose job is it? In many aspects of healthcare patients are expected and encouraged to actively participate and manage their own care – if we want engaged and informed patients we can’t then turn our backs when they have questions about information they found online – no matter how misinformed. Who can blame a parent for seeking out information when their own doctor is not able or too busy to provide them with the information? Recently, Public Health Ontario released a first-of-its-kind comprehensive assessment of vaccine safety in Ontario. The report aims to encourage ongoing assessment of vaccine safety and provide relevant and timely information for health professionals and the public about the safety of vaccines administered in Ontario. In 2012 approximately 7.8 million publicly funded vaccine doses were

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ADVISORY BOARD Jonathan E. Prousky,

BPHE, B.SC., N.D., FRSH Chief Naturopathic Medical Officer The Canadian College Of Naturopathic Medicine North York, ON

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distributed in Ontario. Of those, only 631 adverse events following vaccinations were reported. Of the 631 adverse events reported, most were mild. Only 56 serious events were reported – which represents 7.2 in every million doses distributed. Serious events after vaccines are extremely rare. Are there risks associated with vaccines? Of course. There are risks associated with leaving your house in the morning. There are risks with every single medical procedure. It’s about weighing the risks and benefits. Many scientific studies have demonstrated that the benefits of vaccines far outweigh the risks. Not one death was reported as a result of the 7.8 million vaccines distributed in Ontario. Not one. The same can’t be said for the diseases these vaccines prevent. Many experts are warning Canada’s falling vaccination rates could lead to a public health crisis as once nearly eradicated diseases are reappearing. This month Hospital News takes an in depth look at the vaccine controversy in our cover story that examines why vaccination rates are falling and what can be done about it. Hospital News ethicist provides an ethical analysis of a new and disturbing trend among pediatricians – discharging patients who refuse to immunize their children. On page 16 we provide a brief history of vaccines and Canadian innovation with highlights from an exhibit on display at the Museum of Health Care. Vaccination is arguably the most effective health promotion tool we have in our arsenal. While the report on adverse events in Ontario is a good start, this information needs to be communicated to patients through their health care professional. We need to work harder to dispel the myths of the dangers of vaccines and it is most definitely the job of our doctors and health professionals to educate H their patients. ■

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Senior Communications Specialist Rouge Valley Health System

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Evidence Matters

Side effects of anti-inflammatory drugs:

What’s the evidence? By Sarah Jennings raditional non-steroidal antiinflammatory drugs (NSAIDs) include ibuprofen (Advil, Motrin), diclofenac (Voltaren), naproxen (Naprosyn), and others. These drugs are widely available in many dosage forms and most hospitals have several on formulary. NSAIDs are first-line options for many types of pain, but they can cause stomach upset and occasionally gastrointestinal (GI) bleeding. When cyclooxygenase-2 (COX-2) inhibitors such as celecoxib (Celebrex) became available, they were expected to cause less GI bleeding. Some studies did indeed show less GI bleeding, but some didn’t – and then some studies showed an increased risk of cardiovascular events such as heart attacks and strokes. The COX-2 inhibitor rofecoxib (Vioxx) was removed from the Canadian market in 2004 for this reason. Several conflicting studies led to a COX-2 controversy. Were they safe? Then studies began to emerge showing that traditional NSAIDs might carry cardiovascular risk as well. How big is this risk? Is it the same for all NSAIDs? With so much conflicting data, what information can a clinician trust, and which drugs should hospitals have on hand for treating mild to moderate pain?


Systematic reviews This situation demonstrates the value of a systematic review. Systematic reviews of the medical literature capture all studies available on a given topic. As more studies become available on a given topic, we can have more confidence when we see conclusions repeated, or when a more mature data set is presented in one paper with a critical appraisal of all the included studies. When the design of the studies is similar, the data from different studies can be pooled and re-analyzed together; this is called a meta-analysis. With more data comes more power to detect differences between treatments or to identify rare side effects.

The hierarchy of evidence For all these reasons, systematic review and meta-analysis sit at the top of the “hierarchy of evidence.” This hierarchy is a way of ranking different types of clinical studies. In general, systematic reviews and meta-analyses are more reliable than a single randomized controlled trial (RCT), which in turn is more reliable than non-randomized studies such as cohort studies and case reports. Quality is important, though; a well-done

study at the bottom of the hierarchy may be more reliable than a poorly-done systematic review. Hallmarks of a high-quality systematic review include: a clearly formulated research question, a structured literature search strategy that others can reproduce, explicit methods for selecting and critically appraising studies, and a clear reproducible description of the methods used to analyze the data.

CADTH evidence review CADTH recently critically appraised six systematic reviews and meta-analyses on COX-2 and NSAID safety. Two systematic reviews of RCTs reported no differences in cardiovascular or GI outcomes between celecoxib and high dose diclofenac, but one systematic review of non-randomized studies reported a slightly higher cardiovascular risk with diclofenac. For celecoxib vs. ibuprofen, celecoxib was associated with fewer GI complications without any statistically significant differences in major cardiovascular events. For celecoxib vs. naproxen, the risk of cardiovascular events was higher with celecoxib, but there were more GI complications with naproxen. The bottom line is that:

• naproxen seems to have lower cardiovascular risk than celecoxib • diclofenac and ibuprofen seem to have the same cardiovascular risk as celecoxib •celecoxib and diclofenac seem to have lower GI risk than ibuprofen and naproxen • clinicians may need to beware of underestimating the risks of these drugs These results show the value of using systematic reviews, not only for controversial drugs such as COX-2 inhibitors, but also for commonly used drugs such as NSAIDs. It’s also important to remember that a systematic review has the same limitations as the studies feeding into it. For example, most of the studies in these reviews lasted for three months or less, so by extension, the systematic reviews can only answer questions about shortterm use. Systematic reviews and metaanalyses have more power and precision than individual clinical trials, but their quality and relevance will always depend on the quality and relevance of H the original studies. ■ Sarah Jennings, PharmD, is a Knowledge Mobilization Officer at CADTH.

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Surgery patient George Danylkiw, pictured in the physiotherapy clinic at St. Joe’s. Two months after his shoulder surgery, Danylkiw is pain free.

Innovation in arthroscopic shoulder surgery positioning decreases pain By Michelle Tadique


hen you think about relieving the aches and pains in your muscles and joints, the last thing most people want is

surgery. The thought of being on an operating table is the exact reason Toronto resident George Danylkiw avoided surgery on his shoulder for so long – even though it was filled with pain. “Over the last year or so, the pain became so bad, I couldn’t sleep at night, sitting down was painful and moving my arm above my head was impossible,” he recalls. But thanks to an innovative approach to the positioning which facilitates arthroscopic shoulder surgery, developed by Dr. Amr Elmaraghy, an upper extremity Orthopaedic surgeon at St. Joseph’s Health Centre (St. Joe’s), Danylkiw knew he could overcome his apprehension to surgery for the benefit of his health. Arthroscopic shoulder surgery techniques are less invasive than the traditional open surgery method, and uses a tiny camera called an arthroscope and various instruments to repair the tissues inside or around the shoulder joint. The camera and tools are inserted through small incisions in the skin. In Danylkiw’s case, surgery was needed to remove a bone spur and repair the rotator cuff tendons in his right shoulder. To enhance the procedure in a way that benefits both himself as a surgeon and patients like Danylkiw, Dr. Elmaraghy sits his patients up in the “beach chair” position during the surgery – then applies traction and leverage to their arm to open up spaces within the shoulder. This innovative approach to creating space makes it easier to use the necessary hand and power tools to repair damage in the shoulder, while ensuring that no additional damage is done to the surrounding cartilage and tissue. Two months after surgery George says he www.hospitalnews.com

feels “like a million bucks”. The only proof of his surgery are the five tiny marks left from the incisions made by Dr. Elmaraghy to repair his rotator cuff. His shoulder pain is completely gone. Danylkiw believes his shoulder pain is a result from his days as a body builder. “Body building is great for you but if you don’t do it correctly it causes more damage than good,” he says. As a young adult he was also dedicated to weight training and gymnastics. Today at 68 years old, he’s a semi-retired contractor who still loves to stay active especially through cross country bicycling and several cycling accidents over the last two years have also taken a toll on his shoulders. A number of MRI scans revealed extensive damage to Danylkiw’s shoulder – a bone spur and rotator cuff tears - which were causing him so much pain. He tried everything short of surgery to relieve the pain – physical therapy, cortisone shots, and medication – but nothing helped, explains Dr. Elmaraghy, who initially met Danylkiw five years ago. Sleepless nights, constant pain and the inability to lift his arm properly left Danylkiw with one more choice – surgery. “Beach Chair Traction positioning is an innovation that’s really behind the scenes, meaning patients may not realize the benefit of this technique, to open up spaces while (clinicians are) doing the procedures – but they will see the results,” says Dr. Elmaraghy. “What this means for patients is a surgery that is quicker, safer and more efficient, allowing them to get back to their day-to-day life and be pain free, and to do those sporting activities with better function and range of motion.” All surgeons face the need to work within spaces that don’t normally exist, especially around the shoulder joint and shoulder tendons, Dr. Elmaraghy explains. “Your assistants (in the operating room)

can’t provide that kind of holding force throughout the entire length of the procedure that is stable, predictable and effective as far as opening up space around cartilage and tendons. So that was the need that I faced and the beach chair traction positioning method was the solution I came up with,” he says. When Danylkiw first heard of Dr. Elmaraghy’s approach to arthroscopic surgery he was excited to benefit from this approach and finally find the right solution to relieve his pain. He was even more thank-

ful to receive this level of innovative care close to home at his local hospital. “I really believe that innovation is the wave of future for everything, not just medicine,” says Danylkiw. “Innovation overall is positive especially coming from a community hospital like St. Joe’s, it’s unbelievable. I can’t say enough about all of the H doctors, nurses and staff there.” ■ Michelle Tadique is a communications associate at St. Joseph’s Health Centre Toronto.

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New program helps to reduce readmission rates By Akilah Dressekie new program implemented at Rouge Valley Health System (RVHS) is helping to reduce readmission rates for patients once they are discharged. Studies have shown that inadequate discharge support contributes to a longer hospital stay, higher risk of negative health outcomes, and readmissions. The Care After The Care in Hospital – or CATCH – program hopes to fix that. “CATCH focuses on fully understanding and addressing patient needs upon discharge to more adequately respond to the challenge of readmissions rates,” says Amber Curry, manager of the ambulatory care unit, and pre-op clinic, Rouge Valley Ajax & Pickering (RVAP), and fracture clinic, RVHS. The CATCH program was implemented in November at both Rouge Valley hospital campuses – Rouge Valley Centenary (RVC) and RVAP. It works to improve patient flow by using physicians, nurses and rehabilitation therapists, who work together to help reduce the patient’s chances of being readmitted for the same medical issue. Their goal is to, ultimately, help the patient return home sooner, and to remain within the community. Patients are referred to CATCH when they are discharged from hospital.


“CATCH helps our patients to better manage their own conditions at home, and to be aware of the supports available to them right here in the community,” explains Aaisha Savvas, manager, complex continuing care, RVC, and outpatient rehab services, RVHS. “We’re empowering our patients by giving them the tools they need to self-manage their conditions, helping to reduce readmissions.”

Studies have shown that inadequate discharge support contributes to a longer hospital stay, higher risk of negative health outcomes, and readmissions. Interdisciplinary approach One important element of the program is the interdisciplinary approach between the physician, nurse and physiotherapist in helping to provide the patient with a better ability to manage their condition from in the community. “The physician, nurse and the therapist play a very important and complementary role in ensuring the

patient’s needs get addressed in a more holistic way,” explains Curry. Physician participation ensures that there is appropriate medical follow-up once the patient is discharged. A general internist, based in the hospital’s general internal medicine clinic, can address any medication concerns or additional testing needs, if required. Both the nurse and physiotherapist play a role in helping to educate the patient about their condition, so that they will be able to effectively self-manage in the community. The nurse will assess the patient for different risk factors, including falls, medication, cognition, nutrition and even incontinence. With each of these risk factors, the nurse can develop interventions for individual patient needs. By helping to educate the patient on factors such as proper diet and medication administration, they can teach the patient how these factors can improve their ability to self-manage their condition. By assessing the patient, the physiotherapist can prescribe an individualized reconditioning program. They can also help to educate the patient on preventing falls and deconditioning, and how to maintain good physical activity in the community. “After being assessed by the physiothera-

NATIONAL NURSING WEEK 9th Annual Supplement The May 2014 issue of Hospital News will be celebrating National Nursing Week in Canada (May 12th – 18th) with a special pull-out feature showcasing our “Nursing Heroes” contest winners as well as highlighting outstanding leadership and stories from the nursing frontlines!

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Occupational Therapy/Physiotherapy Assistant Carol Hylton-Ehlers gives physiotherapy to a patient. Rouge Valley's new CATCH program will target specific patients once they are discharged, providing improved support, and helping to prevent future readmissions. pist, patients are assisted to achieve their physical and functional goals by a therapy assistant in an individualized, small group format,” says Curry. The physiotherapist sees patients biweekly and can later assess if more therapy is required, or if they can be referred to less intensive community programs, such as exercise classes. “We’re beginning to see improvements in the outcomes of our patients in the CATCH program,” explains Savvas. “Patients are able to return to the community in a much better condition, and with H improved function.” ■ Akilah Dressekie is a Senior Communications Specialist at Rouge Valley Health System.


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Music therapy

and patient-centred care By Sarah Pearson


know exactly the moment that I decided to become a music therapist. That moment was at a hospital, where I was

the patient. I was diagnosed with Type 1 diabetes when I was 26 years old. At the time I was working as a musician and freelance writer. After experiencing many weeks of debilitating fatigue, dizziness, and weight loss, I had visited my family doctor. A quick blood test revealed that I had dangerously high blood sugar, and needed to get to an ER at once. It was there that I learned that I had Type 1, and would be on insulin shots for the rest of my life. Being diagnosed with a life-changing illness can trigger a host of overwhelming emotions. For me, numbness was the strongest thing I felt. Lying in a hospital bed for two days, hooked up to machines and getting shots every hour, I tried to absorb information about my new disease, and what my life would look like from now on. There was no ER social worker that came to visit, no clear moment where any health care provider asked me how I was doing with my diagnosis. It was that first night in the hospital where something dramatically changed for me. I had just been woken up for my hourly blood-draw, and couldn’t fall back asleep.

The person next to me was experiencing some sort of pain crisis, and the ER was generally a busy, noisy place to have a good night’s sleep. Out of habit (being a lifelong musician and singer), I began humming a song under my breath, “Basement Apartment” by Sarah Harmer.

music can transform patients’ experience of their pain, provide comfort, create relationships, and even soften the whole hospital environment Suddenly, I felt the tide of tears build up inside of me. My whole body, it seemed, was finally experiencing emotion. It was as if the deeper breathing and bodily vibrations of just this simple humming was enough to release all the fear, sadness, grief, and shock of my new diagnosis. Singing, even so softly and for just a moment, made me feel human again. It was too much. I knew instantly that I had to stop singing. The depth of emotion I was accessing was too big for this ER. If I opened that floodgate of feeling, there would be no one there to help me through

it. And I could not go through this swampland of feelings alone. That’s when something crystalized for me: this hospital needs more music therapists, I thought to myself with clarity uncommon for 2am. It needs more music therapists so that people can safely fall apart when they need to. Several years later, I now have a master’s in music therapy, and a growing clinical practice in inpatient and outpatient oncology. As the new music therapist at Grand River Regional Cancer Centre in Kitchener, I am a daily witness to how music can transform patients’ experience of their pain, provide comfort, create relationships, ease family dynamics, and even soften the whole hospital environment for patients and staff alike. Be it offering a patient a chance to express themselves on an instrument, facilitating a drum circle with a family around a patient’s bed, helping a patient write a song to their loved ones, or just quietly singing at a patient’s bedside, music never seems to fail at making an impact. One of the mandates of McGill University’s Programs on Whole Person Care is to “create a space where healing may occur,” regardless of whether changing disease outcomes is possible. Music creates this kind of healing space, and it is often

the smallest music that makes the biggest impact. It took only a few notes of a Sarah Harmer song, hummed under my breath in an ER, to unleash the flood of emotion the night of my diagnosis. On the inpatient oncology unit, working with some of the hospital’s sickest patients, often it is just quiet, barely-audible singing or humming by the patient’s side that can create the strongest connection. While around them machines beep, equipment clatters and nurses rush in and out attending to endless interventions, just breathing and humming with a patient can provide a simple thread of connection, focus, and beauty. It is a privilege to be part of a multidisciplinary team committed to supporting the whole patient through their cancer journey, and to be using music to help meet this goal. My diagnosis story reminds me of how easy it is to lose one’s identity in a hospital bed, and the importance of music in delivering person-centred care. It reminds me of what a powerful gift music can be in the most vulnerable moments H of our lives. ■ Sarah Pearson MMT, is the Program Development Coordinator of the Room 217 Foundation, a registered charity dedicated to caring for the whole person with music. www.room217.ca

NOMINATE A NURSING HERO! Hospital News’ 9th Annual Nursing Hero Awards COMMITMENT  DEDICATION COMPASSION  LEADERSHIP Look around you. Have you been inspired, encouraged or empowered by an employee or a colleague? Have you or your loved one been touched by the care and compassion of an outstanding nurse? Do you know a nurse who has gone above and beyond the call of duty? Now is your chance to acknowledge and recognize the nursing heroes in your facility or community.

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Hospital News will once again salute nursing heroes through our annual National Nursing Week (May 12th to 18th) contest. We hope you will share your stories with us so that we can highlight the exceptional work that our nurses are doing and how they touch our lives. Nominations can be submitted by patients or patients’ family members, colleagues or managers. Please submit by April 15th and make sure that your entry contains the following information:  Full name of the nurse  Facility where he/she worked at the time  Your contact information  Your nursing hero story Along with having their story published, the winner will also take home: 1ST PRIZE: $1,000 Cash Prize

2ND PRIZE: $500 Cash Prize

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10 Focus


Mindfulness: The quiet revolution at Hamilton Health Sciences By: Calyn Pettit here is a quiet revolution going on at Hamilton Health Sciences. The weapon of choice? Stopping and breathing. Health care workers are extraordinary– they embrace those who suffer, while the rest of our culture denies the reality of illness and death. However, extending mind, body and spirit everyday to support patients and families in heart wrenching situations, and working to improve care in a complex and chaotic system, takes its toll. Studies confirm that many helping professionals experience high levels of compassion fatigue. Compassion fatigue refers to the profound emotional and physical exhaustion that occurs over the course of a career when workers are not adequately refueled or recharged to meet the needs of their roles, colleagues and patients. Over the past three years, Hamilton Health Sciences has partnered with the McMaster University Program for Faculty Development (PFD) to offer staff, physicians, students and faculty access to courses designed to alleviate compassion fatigue and promote the resilience of people who work in healthcare. Since its inception in 2011, over 200 staff and physicians at HHS have participated in the “Discovering Resilience” program.



“The first step to alleviating compassion fatigue is awareness of one’s physical and mental state. Awareness is cultivated through mindfulness, which means bringing one’s full attention to the present moment, in a non-judgemental way,” says Dr. Andrea Frolic, director of the office of clinical & organizational ethics at HHS. “It sounds simple, but our energies are pulled in so many directions, it is often hard to focus on the here and now. Mindfulness requires practice, and these courses are designed to support frontline care providers and leaders at HHS to develop a repertoire of practices to reduce stress and enhance resilience.” Through funds provided through HHS’ new strategic plan, one goal of which is to “Be the organization of choice for talented people”, various mindfulness courses are offered at significantly discounted rates to HHS staff and physicians. One such course, Mindfulness Based Stress Reduction (MBSR), provides an in-depth introduction to mindfulness practices and how they can be applied in the clinical setting. In addition, staff and physicians are welcome to attend free weekly drop-in, 30 minute sessions called “Mindfulness for Lunch” offered across HHS’ hospital sites.

Andrea Frolic, director of the office of clinical & organizational ethics at Hamilton Health Sciences, leads a group of staff members through a lunchtime mindfulness meditation session at HHS’ St. Peter’s Hospital site. “MBSR is an evidence-based therapeutic protocol that has been demonstrated to enhance mental health and well-being, and relieve many physical conditions, such as chronic pain,” says Dr. Frolic. “It teaches participants a range of practices, such as breathing meditation, gentle stretching and mindful listening, designed to enhance one’s connection to self and others. Past participants report significant benefits, including better sleep, less anxiety, greater enjoyment of work and improved relationships. These practices are simple, anyone can learn them, but they are truly revolutionary in turning the tide from burn-out to resilience.” Bonnie Buchko, a physiotherapist on the clinical neurosciences unit at Hamil-

ton General Hospital has completed the MBSR program and says it covered many concepts that have supported her day-today work. “Even when there isn’t time for a formal break, being mindful allows me to take a break from the sometimes chaotic ward by stopping my mind, even for half a minute,” says Bonnie. “This helps me recharge and be able to enter my next patient encounter with greater focus and presence. I’m more able to give my patients the opportunity to express what is important to them and what will H help them.” ■ Calyn Pettit is a public relations specialist at Hamilton Health Sciences.



Focus 11

A new dimension in cancer hope By Margaret Valois othing can ever prepare one for a diagnosis of cancer. The emotional, psychological and physical impact is often overwhelming. Not only are the effects of treatment punishing on the body, but the toll from the shock followed by uncontrollable fear often leaves patients reeling. Some say their world stops. They feel isolated from what is normal, cut off from their lives and very much alone.


approximately 85 per cent of patients are affected by the often devastating nonmedical consequences of cancer As many as 40 per cent of Canadians will be diagnosed with cancer and embark on similar journeys at some point in their lives. While they are fortunate to have access to medical care that rivals any in the world, the medical intervention they receive is only one part of the healing process. Research shows that approximately 85 per cent of patients are affected by the often devastating non-medical consequences of cancer – the anxiety, depression, confusion, fatigue, nausea and pain. But, when medical care is complemented with emotional, rehabilitative and practical support, cancer patients not only improve their quality of life but have been proven to experience an increase in longevity. It is in this area

of psychosocial healthcare that Wellspring Cancer Support Network excels, and plays a unique and crucial role in Canada.

a Money Matters case manager who will assess their personal circumstances, provide options to help make the most of available resources, and will identify any government programs for which the patient might be eligible.

A wealth of innovative programs Wellspring is a warm and welcoming network of community-based centres in Southern Ontario and Calgary, providing a comprehensive range of supportive care programs and services for anyone living with any type of cancer, at any stage. Led by qualified and experienced professionals including psychotherapists, physiotherapists, art therapists, dietitians and more, Wellspring’s 40 programs span a wide range of categories, from individual and group support to rehabilitation services, to practical guidance in areas such as nutrition, finance management and workplace issues. The entire continuum of programming opportunities offered at Wellspring is evidence-based, professionally evaluated and developed and piloted through the Wellspring Centre of Innovation. Some of the innovative offerings at Wellspring include the Nourish series of twelve nutritional education and demonstration programs for people with site-specific cancers; for individuals in the treatment phase of their illness who are challenged by palate changes, medical interactions and loss of appetite; or for those who have completed treatment looking to ensure ongoing wellness and recurrence prevention. Exercise is another critical tool in the healing process with evidence showing that benefits are gained when exercise is incorporated into treatment plans right from the

Beyond the door: telling one’s story

The personalized Cancer Exercise program at Wellspring improves physical functioning, fatigue management and overall quality of life for people living with cancer. point of diagnosis. Exercise helps improve physical functioning, fatigue management and overall quality of life; it reduces pain, the side-effects of treatment, improves self-esteem, aids in better treatment compliance and even secondary prevention for some types of cancer. The award-winning Money Matters program helps patients work through the financial consequences of cancer, which for many can be equally as harrowing as the diagnosis. By curtailing the ability to work, coupled with the host of unplanned expenses, cancer drastically affects a patient’s livelihood. Patients concerned about their finances are able to meet privately with

Every person who visits a Wellspring centre has a unique set of needs. While some seek out single items of support, others immerse themselves in an array of programs and activities. Those who find it difficult to acknowledge that they need help find that being surrounded by a community of peers, who are survivors, is a very powerful first step on the road toward healing. Wellspring has helped tens of thousands of men, women and children who have been touched by cancer, as well as their caregivers and loved ones. Beyond the benefits that they offer in the moment, Wellspring’s programs have the ultimate objective of building, in an unrushed manner, a patient’s capacity to manage their own care. Wellspring Centres are places of safety, comfort, ease and confidentiality. Wellspring charges no fees, and requires no medical referral. For more information about a Wellspring centre near you, visit wellspring.ca or call 416-921-1928. Wellspring receives no government or other core funding, and is funded exclusively by independent donors H and corporate partners. ■Margaret Valois is Director of Communications, Wellspring Cancer Support Network.

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12 Focus

Spine stimulation tingles the pain away By Alexa Giorgi n 2011, Deborah Finbow’s hand was bitten by an agitated dog. The wound was treated by her local emergency department, and she was sent home with antibiotics to prevent infection. However, after the wound had healed, Finbow began to experience very painful inflammation not in her hand, but in her left foot. Her foot would periodically swell, become discoloured, and burn and tingle with incessant pain. The symptoms worsened with each bout of inflammation. She was diagnosed with osteomyelitis, a bone infection. Despite a surgical intervention in March 2012 to relieve the now severe inflammation, the pain would not diminish. It was determined that the infection had also damaged the nerve in her foot which was now causing the unbearable pain. This time, she was diagnosed with Complex Regional Pain Syndrome (CRPS). A married mother of four from Collingwood, Ont., Finbow could no longer put any pressure on her foot and relied on a walker and a cane to stand and get around – if she could find the motivation to get out and do anything. She couldn’t stay warm, even in summer, because her body assumed the same temperature as her foot and leg: ice cold. “Chronic pain takes everything out of you,” she says. “The pain and discomfort was so intense that I just wanted to stay home in bed and sleep.” Doctors didn’t think there was anything they could do for her. She was told to get a wheelchair and do her best to manage the pain. But one physician thought it might be worthwhile to see if any of the specialists at Toronto Western Hospital’s Krembil Neuroscience Centre could help. Finbow was first referred to Dr. Anuj Bhatia, an anesthesiologist and pain specialist to determine whether other pain medications might alleviate her CRPS. It was the first time in a year that Finbow felt


Dr. Mohammed Shamji demonstrates how a spinal cord stimulator alleviates pain. Implanted wires deliver a controlled electrical signal to the spinal cord, sending a tingling sensation to the brain while also blocking pain signals that the patient experiences any hope her condition might improve. Unfortunately the medication wasn’t effective, leaving Finbow sluggish, groggy, and unable to participate in family life. It was time to consider a final alternative: surgery. Finbow was referred to Dr. Mohammed F. Shamji, a neurosurgeon who specializes in minimally-invasive and complex spine surgery as well as neuromodulation for neuropathic pain in hands and feet. Conditions caused by neuropathic pain – damage to a complex sensory system responsible for how we perceive things like touch and temperature – often have

symptoms of amplifying normal sensations to the point of unrelenting discomfort. Patients can feel very hot or very cold, “pins and needles” sensations, numbness, and itching; much like what Finbow was experiencing. Shamji is trying to organize a program at Toronto Western Hospital especially for treating patients with neurostimulation, a surgically implanted device about the size of a stopwatch in the epidural space around the spine that delivers a controlled electrical signal to the spinal cord. The electrical impulses deliver a tingling sensation to

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the brain while also blocking pain signals that the patient experiences, essentially overriding the pain sensation. The patient is taught how to operate a remote control that can change the intensity and patterns of stimulation at any time, adjusting them for different activities such as sleeping or walking. Although the technology has existed for a few decades, it is not as well-known as a treatment option for patients with severe, chronic pain. “Neuorstimulation is not for everyone. Some patients don’t receive any benefit from the device and others aren’t comfortable with the tingling sensation it generates,” explains Shamji. “However, we are working on a system to get the right patients to our program so they can be evaluated and treated quickly since this technology is underutilized, but can be extremely efficient in enhancing the quality of life for these patients.” Finbow was assessed as a candidate for such a procedure, in her case called a spinal cord stimulator, but she was advised that it might only lessen her pain by 50 per cent. She decided to go ahead with the surgery. The procedure more than exceeded Finbow’s expectations. Just two weeks after the surgery, with her stimulator properly programmed, Finbow no longer felt any pain and could not only put weight on her foot, but also walk around unassisted. She is now getting back to the activities she thought were lost to her forever such as travelling and riding a bike. “This whole ordeal started the year I turned 50,” she says. “Thanks to Dr. Shamji, Dr. Bhatia and their whole team, I feel like I’m restarting my 50s and resuming the H life I had.” ■ Alexa Giorgi is a Senior Public Affairs Advisor, University Health Network. www.hospitalnews.com

Ethics 13

The ethics of discharging

patients with vaccine hesitant parents By Jonathan Breslin, PhD s an ethicist I try to always be as balanced as possible when I write columns like this one. This is not because I don’t have opinions or I’m afraid to express them. It’s because an important part being an ethicist is to facilitate good decision making by highlighting all the ethical considerations with respect to the relevant issue. I also tend to avoid statements like, “x is the right thing to do,� or “y is morally wrong,� largely because ethical issues tend to be more complex than they appear on the surface, and there can often be more than one reasonable response to an issue. But when it comes to parents who refuse to vaccinate their children, I have a hard time being balanced. I do believe that vaccinating one’s children is clearly the morally right thing to do.


A paediatrician by the name of Russel Saunders recently wrote a column that circulated through social media entitled, “Vaccinate your kids – or get out of my office.� There are two reasons I believe this. One is that vaccinations are a very low risk way to prevent one’s children from being infected with a debilitating or fatal illness. There are literally dozens of studies published in a wide range of academic journals that have debunked all of the misconceptions related to vaccine risk, including the proposed link between vaccines and autism. But don’t take my word for it – download the American Academy of Pediatrics document, “Vaccine Safety: Examine the Evidence,� a 21-page summary of all the published evidence related to vaccine safety (recently updated in April 2013). Some people even question the benefit of vaccines, despite the fact that the introduction of vaccines virtually eradicated diseases like polio from the human race. And now, unfortunately, we’re seeing a resurgence of many of these illnesses around the world, coinciding with dropping vaccination rates. The second reason I believe that vaccinating one’s children is the right thing to do is because it helps to prevent harm to others from contracting debilitating or fatal illnesses. As the Canadian Paediatric Society points out, a healthy unvaccinated child can spread a vaccine-preventable disease to more vulnerable individuals, such as infecting an infant sibling with pertussis or a pregnant woman with rubella. Not only that, but many of the infections can only remain controlled if a critical www.hospitalnews.com

mass of the population is vaccinated (herd immunity). If too many parents refrain from vaccinating their children, illnesses like measles can make a resurgence and spread around the world. With that said, I want to shift to another aspect of the issue: the ethical responsibilities of paediatricians towards parents who refuse to vaccinate their children. A paediatrician by the name of Russel Saunders recently wrote a column that circulated through social media entitled, “Vaccinate your kids – or get out of my office.� He asks new parents in his practice if their children are vaccinated, or if they plan to vaccinate, as part of his intake process. If they say no, he tells them to find another paediatrician. His rationale for doing so is that the physician-patient (parent) relationship is founded upon trust, which means the parents of his patients must be able to trust his judgment and expertise. If they can’t trust his judgment recommending vaccines, something that he believes is so clearly the unambiguous standard of care, how will they trust his judgment if the medical issues become more complicated? While he raises some valid points, the question is whether discharging such parents from his practice is an ethically appropriate response. Both the American Academy of Pediatrics and the Canadian Paediatric Society recommend against discharging vaccinerefusing parents from practice, for several reasons. First, evidence shows that counseling does change the minds of many parents who initially refuse vaccines (or are at least reluctant to consent to vaccines). Scott Halperin categorizes vaccinerefusing parents into five groups, most of which can be counseled or reasoned with (though it can take time). Only a very small percentage of parents are so committed to the anti-vaccine position that they can’t be convinced otherwise. Thus, it is important for paediatricians to understand which group the parents belong to. (The Canadian Paediatric society refers to these parents as “vaccine-hesitant� to reflect the fact that not all of them are adamant about refusing vaccines). Second, discharging vaccine-hesitant parents certainly does not further the paediatrician’s goal of promoting child health. Discharge risks further alienating such parents and may fuel their distrust in the health care system, which can end up having detrimental effects on their children. Discharge from practice cuts off all lines of communication and eliminates any chance for the paediatrician to build a trusting therapeutic alliance for the good of the child(ren). Additionally, if there are too many paediatricians who refuse to accept vaccine-hesitant parents into their practice, these parents may have difficulty finding primary health care for their chil-

dren. Not only does this increase the risk of potential harm to the children, but it also denies these parents equitable access to healthcare (especially in smaller communities with few paediatricians available). In some extreme cases, if all efforts to work with the parents have failed, paediatricians may be justified in discharging such parents from their practice. The College of Physicians and Surgeons of Ontario policy states that physicians are not justified in ending a therapeutic relationship merely because the physician disagrees with the patient or because the patient refuses to follow the physician’s advice. There must be a “breakdown of trust and respectâ€? in the relationship for discharge to be justified, and even then the physician is obligated to ensure that the patient has arranged (or has been given reasonable time to arrange) alternative services. Simply discharging them and sending them on their way is not an ethically appropriate way to H respond to vaccine-hesitant parents. â–

Jonathan Breslin, PhD is Assistant Professor, Institute of Health Policy, Management and Evaluation, University of Toronto Ethicist Member, University of Toronto Joint Centre for Bioethics.


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14 Focus

Vaccine controversy Continued from cover

“I feel this is a looming public health crisis,” explains Dr. Jane Finlay, a Vancouver-based practitioner who counsels vaccine-hesitant parents. Dr. Finlay is also a member of the Canadian Paediatric Society’s (CPS) Infectious Diseases and Immunization Committee. “I often hear concerns about formaldehyde in vaccines – but there is more in a peach than any of the vaccines,” explains Dr. Finlay, who tries to get parents to understand the serious risks associated with refusing vaccination. “When you are crossing the street are you looking up at the sky for an airplane to fall on you or are you going to watch for traffic?” In July 2013, the Public Health Agency of Canada identified 30 cases of measles in six different provinces – five times the number of cases confirmed by the same point in 2012. By the fall, Alberta confirmed 42 cases of measles. The province declared the outbreak over this past January – only to reissue a warning a few weeks later when new cases resurfaced. Measles is the leading cause of death in children worldwide and can cause pneumonia, deafness and brain damage. The vaccine has been available in Canada since 1963. At least 13 children have died from pertussis in the past 10 years. The majority of deaths occurred in infants less than two months – they were too young to be vaccinated – highlighting society’s role in vaccinating to protect others. From October 2011 to April 2013, Ontario experienced a large outbreak with 441 cases. As Hospital News went to press, at least six people in Prince Edward Island had pertussis in 2014. That number seems certain to rise across the country.

The anti-vaccine movement is small, but has a very large voice How vaccines work Vaccines expose the patient to a very small, safe amount of viruses or bacteria. The patient’s immune system learns to recognize and attack the infection in case of future exposure. As a result, the patient will not become ill or will suffer only a milder infection. More importantly, vaccines protect society’s most vulnerable like newborns, the elderly, the immunocompromised,


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the pregnant or those who cannot be vaccinated because of medical reasons. By preventing contagion, vaccines shield the entire community. It’s harder to catch an illness, if those around you have already fought it off. This is also known as herd immunity. Collective resistance fluctuates by disease, but usually falls between 85 and 95 per cent. That’s why Canada’s falling child vaccination rate is so alarming. A UNICEF study published last year found that only 84 per cent of Canadian children were immunized for measles, polio and DPT3, placing Canada in secondlast place out of 29 of the world’s richest countries. (In contrast, Greece topped the list with a 99 per cent immunization rate –in spite of its instability and economic crisis.) Canada’s low childhood immunization rate makes it easier for these highly contagious diseases to find holes in our collective barrier. The Public Health Agency of Canada (PHAC) contests the UNICEF study and says that the current vaccine coverage estimate for DTP, measles and polio, is over 95 per cent coverage. Even still, experts in the field say Canada could be doing a lot better. “I am deeply embarrassed when I go outside of Canada to immunization meetings to come from an OECD country with such a poor immunization uptake rate,” says Dr. Noni MacDonald, professor of paediatrics at Dalhousie University, IWK Health Centre and Canadian Centre for Vaccinology.

Complacency and ambivalence fuel vaccine hesitancy One reason Canadians are hesitant to vaccinate is the absence of imminently threatening disease. Without a visible present danger it’s easy for parents to grow complacent. “Canadians are privileged to live at a time when people no longer remember the severity and how common these illnesses were. Eighty years ago, it was common for children to pre-decease parents in their first five years,” explains Dr. James Talbot, Alberta’s chief medical officer. It’s because of the generations before us, he says, that we live in a time when infant mortality is considered a tragedy, and not a common occurrence. “A slide show of the average pediatric ward from the 1950's and 1960's would illustrate what catastrophes await,” warns Dr. Hirotaka Yamashiro, chair of the pediatrics section of the Ontario Medical Association and president of the Pediatricians Alliance of Ontario. “There is no doubt that the easy access to information, good and bad, has accelerated this process with misinformed or maliciously-inclined individuals given the same credibility as those who have expertise.” This leaves the need to stress vigilance on the shoulders of practitioners – many who are struggling to have quality time with each patient. “The fee schedule encourages a higher volume practice so many can’t spend a half hour discussing vaccination,” says Dr. Finlay.

Physicians urged to be patient, persistent “There are few downright refusers for all vaccines, but there are many who are hesi-

On weighing the risks of vaccination one expert says: “When you are crossing the street are you looking up at the sky for an airplane to fall on you (risks of vaccines) or are you going to watch for traffic?”

tant,” says MacDonald. Finlay and MacDonald encourage health care workers to be patient with parents. They urge doctors to find out what’s behind the parent’s ambivalence. And while many doctors are tempted to dismiss the patient from their practice, Finlay and MacDonald argue it’s in the child’s best interest to be respectfully persistent with the parents – even if it takes multiple visits. “One of the most effective interventions with parents is to be a good listener. It is important to engage parents in a proactive, honest discussion, rather than lecturing. We also must address unfounded allegations about vaccines, refute misinformation and provide credible sites and resources,” says Shelly Landsburg, director of the communicable disease control with the office of chief medical officer of health in New Brunswick. Alberta’s Chief Medical Officer of Health says every health encounter – even in social settings – is a valuable opportunity to improve outcomes. “The decision to get immunized is heavily influenced by health care professionals in personal and professional relationships. Never underestimate how you will affect a parent’s decision,” says Dr. Talbot. The side effects of vaccines are minor when compared to the possible effects of not vaccinating: death, brain damage or permanent disability. The benefits, however, are overwhelming: less antibiotic use; fewer hospitalizations and invasive treatments and tests; fewer longterm disabilities and diminished risk of childhood strokes.

Misinformation messages online Despite the overwhelming scientific evidence in support of vaccine safety, a quick Google search will reveal an active opposition. Purported ‘experts’ use flawed logic and science to contribute to parental confusion. “Parents have access to a wealth of information and many sources of misinformation, including television documentaries, magazines, and hundreds of antivaccine web site links,” says Landsburg. “The difficulty for parents lies in trying to figure out which information to believe.” Those parents who don’t vaccinate their children base their decisions on what they believe is sound research. One mother told Hospital News that she read an article on the negative side effects, which confirmed her intuition against vaccines. Another parent said scientific articles defend his

choice not to vaccinate his 15-month-old son, citing a recent study that found vaccinated baboons infected others with the illness. The study justified his belief that vaccines are dangerous; meanwhile, the scientists who led the study believe their results will help improve vaccines. “We need to teach the difference between one anecdotal case and high-quality scientific studies,” says Dr. Joan Robinson, a Pediatric Infectious Diseases specialist in Alberta. “Vaccines are still the most cost effective way to ensure that you see your child graduate from high school or attend their wedding,” says Dr. Talbot. Admittedly vaccines are not 100 per cent effective all the time. Three Calgarians diagnosed with measles this year were immunized for the illness. “We are still investigating those cases,” explains Dr. Talbot. “But even then, they were only mildly affected by measles. Compare that to the outbreak we had in south Alberta, where the community was not immunized. The spread was much faster.” Still, Dr. Talbot’s assurances frequently fall on deaf ears. “The anti-vaccine movement is small, but has a very large voice. Canadians are not immune to their messaging,” says Dr. Flanders, director of Kindercare Pediatrics and staff physician at North York General Hospital in Toronto. Pediatricians and emergency room physicians confront the consequences of online misinformation every day. One emergency physician told Hospital News of an intentionally unvaccinated toddler who was admitted with fever and a sore neck. The young child had to undergo blood tests and a spinal tap to rule out meningitis. The doctor says the child’s suffering and expensive procedures were both avoidable. Unvaccinated adults are also at risk. “A patient came into our emergency department with weakness and couldn't breathe properly. This patient was diagnosed with tetanus and almost died. Routine vaccinations and boosters could have easily prevented this,” says Dr. Glen Bandiera, chief of emergency medicine at Toronto’s St. Michael’s Hospital. Many unvaccinated patients’ parents base their decision-making on a movement which grew from an infamous, now refuted, study published 16 years ago.

Debunking myths

In 1998, The Lancet published a study claiming a link between autism and the vaccines that prevent measles, mumps and rubella (MMR). The study was quickly called into question. The results could not be replicated by other scientists and subsequent research cleared the MMR vaccine of any connection to autism. The medical journal retracted the study and the lead researcher was stripped of his medical licence, and charged with acting “dishonestly and irresponsibly” in his research. Other common concerns include that vaccines overload the immune system, and undermine the body’s natural ability to protect. Babies are born with antibodies but they are temporary, and leave the child vulnerable to deadly illnesses. There is no evidence that vaccines overload or overwhelm the system. Continued on page 15 www.hospitalnews.com


Focus 15

Vaccine controversy Continued from page 14

There’s also no scientific evidence that vaccines or their ingredients, cause multiple sclerosis, brain damage, increase risk of asthma, or SIDS. Patients are encouraged to sit with a trusted health care professional and address all their concerns.

Other obstacles to vaccination There are some parents, however, who don’t even know which questions to ask. Often these parents are new Canadians or struggle to meet basic needs because of low-income issues. “Our studies show that new immigrants, for whom language may be a bit of a barrier (…) they may not know that these things are available or that they are free,” explains Dr. Talbot. Poverty is another factor according to studies out of Manitoba and Ontario. “A number of factors influence childhood immunization rates. The most important ones appear to be mother’s age at child’s birth (>24 years old), higher family income, continuity of care, primary care physician, and having fewer than four siblings,” says Dr. Alan Katz, professor of Family Medicine and Community Health Sciences at the University of Manitoba, and associate director of the Manitoba Centre for Health Policy.

Collective protection vs. Individual choice “Canadians respect the rights of individuals to make choices. In many countries childhood immunization is not a


choice but is required by law. Others, like Australia, provide financial incentives to parents who have their children vaccinated,” says Katz. While Canadian law protects the right of the individual – ethically – vaccine advocates argue for the collective protection over individual choice. “If we can’t overcome vaccine hesitancy with education and supportive strategies, it may be time to consider making vaccination mandatory for a child to be enrolled in activities which bring them into contact with other children,” suggests Dr. Finlay. One medical ethicist agrees. “It is ethically irresponsible to refuse vaccinations and put other children at risk,” says Maya Goldenberg, associate professor at the University of Guelph. “Your willfully unvaccinated child might spread the disease

A UNICEF study found that only 84 per cent of Canadian children were immunized for measles, polio and DPT3, placing Canada in second-last place out of 29 of the world’s richest countries.

to a baby that hasn’t been vaccinated yet (too young) or someone who is immunecompromised and therefore unable to be vaccinated. Our public health system also needs to pay for those intentionally unvaccinated children that become ill and require care.”

Improving outcomes Where Canada goes next in our efforts to improve vaccination rates is contested. Public health advocate and Globe and Mail Columnist André Picard has some suggestions. “We need a single, coherent childhood immunization schedule (not 13 different ones in each province/territory); harmonized funding so the same essential vaccines are available to all Canadians; and a national immunization registry to link data across the country,” says Picard. Alberta’s Dr. Talbot thinks a registry will do little to increase rates, but agrees that federal funding could help provincial initiatives. Both men agree that public health officials and health care providers need to amp up public health education and communicating vaccines’ benefits. “Misinformation is widespread and public health officials are passive and timid,” says Picard. Picard also argues that we need to move beyond our exclusive focus on childhood vaccination and pay more attention to young adults. “The outbreaks of measles are in college-age kids who have no idea they’re not vaccinated; the mumps and pertussis out-

breaks are in young adults who require boosters but we make no effort to reach out to them. And then there are seniors who could benefit from shingles vaccine,” says Picard. CPS co-authors MacDonald and Finlay would like to see a national committee to examine vaccine hesitancy and develop strategies. “We are already seeing some provinces moving in this direction but we need to learn from each other and work together. Not fragment our talents and resources,” says MacDonald. “There are already so-called national standards like NACI, but the problem is implementation,” explains Dr. Yamashiro. “The way federal funding of healthcare is decentralized makes it harder to create cohesiveness across the country. Unless there is a universal will to implement any such strategy, it would likely not be successful.” All the health care advocates agree on one aspect: public education. They urge all health care workers to embrace the responsibility to debunk myths and be louder than the voices muddying the waters. “I think the vast majority of parents want what is best for their children,” says Flanders. “Armed with the right information, and protected from false anti-vaccine propaganda, they will inevitably make the right choices for H their children.” ■ Tania Haas is a freelance journalist. www.taniahaas.com



16 Focus A 1937 Iron Lung from the Museum’s collection restored at the Canadian Conservation Institute in 2013, is a centrepiece of the exhibition. This iron lung is one of 28 constructed at Toronto’s Hospital for Sick Children during the polio epidemic of 1937. So many cases were admitted to hospital that an ‘emergency’ crew of engineers and tradesmen ran an assembly line in the basement of the hospital to construct the iron lungs. The iron lungs were paid for by the Ontario government and shipped to parts of the province where they were needed during the epidemic. This one was used in Kingston General Hospital for several decades.

Vaccines & Immunization: Epidemics, Prevention and Canadian Innovation By Pamela Peacock accines save lives. The history of disease, epidemics, and public health clearly demonstrates this. And yet, there has always been a very vocal opposition to vaccines, an opposition that continues to rage in very public forums. More public education about the benefits and potential risks of vaccines – which are typically quite minimal as vaccines are a highly tested and regulated product – is needed to enable people to make educated, con-


sidered choices about whether they vaccinate themselves and their children. The exhibit, Vaccines & Immunization: Epidemics, Prevention and Canadian Innovation, which opened at the Museum of Health Care in November and will remain as a semi-permanent exhibit for the next several years, attempts to do just this. Developed with Guest Curator Dr. Christopher Rutty, and funded in part rt by the Kingston and United Way Commmunity Fund, the Coalition of Canadian n

Healthcare Museums and Archives, and Sanofi Pasteur, the exhibit uses case studies of diseases that saw significant decreases in the twentieth century because of immunization – smallpox, diphtheria, polio, and whooping cough – to identify the cost of epidemics to society and explore the search for adequate treatment and preventative measures, such as vaccines. By discussing the impact of epidemics on individuals and society in the

short- and long-term, and showing how drastically vaccines affected incidence and mortality rates, the exhibit strives to make people think not only of the risks (perceived or real) of vaccines but also why they were celebrated discoveries. Let us look more closely at the case of polio, which is a focal point of the exhibit. Polio presents initially much like the flu. Continued on page 17

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Three members of a family brought to the hospital with the mother who was suffering from small pox. The child in the center was unvaccinated. The other two had been vaccinated the previous year because of school vaccination requirements. These two children remained in the small pox wards several weeks and did not contract small pox. Image courtesy of Sanofi Pasteur Canada (Connaught Campus) Archives. www.hospitalnews.com


Focus 17

Franklin Delano Roosevelt contracted polio in 1921 while vacationing in New Brunswick. He later spearheaded the foundation of the March of Dimes, which raised much needed funds to support polio research. Image courtesy of the March of Dimes.

Vaccines & Immunization Continued from page 16 Throughout much of history, most people were exposed to polio in their youth creating adult immunity; however, by the early twentieth century improvements in hygiene meant that more and more adults had never been exposed to polio and were vulnerable to the disease. Many people are able to fight off the disease with only minor symptoms, but in others the viral infection affects the nerves causing muscle weakness and paralysis. In the most life-threatening cases, paralysis affects the tongue, throat muscles and diaphragm, leaving the patient at great risk of suffocation. How was the disease treated in the past? For some, paralysis was temporary and with rehabilitation therapy full mobility could be restored. Others required braces, canes, or wheelchairs for the rest of their lives. Similarly, for those who suffered through bulbar polio – affecting the respiratory system – the primary treatment was an iron lung. Iron lungs use negative pressure to inflate and deflate the lungs of the patient inside, helping them to get oxygen. The patient’s body is placed inside the iron lung while the head and neck protrude onto a canvas stretcher at one end. When the motor is running, pressure will alternatively build up inside the machine, causing the lungs to become smaller, and then decrease inside the machine, causing the lungs to expand and fill with air. Since cases of polio seemed to increase in the warmer months, fear and anxiety settled over many communities in the summer and early fall. Parents would keep their children close to home and forbid activities, such as swimming in the local pool, that were associated with contracting of polio. The polio virus was first isolated in 1908, but the search for a polio vaccine made great strides in the 1940s and 1950s thanks to innovations by a number of rewww.hospitalnews.com

Dr. Jonas Salk discovered the first polio vaccine in 1954. Image originally published in Health, April-May 1955. searchers. Connaught Laboratories made critical contributions when its scientists discovered a synthetic medium in which to grow the virus and a way to effectively grow large amounts of virus by rocking the cultures. This enabled enough vaccine to be produced to conduct field trials of an inactivated polio vaccine developed by Dr. Jonas Salk in 1954. North America waited on tenterhooks to hear the results, broadcasted on 12 April 1955. The vaccine was successful at protecting against polio! It should not be underestimated how excit-

ing this news was. From a peak rate of 60 cases per 100,000 in the early 1950s, incidence dropped to nearly zero by 1962. With a vaccine for polio only discovered in 1954, many Canadians can still recall the fear of polio and remember friends and family members who were stricken with the disease; yet, younger generations have little personal connection to the disease and less understanding about what its consequences can be. Without being educated about the dangers of polio – which is still endemic in

several countries – and other infectious and contagious diseases it is possible that the much publicized “risks” of vaccines will have no counter-balance. It is important to provide balanced, well supported evidence to people so that they can make informed decisions. We hope that this exhibit will contribute to critical reflection and much needed discussions around the H family dinner table. ■ Pamela Peacock is the former Curator, Museum of Health Care in Kingston.

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18 Focus


Ontario Health Study gives everyday people a chance to

improve public health By Hal Costie early 225,000 Ontarians have helped advance the public health of future generations right from their computers by taking the Ontario Health Study’s (OHS) online questionnaire. The OHS continues to recruit participants to provide important health data and samples. This information will help researchers understand the risk factors and causes of chronic diseases and to develop new prevention strategies and treatments. Getting involved in the OHS is a simple, straightforward process. Anyone who is 18 years of age or older and a resident of Ontario can take part in the Study. They just need to go to www.ontariohealthstudy.ca, register and then take the survey, which takes about 45 minutes. The OHS follows strict privacy practices that govern how personal information is collected, who can see it and how it can be used. The OHS recently celebrated its third anniversary, and is already one of the largest long-term health studies in Canada. The OHS continues to enrol new volunteer participants to take the online questionnaire. Some participants have taken their involvement further with 5,800 providing a sample through the Blood Collection Program and 3,600 have paid a visit to the Toronto Assessment Centre to provide other physical measures. “Long-term health studies like the OHS are essential to our understanding of chronic diseases,” says Dr. Vivek Goel, Principal Investigator of the OHS and President and CEO of Public Health Ontario. “With only a small investment of your time you can make a real and lasting difference in the health of future generations. We appreciate the participation of so many Ontarians,


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A health study participant has blood drawn at the assessment centre. and if you haven’t yet joined the study, I encourage you to sign up today.” The OHS is just one piece of an even larger national effort called the Canadian Partnership for Tomorrow Project (CPTP). The CPTP consists of the OHS and four other regional studies: The BC Generations Project, Alberta’s Tomorrow Project, Quebec’s CARTaGENE and the Atlantic PATH. Nationally, the CPTP has more than 289,000 participants aged 35 to 69 and more than 100,000 have provided a blood sample.

“By joining this landmark study, Canadians have contributed to the creation of a rich national bank of health information to help researchers answer fundamental questions about the causes of cancer and chronic disease for future generations. This platform will be available for researchers beginning in 2015 and will serve as an important resource for decades to come," says Dr. Heather Bryant, Vice President, Cancer Control, Canadian Partnership Against Cancer. Those who want to contribute even more to the Ontario Health Study can add their name to a pool of participants who are interested in providing a blood sample or visiting the Toronto Assessment Centre. The OHS Blood Collection Program is run in partnership with LifeLabs, which operates a number of Patient Service Centres located around the province. Those invited to provide a blood sample simply fill out a five-minute questionnaire online and then take their requisition form to the nearest LifeLabs Patient Service Centre. Not all those who express interest in providing a blood sample or visiting the Toronto Assessment Centre will be chosen to participate. “The information provided in the initial online questionnaire provides us with an overall snapshot of the health of Ontarians as well as their exposure to chronic disease risk factors,” says Dr. Karen Menard, Chief Planning and Administrative Officer of the OHS. “By providing a blood sample or visiting the Toronto Assessment Centre, participants allow us to get a more detailed look at their health. We can then compile this data to draw broader conclusions about the health of the overall population.” Menard says that although the Study has grown quickly over its first three years it is important for Ontarians to keep participating. “In three years we have had

Photo JP Moczulski, CP Images.

How to get started: • Visit www.ontariohealthstudy.ca to register for the Study and complete the online questionnaire. It only takes about 45 minutes. You have six weeks to complete the questionnaire from the time you start it; • After you have completed the questionnaire you will be able to volunteer to provide a blood sample and/or visit the Toronto Assessment Centre by clicking on the appropriate “Express Your Interest” button. Not all those who volunteer for this portion of the Study will be selected; • If you are selected for blood collection or a visit to the Toronto Assessment Centre you will receive an email invitation; • Once you receive this email, log into your OHS account and click on the orange “Next Step” button to proceed with arranging your participation; • If you have any questions you can speak to an OHS staff member by emailing info@ontariohealthstudy.ca or calling 1-866-606-0686. more than 200,000 people complete the questionnaire and the Study has gained the endorsement of Ontario’s universities, research teaching hospitals and other relevant organizations,” she says. “But this is just the beginning of a very long-term project. Now we are working on taking this great opportunity to as many communities as possible to keep this momentum going.” The Study is currently focusing on faceto-face outreach with community groups and hospitals. If you would like someone from OHS to visit your organization to discuss the Study, contact Jocelyn Garrett at H Jocelyn.Garrett@ontariohealthstudy.ca. ■ Hal Costie is a Senior Communications Officer at The Ontario Institute for Cancer Research. www.hospitalnews.com

Nursing Pulse 19

A story of fire and ice A group of northern nurses had to ‘hurry hard’’ e to transform a curling rink into a health centre following a devastating fire. By Daniel Punch large section of the Moosonee Health Centre was smouldering. The charts of nearly 9,000 patients were covered in soot. It was December 2012, and the Weeneebayko Area Health Authority (WAHA) had no choice but to send out an alert that read: “To all residents of Moosonee: Please be advised that due to fire and smoke damage…Moosonee Health Centre is closed for all medical treatment effective immediately.” The small town near the southern tip of James Bay, inaccessible by road, was without a health-care facility. The nearest hospital is a 10-minute helicopter flight away on Moose Factory Island. No one was injured in the blaze, caused by an electrical fire that ignited in a storage room, but 70 per cent of the centre’s supplies and equipment was lost. The nurse-led Moosonee Health Centre employed 12 RNs and an NP working on rotation. They provided primary care, emergency services and dispensed medication, but were now without a roof over their heads. “We’re thinking ‘what happens next? What if we have an emergency, what are we going to do?’” says RN Weena Saunders, director of patient care. “We wanted to get (re)established quickly, so people would feel safe and have a place to go.” Fire may have destroyed the centre, but the solution would soon come on ice. With the help of the close-knit Moosonee community and Ontario’s Emergency Medical Assistance Team (EMAT), Saunders and her colleagues now provide care in the unlikeliest of venues – the town’s curling rink. Mike Merko and his eight-member EMAT deployment team, specially trained in disaster management for all kinds of medical emergencies, put boots on the ground in Moosonee roughly 24-hours after the fire. They boarded a plane in Toronto on a mild, late-autumn day, and stepped off into a bone-chilling minus 32 degrees in Moosonee, proclaimed The Gateway to the Arctic by its railway station sign. “The cold was the first shock,” recalls Merko, EMAT incident commander. He would soon discover that cold would be a constant challenge throughout this deployment. The team found patients temporarily diverted to the ORNGE helicopter hangar 10 minutes outside of town, where nurses performed triage, and some patients were airlifted to Moose Factory Island. Other local nurses had started the process of setting up shop in Moosonee’s curling rink, part of a larger facility which includes a skating rink and community hall. It was chosen because it already served as the town’s emergency meeting point. Though it hadn’t been used for years and the ice was gone, the rink was designed for temperatures barely above the www.hospitalnews.com


freezing mark. “Our biggest challenge nge was to take something that was designed ed to be cold and make it hot,” Merko says.. EMAT is trained in everything from fighting ing outbreaks to resuscitating critically injured patients, but heating and cooling was outside of its expertise. At first, they could only raise the temperature to 14 degrees despite an arsenal of heaters. “You can’t expose and assess a patient in that environment,” Merko says. When the team realized the heat was rising to the top of the rink’s seven-metrehigh ceilings, they strategically placed six rotating fans to push the warm air down, and the temperature climbed to 24 degrees. Merko says he admires the Moosonee nurses for their tenacity despite many constraints, including the town’s isolation. When the team needed an electrical breaker, they couldn’t just pop in to the local big-box hardware store. Everything had to be sourced and brought in by air or train. “They’re an amazing group of people,” he says. “We probably learned more from them and how they deal with logistical issues.” The nurses, with help from community members, wired the rink for electricity, built accessibility ramps, and addressed plumbing challenges. The next major issues were infection control and privacy. EMAT came equipped with seven large positive/negative pressure tents, capable of refreshing a room’s air supply 15 times per minute. The light, plastic tents can be set up in less than 30 seconds, and served as the centre’s makeshift ER and examination rooms, providing much-needed visual barriers. “It was like rebuilding a clinic from the ground up,” Saunders says. “You improvise and compromise; you try to make things happen.” More than a year after the fire, nurses are still providing care in Moosonee’s old curling rink. Work to rebuild the old location has stalled, and it won’t be ready for months. Inside the arena, the huge blue and white EMAT tents are still dwarfed by the massive room. Medical supplies and equipment line all four walls. A makeshift staff lounge is cordoned off in a corner with drapes held up by PVC pipes and buckets. During the day, the crash of hockey pucks and slash of skates can be heard beyond one wall. Some evenings, music blares in from community dances held beyond another. “You feel like you’re in a different world,” Saunders says. “(But) it’s business as usual.” Saunders says nurses and patients are getting used to their unusual surroundings. The number of patient visits, which dipped following the fire, is back to normal. The temporary centre is now equipped for nearly every procedure available at the old centre. Nurses are forever

thankful for EMAT, who Saunders calls their guardian angels. “They were like our drill sergeants, but in a good way,” Saunders says of EMAT. “They pumped (us) up and gave (us) something to look forward to.” Sadly, the fire wasn’t the only tragedy to strike Moosonee that year. The attention of the country turned on the small town after the May 31, 2012 ORNGE air ambulance crash that killed four people. The helicopter took off from the Moosonee airport carrying two pilots and two paramedics and went down just 850 metres away. “It really hit hard because we work closely with the paramedics,” says Saunders. “But the community came together. We put an orange ribbon on the

door (of the health centre) so when everybody walks in the clinic, they think about ORNGE.” Through it all, the Moosonee Health Centre hasn’t lost a single staff member. In a region where the average turnover rate is about a year, this is impressive. “It shows the staff is dedicated to the patients and the people of the region,” says Nicole Blackman, an RN and director of professional practice for WAHA. “To not give up and keep persevering and finding new options and working well with the options H they were given, this staff is resilient.” ■ Daniel Punch is editorial assistant for the Registered Nurses’ Association of Ontario (RNAO), which represents registered nurses wherever they practise in Ontario.



20 Focus

Enforcement of Natural Health Products By Deborah A. Campbell lternative medicine and especially Natural Health Products (NHPs) are growing in use, but when people visit hospitals and ask about such things, most health care practitioners they encounter have little knowledge in this area. The NHP Products Regulations came into effect in 2004 and define the category as vitamins and minerals, herbal remedies, homeopathic medicines, traditional medicines such as traditional Chinese medicines, as well as probiotics, and other products like amino acids and essential fatty acids. Why is this important? According to a 2010 Ipsos-Reid survey, 73 per cent of Canadians regularly take vitamins and minerals, herbal products, and homeopathic medicine. The role of the NHP Directorate – it’s part of the Health Products and Food Branch of Health Canada – is to ensure that we have ready access to NHPs that are safe, effective and of high quality. But NHPs are over-the-counter products and don’t require prescriptions, and keeping tabs on their sale and distribution isn’t easy. Consider the retailer who faced repeated Health Canada recalls because of selling products found to contain hidden ingredients and unauthorized substances similar to the prescription drugs sildenafil and tadalafil. There was nothing on the product labels or packaging to indicate such ingredients. Another retailer who manufactures and distributes NHPs also got a recall order,


but refused to comply, despite the fact that one of its nutritional shakes contained the prescription drug chloramphenicol. Health Canada says this is an antibiotic associated with the risk of a potentially fatal blood disorder. The retailer said contamination wasn’t a health risk because of low concentration in its shakes. Nevertheless, an NHP product for sale containing a known pharmaceutical is against the law. Enforcing the law is something else again.

73 per cent of Canadians regularly take vitamins and minerals, herbal products, and homeopathic medicine.

Health Canada has a major challenge because of a lack of resources. While most players involved in the NHP industry are ethical, there are unscrupulous retailers, manufacturers and distributors who are less than honest with the consumer. The industry is not subjected to audits, and even when problems arise, the process in dealing with them is bureaucratic and time-consuming. Also, it’s easy to get around loopholes.

For example, a U.S. company shipping product to Canada must deal with added levels of security at the border, but if the company establishes a manufacturing facility in Canada, the same level of security no longer exists. The company can make what it wants and sell it, even if the information on the label or packaging is less than accurate. Health Canada reacts when a complaint is lodged, but there is very little that is proactive in the process. Even though the NHP world is regulated, the rules are not enforced, giving an unfair advantage to unscrupulous players who can make any claims about their products. The federal government recently announced new legislation called The Protecting Canadians from Unsafe Drugs Act. The Act, which could become law this year, applies to prescription and over-thecounter drugs, as well as medical devices, vaccines, gene therapies, cells, tissues and organs. The Act: • Imposes stiff penalties for unsafe products with fines up to $5 million a day and two years in prison for those who do not comply with orders; • Speeds up product recalls or label changes when a problem is identified; and, • Increases patient safety by improving Health Canada’s ability to collect safety information on products sold for therapeutic use. While this legislation does not specifically address NHPs, it would deal with those who defy a Health Canada order to

recall product found to contain a prescription drug, or a product similar to a prescription drug. Thus, a business that defies a Health Canada recall could face severe penalties. A University of Guelph study published in the journal BMC Medicine should serve as a wake-up call about the potential dangers of some NHPs. The study used DNA barcoding technology to test 44 herbal products sold by 12 manufacturers, and showed that most of the NHPs surveyed contained fillers and plant ingredients not listed on the label. One ginkgo product was contaminated with Juglans nigra (black walnut), which can be fatal for anyone with a nut allergy. Almost 60 per cent of the herbal products contained plant species not listed on the label, and more than 20 per cent included such fillers as rice, soybeans and wheat which, again, were not on the label. There is virtually no enforcement of quality control for the manufacture and labelling of Natural Health Products in Canada, and while the University of Guelph study concluded that we need more regulations, in fact, we don’t. But existing regulations should be better enforced. People who suffer from plant allergies or seek gluten-free products should not to be exposed to these hazards because they buy NHP H products that are improperly labelled. ■Deborah A. Campbell is, an advisor to the Natural Health Products Directorate of Health Canada.




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Focus 21

A Holland Bloorview client receives Snoezelen therapy.

Taking control of pain By Michelle Halsey hild life specialists at Holland Bloorview Kids Rehabilitation Hospital are empowering young patients to take control of their pain and helping parents develop strategies to support their kids. The response to pain is not simply a result of tissue or nerve damage, but rather a combination of both physical and psychological variables. â&#x20AC;&#x153;Literature shows that the best approach to pain management is a blend of pharmacological and non-pharmacological interventions,â&#x20AC;? says Breanne Mathers, child life specialist at Holland Bloorview. â&#x20AC;&#x153;With this in mind, we create individual plans to proactively manage pain rather than chasing it.â&#x20AC;? While strategies are patient-directed, families can also play an important role in pain management. This is especially true when a patient has communication challenges since parents can often recognize subtle pain indicators. Mathers says that patients and families should not resign themselves to a certain level of expected pain since patients as young as four years old can be taught pain management strategies.


Successful pain management requires a plan that outlines personalized goals that can be assessed and adjusted regularly â&#x20AC;&#x153;Parents often report that they feel there is nothing they can do about watching their child in pain. When parents are taught non-pharmacological pain management techniques, they can proactively coach their child to manage pain. Parents are then empowered when hospital staff is not at the bedside or when the child is at home.â&#x20AC;? www.hospitalnews.com

Mathers and other child life specialists at Holland Bloorview run a group for patients and families to teach them about pain management. Patients and families attend 30 minute sessions to become familiar with a variety of non-pharmacological techniques to reduce acute, chronic or recurrent pain. Session topics include humour, multisensory environments like Snoezelen, distraction boxes and advocacy. Feedback from the sessions shows it has been an effective way to provide information to patients and their families while helping them learn how to support each other. Patients can experiment with a variety of techniques to find those best suited to their needs. Some patients may find cognitive techniques like distraction and imagery to be most effective while others may prefer behavioural techniques like meditation or deep breathing. There are also a range of biophysical techniques like heat therapy and massage as well as emotional expression strategies such as art. Once learned, pain management strategies have also been shown to be effective tools for managing stress, anxiety and nausea. Successful pain management requires a plan that outlines personalized goals that can be assessed and adjusted regularly. Communication both ways between the health care team and the patient and family is paramount to the success of the plan. Honest explanations from clinicians about procedures that may cause pain can go a long way in reducing the patientâ&#x20AC;&#x2122;s anxiety. In fact, the act of developing a plan in itself helps to minimize fear and can give patients a sense of control over the situation. The individualized plan should also include an outline of which medications will be used and an explanation of how each works. Explaining to patients the type of pain a medication will target, along with an understanding of how it works, will complement non-pharmacological strategies.

Clients at Holland Bloorview generally have stays that are long enough to trial different techniques and master skills, however, patients experiencing shorter stays can quickly learn certain pain management techniques. Simpler strategies like therapeutic touch, deep breathing and management of physical space can be implemented with little instruction. In all cases, patients should be encouraged to have a dialogue about pain management rather than simply accepting pharmacological strategies as the total plan. Ideas for a patient distraction box:

â&#x20AC;˘Party blowers and pinwheels that encourage deep breathing â&#x20AC;˘Bubbles for deep-breathing and therapeutic popping â&#x20AC;˘Squishy items like stressballs for therapeutic touch and massage â&#x20AC;˘Toys like dinky cars can bring attention to or away from pain area â&#x20AC;˘CDs with calming music â&#x20AC;˘Joke book or other items that employ humour H â&#x20AC;˘ Hot or cold packs â&#x2013; Michelle Halsey is a Senior Communications Associate at Holland Bloorview Kids Rehabilitation Hospital.






22 Focus

Solving the

pain puzzle? By Dr. Alejandro Elorriaga Claraco he November 2013 â&#x20AC;&#x153;Pain in Canada fact sheetâ&#x20AC;? published by the Canadian Pain Society states some hard facts summarized under the heading Pain is Poorly Managed in Canada. These facts include: â&#x20AC;˘ Canadians are left in pain after surgery even in our top hospitals â&#x20AC;˘Surgery itself is the cause of almost 10 per cent of chronic pain in Canada â&#x20AC;˘Pain is the most common reason for seeking healthcare (78 per cent ER visits) â&#x20AC;˘One in five Canadian adults suffer from chronic pain â&#x20AC;˘One in five Canadian children have weekly or more frequent chronic pain â&#x20AC;˘Chronic pain is associated with the worst quality of life as compared with other chronic diseases â&#x20AC;˘The annual cost of chronic pain in Canada is $56-60 billion dollars If we are [officially] practicing â&#x20AC;&#x153;Evidence-Based Medicineâ&#x20AC;? in Canada, why is the â&#x20AC;&#x153;empirical evidenceâ&#x20AC;? presented above showing that we are seriously failing to treat pain? One answer, based on the hard data that shows where money is spent in the medical systems of developed countries, is thatâ&#x20AC;Ś even though â&#x20AC;&#x153;pain is a puzzleâ&#x20AC;? with many pieces, we are approaching its treatment in an over-


simplified manner, favoring pharmacological and surgical interventions over any other approach. For many years, scientific knowledge of pain has been providing new clues to help us understand â&#x20AC;&#x153;the pain puzzle.â&#x20AC;? Perhaps the most important scientific fact regarding pain is that the experience of pain is paradoxical: while pain is perceived â&#x20AC;&#x153;as ifâ&#x20AC;? occurring in the body, in actuality, pain is the result of the brainâ&#x20AC;&#x2122;s integration of complex neurological activity involving cognitive, affective and sensory dimensions, what Dr. Melzack termed years ago â&#x20AC;&#x153;the neuromatrix.â&#x20AC;? The immediate corollary is that if â&#x20AC;&#x153;pain is in the brainâ&#x20AC;?, there is where we need to start solving the pain puzzle. In addition to the brain dimensions, there are other contributors to the â&#x20AC;&#x153;pain puzzleâ&#x20AC;? also identified by science, such as the peripheral nerve pathways involved in the transmission and processing of â&#x20AC;&#x153;unpleasant sensory informationâ&#x20AC;?, as well as the many spinal cord processes that influence the final passage of these signals to the brain. As a reflection of its phenomenal complexity, the physiology of the pain experience involves all our important levels of function: neurological, metabolic, hor-

monal, immune, visceral, biomechanical and psycho-emotional. With this picture, itâ&#x20AC;&#x2122;s not surprising that chronic pain research has proven the most effective approach to the management of pain is the bio-psycho-social model. This model proposes that health is best understood in terms of a combination of biological, psychological, and social factors rather than purely in biological terms. Why then are we are still treating pain in daily practice armed mainly with pills, injections and surgical scalps? Well, that is a $60 billion dollar question for Canadians ($600 billion for the USA).

The answer? Self evident: consumers of healthcare are extremely naĂŻve expecting that a system dominated by multibillion dollars interests (pharmaceuticals, diagnostics, etc.) would care to change a working model that produces phenomenal profits year after year. Really? Well, ponder this undeniable fact, based on hard cold data from the Organisation for Economic Co-operation and Development: pharmaceutical expenditure and diagnostics are bankrupting the medical systems of developed countries without providing any additional value to our health. Continued on page 31





Focus 23

Feeding Disorders Clinic sets table for successful eating

By: Amanda Roffey

s parents, we want our children to eat a well-balanced and healthy diet, but when your child doesnâ&#x20AC;&#x2122;t eat his or her vegetables or more than a few selected food items â&#x20AC;&#x201C; ensuring your childâ&#x20AC;&#x2122;s growth can become a constant cause for concern. A feeding disorder is defined as a child or infant who has the inability to take in nutrition in order to meet their needs. For some children the smell and texture of food causes them significant distress which can lead to low growth rates and serious health issues or a failure to thrive diagnosis. Since 2009, the Peterborough Regional Health Centreâ&#x20AC;&#x2122;s (PRHC) Family and Youth Clinic has offered a focused intervention for young children and their families dealing with significant food refusal. More recently the service has been a collaborative partnership between the hospitalâ&#x20AC;&#x2122;s Family and Youth, and Paediatric Outpatient Clinic. The clinic treats approximately 60 patients per year for feeding disorders and sees another 60 patients for picky or selective eating concerns. Most have said or heard the classic mealtime tug of war â&#x20AC;&#x2DC;you canâ&#x20AC;&#x2122;t leave the table until you finish your dinnerâ&#x20AC;&#x2122;, but this tactic can actually cause more harm than good for children with feeding disorders. â&#x20AC;&#x153;Negative mealtime experiences can be a trigger for children who struggle to eat enough to stay healthy,â&#x20AC;? says Lise Leahy, Registered Dietitian at PRHCâ&#x20AC;&#x2122;s Pediatric Outpatient Clinic and Feeding Disorders Clinic. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s hard to feel hungry when you are stressed because itâ&#x20AC;&#x2122;s time to eat.â&#x20AC;? The teamâ&#x20AC;&#x2122;s multidisciplinary assessment includes psychology, nutrition, social work and medical providers. The first appointment focuses on getting to know the family and child. â&#x20AC;&#x153;Our goal is to listen to the familyâ&#x20AC;&#x2122;s story and learn when the problems emerged, what the child eats or doesnâ&#x20AC;&#x2122;t, is there a time of day they eat more, and review the child or infantâ&#x20AC;&#x2122;s growth and development,â&#x20AC;? explains Connie Oates, Psychological Associate at PRHCâ&#x20AC;&#x2122;s Family and Youth Clinic. The clinicâ&#x20AC;&#x2122;s family based approach takes a holistic view of the infant or child. The clinicâ&#x20AC;&#x2122;s team carefully considers all issues that may interfere with healthy eating and contribute to the disorder such as medical complications, hypersensitivities, atypical neurodevelopment such as Autism, stress around feeding or food, anxiety in child or caregiver or gastroesophageal reflux disease(GERD). â&#x20AC;&#x153;Our first task is to remove stress at meal time,â&#x20AC;? says Leahy. â&#x20AC;&#x153;Through coaching, we teach parents to reduce their own level of stress through deep breaths and positive statements. Once parents believe that their child will eat and that they have a role in helping, we are well on the way to creating a positive meal time experience.â&#x20AC;? For example if you are making a stir fry for the family and your child will only eat bread and cheese, then make sure that bread and cheese are on the table for the child to select. â&#x20AC;&#x153;If the bread and cheese are the only items your child eats in a nonstressed situation then it was a positive and successful interaction,â&#x20AC;? adds Leahy.



Tammara Howting (left) and daughter Evelyn Howting enjoy a cookie thanks to the help of Peterborough Regional Health Centre's Feeding Disorders Clinic. The child was also exposed to the sight and smell of a stir fry and watched other people enjoy it. For the Howting family, this advice was instrumental in their 13-month-old daughter Evelynâ&#x20AC;&#x2122;s success. Evelyn was six weeks old when she was diagnosed with a slow rate of growth. After numerous appointments it was determined that there was nothing physically wrong with her â&#x20AC;&#x201C; Evelyn continued to eat, but growth was slow.

A feeding disorder is defined as a child or infant who has the inability to take in nutrition in order to meet their needs. Then in October 2013, Evelyn came down with the flu and high fever and refused to eat. â&#x20AC;&#x153;Evelyn stopped going into her high chair, or sleeping in her crib,â&#x20AC;? says Tammara Howting, Evelynâ&#x20AC;&#x2122;s mother. â&#x20AC;&#x153;We went to Emergency, but after a week of no sleep and little feeding â&#x20AC;&#x201C; it was clear that we needed help.â&#x20AC;? In November, the Howting family was referred to PRHCâ&#x20AC;&#x2122;s Feeding Disorder clinic. After gathering Evelynâ&#x20AC;&#x2122;s story, clinic staff members determined that Evelynâ&#x20AC;&#x2122;s illness caused stomach pain which contributed to Evelynâ&#x20AC;&#x2122;s refusal to eat and sleep. For Evelyn, she associated her stomach pain to eating in her highchair and sleeping in her crib. â&#x20AC;&#x153;Connie and Lise taught us to give Evelyn foods that she always liked eating,â&#x20AC;? notes Howting. â&#x20AC;&#x153;We now give her a â&#x20AC;&#x2DC;mumâ&#x20AC;&#x2122;s cookieâ&#x20AC;&#x2122; on her highchair to signal that itâ&#x20AC;&#x2122;s time to eat and Evelyn now sits in her chair again.â&#x20AC;? After three months of clinic appointments, Tammara and Evelyn are seeing progress. â&#x20AC;&#x153;Evelyn now sleeps in her crib again,â&#x20AC;? says Howting. â&#x20AC;&#x153;Another strategy the clinic taught us was to never leave her bedroom when she was upset. This teaches Evelyn that her room is a happy and safe place.â&#x20AC;?

Now at 16.5 lbs, Evelyn is still small for her age, but the Howting family has tools and strategies to help their daughter grow. â&#x20AC;&#x153;We still get the odd â&#x20AC;&#x2DC;your child weighs how much commentâ&#x20AC;&#x2122;, but itâ&#x20AC;&#x2122;s wonderful to know we have people on our team supporting us,â&#x20AC;? says Howting. â&#x20AC;&#x153;PRHCâ&#x20AC;&#x2122;s Feeding Disorders Clinic provides compassionate care â&#x20AC;&#x201C; in the beginning they met with us weekly, answered all our questions, and reassured us that we were not to blame for Evelynâ&#x20AC;&#x2122;s slow growth.â&#x20AC;? Another strategy used at the clinic involves parents packing a picnic or snack to bring to their second appointment made up of food that their child usually eats. â&#x20AC;&#x153;With the parentsâ&#x20AC;&#x2122; permission we video tape these sessions, and use the footage to identify opportunities and tactics to use when trying to introduce a new food or getting a child to eat more of the same food that he/she enjoys,â&#x20AC;? notes Leahy. â&#x20AC;&#x153;One of the biggest challenges facing families attending the clinic is that change will not happen overnight,â&#x20AC;? adds Oates. â&#x20AC;&#x153;The ongoing medical monitoring of growth and liaison with the infant or childâ&#x20AC;&#x2122;s physician is a key to easing parental anxiety. Families are encouraged to keep a mealtime journal and document informa-

tion like what mealtime was easier than others, what worked well, what your child ate, touched, or smelled.â&#x20AC;? Itâ&#x20AC;&#x2122;s important to remember that children are curious by nature and will start to show signs that they are interested in other types of food. Parents are encouraged to provide opportunities for their child to interact with food such as going to the grocery store, helping to prepare snacks, growing a garden or even using food for art projects. Listen for key phases such as â&#x20AC;&#x2DC;that smells good or what is it?â&#x20AC;&#x2122; and watch for your child noticing where you place food during meals to gauge his/her interest and reaction. If you think your child has a feeding disorder or if you have concerns regarding his/ her picky or selective eating habits, speak to your family doctor or Nurse Practitioner. Some symptoms to look for include highly restrictive food choices, significant conflict involving meal times or feeding, frequent refusal to approach the table for meals, gastrointestinal distress, and failure H to grow or slow growth rate. â&#x2013; Amanda Roffey is a Communications Advisor at Peterborough Regional Health Centre.

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24 From the CEO's Desk

Osler’s journey toward

service excellence By Matthew Anderson ike every other hospital across the province, William Osler Health System (Osler) is continuously striving to make life better for patients and their families. With thousands of patients walking through our doors each and every day, we are steadfastly committed to ensuring that each and every one of them has positive interactions with our staff, physicians and volunteers. I think my hospital colleagues would agree that while this sounds like a reasonable goal, it is unbelievably challenging to put into practice. A negative impression can be formed even if the care that was provided at the bedside during a stay was excellent. This impression may form in any number of places away from the inpatient floor – locations like the parking lot, the cafeteria, or even in the elevator. These impressions can also be extremely difficult to identify and address if mechanisms aren’t in place to capture the information. As one of Ontario’s largest hospitals, we serve a population of over 1.3 million people living in one of the fastest growing and most culturally diverse regions in Canada. Osler’s emergency departments (ED) are among the busiest in the province and our labour and delivery program is one of the largest in Ontario.


With our growing and diverse community always top of mind, we have made service excellence a key driver behind everything we do. At Osler, service excellence represents the softer side of healthcare – the human touch that makes a significant difference to patients and families during a hospital stay. Service excellence was made a significant component of our 2013-2018 Strategic Plan and called out as our first strategic direction – stating that we will improve how we communicate with patients and families, listen to what they are telling us, and take action so that we can better serve their needs. Long before the launch of our Strategic Plan and following a period of time when patient satisfaction scores were at an alltime low, Osler identified the need for more timely information about a patient’s stay in order to better understand where it needed to improve – and to then be able to feed that information back to our clinical units for quick action. Recognizing the tremendous opportunity to make a difference for our patients and their families, we launched a ‘Service Excellence Call Centre’ in 2011 that conducts outbound calls to inpatients 48 hours after discharge for the purpose of gathering feedback on their hospital stay.

The call centre is staffed by modified workers (nurses who may need to be off their feet), college students (who need practicum hours to complete their diplomas) and volunteers, and is able to collect rich feedback through what we like to call, ‘the voice of the patient’. Over the course of the call, patients are asked a few short questions about their satisfaction with their stay, if they were treated with respect and dignity, if they would recommend the hospital to family and friends, and if they have any suggestions for ways we could improve. All comments are immediately documented and stored within a secured hospital database.

Osler launched a ‘Service Excellence Call Centre’ in 2011 that conducts outbound calls to inpatients 48 hours after discharge for the purpose of gathering feedback on their hospital stay.

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This feedback is then shared with hospital staff on the front-lines where it is used immediately to help us better understand and evaluate each patient’s experience, celebrate success stories and identify where staff and physicians can focus their energies to further improve the patient experience. With establishment of the call centre, we soon recognized that we needed a means of feeding information back to the front-lines where it could be used immediately to influence behaviours and improvement strategies. As a result, we implemented daily ‘performance huddles’ across all clinical areas in the hospital in early 2012. These huddles are short, 10-minute sessions where managers and front-line staff come together to discuss their performance against four key metrics.

It has also been extremely effective in identifying outstanding services and giving us an opportunity to recognize good work. The ability to immediately collaborate on solutions and share patient stories has positively influenced staff satisfaction. Recent survey results show a 10 per cent improvement year over year. In just three years, our call centre has provided us with more robust knowledge to better inform the care we deliver, impact decision-making, identify areas for improvements, and acknowledge our highperforming areas. Given the diversity of our community, it also helps to ensure that we continue to deliver quality care that respects the traditions, religion and culture of our patients and their families. With such a diverse community, we incorporate our interpretation services program into the operations of the call centre to ensure staff are able to communication effectively with every patient. A number of call centre staff are also multi-lingual, so they are encouraged to speak in different languages to ensure we are being as inclusive as possible. Some of our successes to date have come in the form of an award from Accreditation Canada and even national and international attention with requests to speak about our call centre and service excellence program at a number of conferences. In April, we will be presenting at the Beryl Institute’s Patient Experience Conference, and in May, we will be speaking at the Cleveland Clinic’s Patient Experience Summit. While it’s safe to say we still have some work to do on improving the patient experience, we are enthusiastic that the tools we have put in place will guide us on this H journey. ■ Matthew Anderson is the President and CEO of William Osler Health System – comprised of Brampton Civic Hospital, Etobicoke General Hospital and the new Peel Memorial Centre for Integrated Health and Wellness. www.hospitalnews.com


Focus 25

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26 Focus

Falls prevention program aims to empower those at risk By Catherine Pringle orothy Masih was visiting Trillium Health Partners for a routine appointment when she suffered a fall walking through the hospital corridors. She was quickly assisted by a hospital volunteer and taken to the emergency department where she was screened by the attending physician who determined that she was at risk for future falls. Her name was then entered into a database as part of Trillium Health Partners’ falls prevention strategy.


According to a report from the Ontario Injury Prevention Resource Centre, falls are the second leading cause of injury-related hospitalizations for all ages Dorothy was treated for cuts and bruises suffered in her fall, and released. A few weeks later, Dorothy received a phone call asking if she would be interested in coming to the hospital to take part in a falls prevention program where she and other participants would learn how to better protect themselves from another painful fall. Dorothy agreed, and says what she gained from that clinic has changed her life. According to a report from the Ontario Injury Prevention Resource Centre, falls are the second leading cause of injury-related hospitalizations for all ages. Seniors 65 and older are nine times more likely to suffer fall injuries than younger persons.

Sabina Sobota, rehabilitation assistant, Trillium Health Partners with Viscilsa Alexander. Falls are a huge problem. They can be life altering for many people and in the worst cases can result in death. Falls often result in psychological harm. Victims become frightened of falling again and as a result limit activities, which can lead to other issues, such as isolation and immobility issues. The fact of the matter is that falls are often preventable. Understanding this reality, Trillium Heath Partners recognized an opportunity to promote health and safety within the community by helping to prevent falls for those who are particularly prone to

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them. While there had always been a falls prevention strategy in place, there was a chance to really address this problem in a more strategic manner. The new program is an initiative of the internationally-recognized Best Practice Guideline in falls prevention, which the hospital has committed to achieving as part of its candidacy for the Registered Nurses Association of Ontario’s (RNAO) Best Practice Spotlight Organizations (BPSO) designation. “Our fall rate was above where we wanted to it to be so we were very driven to

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reduce it and improve outcomes for patients,” says Chris Zettler, Manager, Professional Practice Portfolio,Trillium Health Partners. “In addition to that, we have a large seniors’ population in our community so it was important for us to create programs that addressed their needs.” The hospital introduced a post-fall huddle across all sites for in- and out-patients. This tool promotes team discussion and analysis of the event in an effort to prevent it from happening again. The hospital implemented a trial use of low beds to prevent injuries in patients who are prone to repeat falls. A number of visual cues are also now in use, including screening information that appears on status and electronic white boards, as well as “fall precaution” stickers on patients’ armbands, charts alert sheets and other relevant areas. Trillium Health Partners has also begun screening out-patients at registration to identify whether or not they are at high risk for falls. If patients are at risk staff will make sure they have the proper assistance from volunteer escorts while visiting the hospital and will follow up with them once they are home to see if they are interested in participating in a falls prevention clinic. While the initiative is nurse-led and driven, Trillium Health Partners broadened the program to include all allied health staff, physicians and volunteers from across the organization; it is a truly interdisciplinary approach. “It takes a village,” says Zettler. “Our professional service team attains information from our patients in order to assess whether or not they are prone to falls, our volunteers utilize wheelchairs set up by their stations to help patients get from one part of the hospital to another and our porters help get patients and their information from one unit to another.” Trillium Health Partners’ goal for the inpatient program is to achieve the industry standard of four falls per thousand patient days. For our outpatient program, we really wanted to see a reduction in the number of falls and fall-related injuries while people are visiting our facilities. Trillium Health Partners has experienced great success with a number of its falls prevention tactics. The trial use of low beds resulted in an 80 per cent reduction of falls and there were no injuries for the patients who used low beds. Furthermore, the implementation of visual cues has played a significant role in raising awareness amongst staff, physicians and volunteers. “We are very pleased with our progress to date. The falls prevention strategy has increased the overall awareness of falls and the need to prevent them both within the hospital and outside its walls,” says Zettler. “As a result of this program and the efforts of all those involved, we have seen our inpatient fall rates decrease steadily. The outpatient program is a more recent initiative and we are continuing to monitor the data on a quarterly basis but we are encouraged by the preliminary results for H people like Dorothy.” ■ Catherine Pringle is a Senior Communications Advisor at Trillium Health Partners. www.hospitalnews.com


Focus 27

Acupuncture turns addict into a believer By Donna Danyluk d Dowdell can’t remember a time when he wasn’t on something. He started drinking at the age of seven and then added drugs into the mix as a young adult. His life was a vicious cycle of abuse and addictions. The addictions helped numb the pain of his Post-Traumatic Stress Disorder (PTSD), but caused his mind to race and his hands to shake. Sleeping was never easy and relaxing was out of the question. He became a workaholic – a man always running at full speed. And so when his addictions counselor at Barrie’s Royal Victoria Regional Health Centre (RVH) suggested he try acupuncture as a way to relax, he just had to laugh. “I thought it would be a waste of time. I actually thought it was joke. I was so skeptical,” says Dowdell. And so with his arms crossed and a scowl on his face, the 51-year-old Barrie man sat against the wall in the group therapy room. He didn’t really want to be there, but he had no place else to be, so the frowning cynic stayed. And all it took was one session to make a believer out of this ‘Doubting Thomas’.


“Once Brian put the music on, and put the acupuncture needles in my ear, I shut my mouth, put my head back, closed my eyes and for the first time in as long as I can remember I relaxed,” says Dowdell. “I have never felt so at peace. I felt like I was floating down a river - so safe and calm. That night I had the best sleep in 36 years.” Dowdell was among the first group of patients at RVH to be offered auricular acupuncture as an alternative therapy for addictions or mental health issues. The service began in May 2013 and since then almost 1,700 such therapies have been administered in RVH’s Inpatient Mental Health program. The program has been so successful that an additional five staff members have been trained to deliver acupuncture treatments. “Adding an alternative therapy, such as acupuncture, into a client’s treatment plan is part of RVH’s ongoing commitment to deliver safe, quality, patient-centred care with a focus on individualized treatment plans that best meet the unique needs of our clients,” says Chris Nichols, manager, Mental Health and Addiction Services. “This alternative therapy is an

‘Hospital Spam’ an Oxymoron? Not according to the new Canadian Anti-Spam Law By Patricia North, LL.B., LL.M. ver the next three years, new Canadian law will come into force regulating commercial electronic messaging (CEM). Known as Canada’s Anti-Spam Legislation (CASL), and widely considered the toughest law of its kind in the world, it will require express or implied consent to email and other electronic communications caught by the law’s broad definition of ‘commercial’ unless they fit within one of the law’s specific exceptions. Unfortunately, the definition of CEM casts a very wide net: electronic messaging is considered commercial if one of its purposes is “to encourage participation in a commercial activity”. Commercial activity includes transactions, acts or conduct of a “commercial character” regardless of whether making a profit is the expectation. Making hospitals spend scarce public resources to comply with CASL given their trivial contribution to the propagation of spam is akin to using a sledgehammer to crack a nut. However, despite this seemingly obvious fact, hospitals are not exempt from this law.


Application to hospitals In order to apply CASL to the health care context, hospitals must look at their email traffic and consider whether electronic communications are commercial in www.hospitalnews.com

nature. While hospitals might expect that revenue-generating activities would be caught by CASL, one would have hoped that the regulator would at least acknowledge, ideally in writing, that core activities of hospitals (i.e. the provision of health care services) are not commercial, as was done with the federal privacy legislation. Without such direction, hospitals are left to grapple with such questions as whether electronic messaging relating to uninsured services and products or programs offered to patients for a fee would be considered commercial. Similarly, would electronic messaging relating to pharmacy sales or the leasing of space to Canada’s favorite coffee franchise be considered commercial in nature? If the electronic messaging is determined to be commercial, does it fit within one of the exemptions or implied consent provisions (which are detailed and specific) or will express consent be required? Note that even if there is implied consent under CASL, certain form and content requirements may apply. The range of electronic communications sent by hospitals is incredibly broad and diverse, including everything from communication with patients and other health care providers, to research institutes and academic partners, vendors and other commercial entities. Continued on page 31

Ed Dowdall was one of first patients at Royal Victoria Regional Health Centre to be offered auricular acupuncture as an alternative therapy for addictions or mental health issues. innovative practice in an inpatient setting. It promotes a holistic approach to recovery and teaches patients techniques for relaxation, other than substance or prescription medication.” According to Nichols, more than 75 per cent of RVH mental health clients suffer from both addiction and mental illness, which are chronic in nature and can be very debilitating. “That is why it is so important to teach people how to manage their symptoms with more natural methods and ones they can do at home or at work,” says Nichols. Brian Irving, RVH addictions counselor, has witnessed first-hand the benefit of using acupuncture. “People find it very calming and are more open and relaxed. Acupuncture is a way to build trust with clients who, after the treatment, are more willing to open up and talk about their other issues during counseling,” says Irving. “I know many people view acupuncture as holistic, but it is actually very complementary to modern science. Acupuncture won’t cure anyone, but it can ease the symptoms of substance use, withdrawal and various mental health issues, including depression, anxiety and PTSD.” Typically, an acupuncture session at RVH is done in a group setting. Irving inserts five needles in the ears of each

client, dims the lights, puts on calming music and lets the group relax. Acupuncture is being utilized in RVH’s inpatient mental health unit, the outpatient mental health program and more recently it has been offered to patients in the withdrawal management program and 21-Day residential treatment program. “Part of the purpose of acupuncture is to learn to relax. When people are stressed they sometimes turn to addictive behaviours as a way to escape and cope,” says Irving. Dowdell knows all about that. “I was tense all the time and when I first came here my hands were shaking so badly I couldn’t hold a glass. My mind was racing so fast I couldn’t think straight,” says Dowdell. “It has calmed me down – I’ve never felt this way before. I couldn’t wait for the next session.” Dowdell has since been discharged from RVH to a community-based 90-day treatment program where he is looking forward to cleaning up and get back to enjoying his family. “I’m definitely a believer now. And I hate needles – really do,” H he laughs. ■ Donna Danyluk works in communications at Royal Victoria Regional Health Centre in Barrie.


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28 Healthcare Technology

The tipping point for healthcare technology By Ken Jarvis

he health care industry has been more cautious in adapting new technology trends than other sectors, and rightly so. Personal health information must be confidential and secure, and is closely governed by regulation – PIPEDA in Canada. Any changes to how this information is stored, secured or shared would likely require regulatory revision. Further, the accuracy and authenticity of information used by health care professionals in treating a patient is literally a matter of life and death. When so much is at stake, it is clear why the medical community is slow to change and still relies heavily on handwritten notes and documents. Nonetheless, healthcare has reached a tipping point in terms of adapting new technology. The mobile revolution continues, and patient involvement in their own treatment is an unstoppable force. There is tremendous pressure on health care facilities to improve not only patient health and wellbeing, but also the caregiver experience. The opportunity to improve patient outcomes while reducing wait times and lowering costs to the system – in other words, to enhance the productivity of health care delivery – is so great that adaptation of the enabling technology is inevitable. Here are five trends that will continue to impact the health care industry in 2014 and beyond.


1. BYOD is becoming mainstream Employees today want to be connected to everything, and increasingly they want that connectivity on their personal mobile devices. Faced with an influx of personal smartphones and tablets brought to work by their medical staff, hospitals are beginning to embrace the BYOD (Bring Your Own Device) trend and are looking at the support requirements and protocols needed to manage confidentiality and privacy requirements. Does your hospital have a BYOD policy that includes an enabling IT infrastructure, and governance and compliance issues? The good news is that there are now tools available to securely support the multitude of mobile devices your staff are already bringing to work. The return on investment for BYOD in a hospital setting is still not easy to compute, but the payoff in terms of employee satisfaction and the potential for productivity gains in delivering patient care can no longer be ignored. BYOD is here to stay, and 2014 may be the year to fully embrace it.

2. Big Data plays a vital role in patient care With advanced technologies, we are now able to analyze and retrieve valuable information from collections of large and complex data sets (known as “Big Data”) that until recently were too difficult to process with traditional data processing appliHOSPITAL NEWS MARCH 2014

cations. In the health care world, this is a huge benefit for individual patient care, research into diseases, and overall productivity in the delivery of services. As Electronic Health Records evolve and are capable of working with outside apps, critical information is being captured and recorded by both caregivers and patients themselves. Data from all sources needs to be integrated to provide a holistic view of patient diagnosis and treatment. Patients can also access their information from almost any device at any location.

Personal health information must be confidential and secure, and is closely governed by regulation With this new capability to manage and analyze Big Data, and the reality that information is increasingly being stored on and retrieved from mobile devices, the era of Big Data in patient care has arrived. Access to comprehensive health data enables more accurate prognosis and treatment decisions. Health care providers are realizing the benefit of Big Data to deliver better care at lower costs as well as more customized treatment plans.

EHR systems have become more affordable and information can be exchanged more easily than ever before.

3. Telemedicine will deliver cost-effective care for the future Technology is continuing to push the envelope of treatment options available to all patients. With video conferencing through laptops, smartphones and tablets, patients can easily connect with their medical staff. Self-monitoring devices make it easier for patients to monitor and report their vital signs without a trip to the doctor or hospital. Post hospitalization, patients can check in and upload their data, and medical staff can videoconference with the patient or with other members of their team. Such ‘virtual’ care will continue to increase through 2014 and beyond.

4. Data security solutions are at hand Personal health information must always be encrypted, and ensuring patient confidentiality and compliance with regulatory requirements has become more challenging as the IT environment becomes increasingly complex. At the same time, the platforms that provide data security continue to evolve to meet these challenges. A great backup tool is the ability to track and erase information from devices that have been stolen or compromised.

This security solution is now readily avail able, as well as products that provide secure leads for email, texting, file sharing and videoconferencing.

5. Mobile apps are on the rise Medical staff access mobile apps to quickly gather many types of information. Patients use mobile apps to count their calorie intake or measure heart rate, to assist with more complex regimens like managing chronic disease, or to be reminded to take their medication. EHRs are also evolving to work better with outside apps for data input and monitoring. Health systems are developing and implementing their own apps to help improve the patient experience. Finally, apps are being developed to span many different devices, and will play a vital role in healthcare now and in the future. Technology continues to develop at a dramatic pace. Tablets, servers, cloud computing, smart machines and smart printers will all encourage a major work shift – and less use of paper – in hospitals and medical facilities throughout the world. The potential for new technologies to improve patient outcomes while reducing costs is H swiftly becoming a reality. ■ Ken Jarvis is Healthcare Industry Practice Manager, Printing Personal Systems-Americas, HP.

Electronic record transforms care By Stefanie Kreibe hen treating patients requiring mental healthcare, caregivers need compassion, understanding and quick, complete and accurate access to previous treatment and health records. “Time is of the essence,” says Thomas Jones, Manager of the Mental Health Program at Mackenzie Health. He knows that medical decisions on how best to treat a patient need must be made quickly and correctly. If a patient comes into the hospital in need of urgent mental health care, having the most up-to-date information can help staff make clear and informed care decisions. Until this past July, staff treating mental health patients in the Emergency Department and other outpatient clinics faced a number of challenges in accessing patient histories in an efficient and timely manner, Mr. Jones says. “Up until that time, if a patient came to the Emergency Department in crisis, his or her complete mental health record was not always readily available,” he says. To overcome these challenges, Mackenzie Health in Richmond Hill, Ontario and Southlake Regional Health Centre in nearby Newmarket, collaborated to improve care for patients seeking mental


Photo Jim Craigmyle

Melissa Petriglia, and Thomas Jones, use the new single electronic mental health record. health services at the hospitals with a new Ambulatory Electronic Mental Health Record (AEMHR). This software, provided by B Sharp Technologies and McKesson Canada is enabling the hospitals to create, view and update existing mental health records for patients in real time, providing instant access to previous records and better coordination and integration of care for adult mental health encounters. With funding from Canada Health Infoway, the system gives mental health professionals from both facilities secure access to their patients’ entire inpatient and out-

patient encounter history within their hospital network, providing seamless mental healthcare across the entire organization. The new AEMHR is improving access to information for more than 200 clinicians resulting in improved care for thousands of patients at Mackenzie Health and Southlake. The system went live at Mackenzie Health in July 2013 and Southlake Regional Health Centre in November 2013 providing enhanced care for patients who visit outpatient clinics and improve safety for those receiving prescriptions for mental health. In addition, as part of this project, patient assessments are being sent to the provincial Integrated Assessment Record (IAR) Portal using the B Care Mental Health Solution, so other authorized clinicians involved in patient care can access appropriate information to optimize care coordination and treatment. With this innovative approach, Mackenzie Health and Southlake are working together to help simplify the journey that many mental health patients face by creating a comprehensive record that more effectively communicates their story, in the H event the patient cannot. ■ Stefanie Kreibe is a Consultant in Communications and Public Affairs at Mackenzie Health. www.hospitalnews.com

Tele-mentoring brings specialists close to home

Healthcare Technology 29

By Donna Faye

hen a migraine brought Sara Hampel to Thunder Bay Regional Health Sciences Centre (TBRHSC) earlier this year, she had no idea that she would have access to one of the countryâ&#x20AC;&#x2122;s leading neurosurgeons, based in Toronto, without even stepping into an airplane. Thunder Bay neurosurgeon Dr. Stephen McCluskey saw Hampel and recommended a minimally invasive surgery for the treatment of hydrocephalus called Endoscopic Third Ventriculostomy (ETV). In an ETV, the surgeon uses a small video camera to â&#x20AC;&#x153;seeâ&#x20AC;? inside the brain and makes a hole in the bottom of one of the ventricles or between the ventricles to enable cerebrospinal fluid to flow out of the brain. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s not appropriate for everyone but she was an excellent candidate for ETV,â&#x20AC;? says Dr. McCluskey. The only obstacle â&#x20AC;&#x201C; a significant one â&#x20AC;&#x201C; was accessing the necessary equipment. Dr. McCluskey was able to rent the equipment, which took several weeks to arrive. Because he had not had access to a ventriloscope for a number of years, Dr. McCluskey had also not performed an ETV since his training. For that reason, he wanted an expert present during the operation. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s always good to have mentoring when you havenâ&#x20AC;&#x2122;t performed a specific procedure in a long time,â&#x20AC;? he says. He contacted Dr. James Drake, a neurosurgeon in the Division of Paediatric Neurosurgery at the Hospital for Sick Children (SickKids) in Toronto and an expert in the science and surgery of hydrocephalus. Dr. Drake agreed to be present via Telemedicine. TBRHSCâ&#x20AC;&#x2122;s Telemedicine Department worked to make sure the connection with SickKids would work and then scheduled the surgery via the Ontario Telemedicine Network, with a studio at SickKids and the TBRHSCâ&#x20AC;&#x2122;s Operating Room, which is equipped with Telemedicine cameras that allow off-site surgeons and/or students to see the surgery. Dr. McCluskey says that the operation went very smoothly under Dr. Drakeâ&#x20AC;&#x2122;s telementoring. â&#x20AC;&#x153;As a physician, itâ&#x20AC;&#x2122;s very satisfying to be able to provide that service, rather than send a patient to Winnipeg or Toronto,â&#x20AC;? says Dr. McCluskey. â&#x20AC;&#x153;Eventually we would do this without mentoring.â&#x20AC;? Hampel says she feels great and was glad she didnâ&#x20AC;&#x2122;t have to travel to Toronto. â&#x20AC;&#x153;Telementoring is wonderful for people living in isolated communities like Thunder Bay and other towns in Northwestern Ontario. I think itâ&#x20AC;&#x2122;s wonderful that we have technology that allows us to access out-of-town specialists.â&#x20AC;? Trina Diner, Manager of Palliative Care and Telemedicine, says there are plenty of opportunities for health care providers, including physicians, dietitians, pharmacists, social workers to take advantage of Telemedicine. â&#x20AC;&#x153;Even if the appointment or consult is only 15 minutes, we can reduce stress for patients and families having to take time off work to travel. This



saves time and money, as well as separation from their support network of family H and friends.â&#x20AC;? â&#x2013; Donna Faye works in communications at Thunder Bay Regional Health Sciences Centre

I think itâ&#x20AC;&#x2122;s wonderful that we have technology that allows us to access out-of-town specialists,â&#x20AC;? says Sara Hampel (centre), seen here with Telemedicine Nurse, Karen McPhail (left) and Director of Supportive Care and Cancer Care, Dr. Scott Sellick (right).

â&#x20AC;&#x153; Focus on the things you can do, not ZKDW\RXFDQĂ&#x2013;WDQG\RXZLOOĂ&#x;QG just like I did, that life is fantastic.â&#x20AC;? â&#x20AC;&#x201C; Danny McCoy

Danny McCoy was rendered a paraplegic in a terrible car accident at the age of 43. Before the accident he was an avid sailor. After the accident, Danny became one of the top ranked competitive disabled sailors in the world. Heâ&#x20AC;&#x2122;s also the founder of the Disabled Sailing Association of Ontario and one of the sportâ&#x20AC;&#x2122;s foremost international ambassadors. Thomson, Rogers is a proud supporter of The Disabled Sailing Association of Ontario. We are honoured to have represented Danny McCoy in his lawsuit and to count Danny as a friend and one of the many everyday heroes we have been able to help.

YOUR ADVANTAGE, in and out of the courtroom

416-868-3100 | 1-888-223-0448 www.thomsonrogers.com MARCH 2014 HOSPITAL NEWS

30 Travel: The Best Medicine

Educational & Industry Events To list your event, send information to “events@hospitalnews.com”.

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

Q March 5, 2014 Islamic perspectives on End-of-Life Issues and Death University of St.Michael’s College, Toronto Website: www.ccbi-utoronto.ca

Crete, a large island in Greece offers pretty much anything a traveller could wish for.

Greek island hopping in style By Victoria Brenner y heart tells me that I WANT adventure but my head tells me I NEED clean bedding, comfy pillows and a good night’s sleep. Where is that perfect balance between living life a little more fully and enjoying the comforts of life that make the experience enjoyable? Island hopping around the Greek Islands is for me that perfect balance between the two – the thrill of exploring new places and meeting new people while enjoying some of the best quality accommodation and food in the beautiful Mediterranean. When deciding on a route, a good map of the ferry routes is essential. Remember that in high summer there are many extra routes and scheduled ferries running.


One thing not to miss before leaving Mykonos is a day trip to neighbouring Delos, the ‘Island of the Gods’ If you are starting from Athens then head down to the ferry port at Piraeus harbour and hop on a boat headed for Mykonos – a large island with a great history, a warm welcome for visitors and some of the finest bays and beaches in Europe. The Mykonos Blu resort is a definite star choice for somewhere to stay if you want to ease into your Greek adventure with some real first class pampering. A few days exploring the island or zoning out on the beaches of the impossibly pretty Psarou bay may be all you need before the wanderlust kicks in. One thing not to miss before leaving Mykonos is a day trip to neighbouring Delos, the ‘Island of the Gods’. This was a cult centre and pilgrimage site in Classical times. Rules imposed on earlier visitors to Delos included a law forbidding anybody from dying on the island. HOSPITAL NEWS MARCH 2014

If you want to get to Santorini (and you really should want to see this beautiful island created when a volcano blew apart the island of Thera between three and four thousand years ago) you will need to take a ferry to Naxos and then swap to a Santorini bound boat. Once you get there you will be faced with a wall of rock rising from the ferry port with one switchback road taking you to the top of the cliff for your first of many heartbreakingly beautiful views. If you want a suggestion of where to stay, the Grace Santorini in Imerovigli (just a few miles north) has an entrancing combination of luxury rooms, great service and possibly the most perfect infinity pool on the planet. If you find the pace just right, then just spend whatever time you have left wandering from island to island as you see fit. You are now au fait with the ferries and can look after yourselves. If you want to up the excitement, keep going south to the huge island of Crete. If you are in a hurry to get there the Hellenic Seaways-Flying Cat can get you to Heraklion in just 1 hour and 45 minutes. Once there the island is big enough to offer pretty much anything you could wish for. Between May and October the sixteen kilometre long Samaria Gorge hike is famous for amazing views, wild goats and the deep dark sections where the walls rise vertically on either side of you. At the end of the Gorge the quiet seaside village of Aghia Roumelli can only be reached on foot down the Gorge or by boat. This is just one suggested route for a little luxury island hopping, but with hundreds of inhabited islands the options are legion. Wherever in the Greek islands you choose to explore you will be rewarded with new experiences and memories to last H a lifetime.■ Victoria Brenner is Director at The Couture Travel Company. This article appeared on www.aluxurytravelblog. com and is reprinted with permission.

Q March 11–12, 2014 The National Forum on Patient Experience West Hyatt Regency Hotel, Vancouver Website: www.patientexperiencewest.com Q April 1–2, 2014 National Patient Relations Conference Hyatt Regency, Vancouver Website: www.healthcareconferences.ca Q April 10–11, 2014 National Telemedicine Conference Metro Toronto Convention Centre Website: www.healthcareconferences.ca Q April 27–29, 2014 Hospice Palliative Care Ontario (HPCO) 2014 Annual Conference Sheraton parkway Toronto North Hotel & Conference Centre, Richmond Hill Website: www.hpco.ca Q May 12–15, 2014 CAHSPR Conference 2014 Hilton, Toronto Website: www.cahspr.ca Q May 13–14, 2014 Human Resource Strategies For Healthcare Toronto, Ontario Website: www.healthhrcanada.com Q May 20–23, 2014 &DQDGLDQ3DLQ6RFLHW\WK$QQXDO6FLHQWLÀF0HHWLQJ Quebec Convention Centre, Quebec City Website: www.canadianpainsociety.ca Q May 23–24, 2014 International CT Symposium Fairmont Hotel, Vancouver Website: www.toshiba-medical.ca Q May 25–28, 2014 Prevention – A Port in Any Storm 2014 National Education Conference on Infection Prevention and Control Halifax World Trade and Convention Centre Website: www.ipac-canada.org Q May 29–30, 2014 e-Medication Management Conference Metro Toronto Convention Centre Website: www.healthcareconferences.ca Q May 29–June 1, 2014 CAMRT Annual General Conference Shaw Conference Centre, Edmonton Website: www.camrt.ca Q June 2–3, 2014 2014 National Health Leadership Conference Banff, Alberta Website: www.cha.ca Q June 12–13, 2014 Emergency Department Management Conference Metro Toronto Convention Centre Website: www.healthcareconferences.ca

To see even more healthcare industry events, please visit our website www.hospitalnews.com/events www.hospitalnews.com


Hospital spam Continued from page 27

This, coupled with the fact that electronic communications within hospitals are generally quite decentralized, will make for a fairly detailed and onerous internal administrative compliance exercise, particularly in larger facilities with research institutes and revenue-generating groups and programs.

Beginning the CASL Compliance Process In order to comply with CASL, hospitals should start by: 1. Reviewing the organizationâ&#x20AC;&#x2122;s electronic messaging traffic; noting that electronic messaging includes email, text,

Pain puzzle Continued from page 22

What could then be the solution to the pain puzzle? Evident too, all true solutions start with ourselves. If we want the Canadian medical system to provide a true science based approach to the treatment of pain, we have to start by giving ourselves a better education in this and other health related topics (becoming responsible consumers), so we can then question the clinical models that are failing to provide pain relief to so many of us. Otherwise, like in physics, things will just keep moving in the direction where forces push them. For practitioners, we now know enough to start using a more refined diagnostic and treatment model that favors interven-

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instant and social media messaging; 2. Determining which electronic messaging falls under CASLâ&#x20AC;&#x2122;s definition of CEM, and identify situations where exemptions or implied consent apply; 3. Conduct audits of the organizationâ&#x20AC;&#x2122;s current electronic communications policies and practices with respect to CEM and computer programs to ensure compliance with CASL; 4. Ensure that appropriate consent is in place prior to July 1, 2014 for CEM; and 5. Put procedures in place to ensure ongoing compliance with CASL, including form and content requirements, consent tracking and the scrubbing of implied consents in accordance with CASLâ&#x20AC;&#x2122;s specified time frames (as applicable). Fortunately for hospital foundations, CEM sent by charities with the primary tions that modulate neurofunction at all relevant levels. Interventions such as electroacupuncture and manual techniques, complemented then with appropriate interventions, including pharmaceutical agents when they have a well-defined role to play. If evidence-based medicine tells us that only a minority of chronic pain is associated with inflammation, why are antiinflammatories one of the most prescribed drugs to chronic pain patients? Perhaps we can find an explanation from the same â&#x20AC;&#x153;Pain in Canada fact sheetâ&#x20AC;? mentioned before: Veterinarians receive five times more training in pain management H than people doctors. â&#x2013; Dr. Alejandro Elorriaga Claraco, Sports Medicine Specialist (Spain) is Director, McMaster University Contemporary Medical Acupuncture Program.


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Focus 31

objective of â&#x20AC;&#x2DC;raising fundsâ&#x20AC;&#x2122; for the charity have the benefit of an exemption from CASL. However, even this exemption has left some scratching their heads regarding electronic messaging sent by hospital foundations for purposes other than fundraising given the broad definition of the term â&#x20AC;&#x2DC;commercialâ&#x20AC;&#x2122;.

Grandfathering and transition One element of relief comes from FAQâ&#x20AC;&#x2122;s published by the CRTC which state that valid express consents obtained prior to CASL coming into force will be grandfathered even if they didnâ&#x20AC;&#x2122;t meet CASLâ&#x20AC;&#x2122;s identification and contact information requirements, although opt-out consents obtained under the federal privacy legislation will not be grandfathered. There is also deemed implied consent for 36 months where there is an existing business or non-business relationship.

Penalties The maximum penalties for non-compliance with CASL are very steep: up to $10 million for corporations, $1 million for individuals. As well, a private right of action will allow consumers and businesses to commence enforcement proceedings

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Patricia North, LL.B., LL.M. is Legal Counsel, University Health Network.

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and recover damages (mercifully, the private right of action will not be in force until July 1, 2017). Also important to note is that officers, directors and agents are liable, and can be subject to a private right of action, if they directed, authorized or participated in a contravention, unless they can establish that they exercised due diligence to prevent the commission of the violation. The computer programming provisions (the subject of a future article) will not be in force until January 15, 2015. With the exceptions noted above, the rest of CASL will come into force on July 1, 2014. In light of the short timelines, hospitals would be best served by working together, and with the OHA and HIROC, to make sense of this new legislation in the health care context. Develop a standardized approach to CASL would help hospitals become compliant and reign in all of those rogue hospital spammers. *This article is a summary of a current legal issue and is not meant as legal opinion or advice. Readers are cautioned not to rely or act upon the information provided in this article without seeking legal advice H relating to their specific circumstances. â&#x2013;


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32 Focus

Keynote Speakers

Dr. Samantha Nutt Sunday June 1

Mr. Ray Zahab Monday June 2

Dr. Ian Stiell Tuesday June 3

Dr. Mel Herbert Tuesday June 3

Mr. Jeffrey Simpson Wednesday June 4

Dr. Jeffrey Turnbull Wednesday June 4

EARLY REGISTRATION DEADLINE: APRIL 7TH May 31 - June 4, 2014 Ottawa Convention Centre HOSPITAL NEWS MARCH 2014

For more information visit caep.ca/Conference www.hospitalnews.com

Profile for Hospital News

March 2014 Edition  

Hospital News Focus on Pain Control, Rheumatology, Complementary Health and Health Promotion

March 2014 Edition  

Hospital News Focus on Pain Control, Rheumatology, Complementary Health and Health Promotion